Lesson 7: Bumping the Walls. Questions from the ICU.

Charles River, Boston Massachusetts
Yesterday, in an attempt to escape the world of scrubs and sanitizer, I laced up my running shoes and walked home from the hospital.  90 minutes later I arrived at my doorstep with sagging shoulders (I think my bag gained 10 pounds along the journey), and brimming over with fresh musings about the dietetic internship.  I'm currently working with the dietitian on the Surgical Intenstive Care Unit (SICU) and Medical Intensive Care Unit (MICU).  Here's some thoughts.
Longfellow Bridge, looking into downtown Boston
What's to like about the Intensive Care Units (my opinion!):
  • Morning rounds.  I enjoy listening to the MDs and residents talk their stuff, and it's much easier to stay updated on my patients.  I like to measure my learning progress by counting the number of terms and abbreviations I don't understand.  Each day the long list is shrinking!
  • Complex medical conditions.  Our body is smart, but so much can go wrong.  Amazing pathophysiology.  I want to know more.
  • Calculating tube feeds and IV nutrition (TPN).  This is why the doctor needs a dietitian!

Intensive Care Units, Dislikes (my opinion!):

  • Minimal patient interaction.  Once a patient is sedated and on a breathing machine, be prepared for  a one-way conversation.  *wink*  But honestly, I do not like spending the entire day talking only with the medical team and family.  Talking with a patient makes me feel like I am helping them.
  • The limited scope of nutrition in critically ill patients.  I feel silly worrying about a patient's eating when the rest of the team is working hard to keep their heart pumping, their lungs breathing, and their blood vessels open.  It's frustrating, but I understand.
Here's where nutrition leaves me hungry.  In these critically ill patients, I want to dig deeper into the medical state, I want to understand the disease process, I want to directly affect the medical plan.  As a dietitian-in-training, I wish that the field of nutrition could be more involved, more helpful.  Is Dietetics in a glass house, and do I keep bumping the walls?
Questions that I'm trying to figure out:
How does a dietitian justify his/her usefulness in the ICU, without overstepping his/her scope of practice?  Do you know what I mean?
How does a dietitian assimilate to the medical plan, while also gracefully asserting his/her nutrition recommendations?  Hopefully this comes with experience.

Welcome to new readers!  I'm very pleased to make your acquaintance.
Cheers for Thursday,


MelindaRD said...

Great questions about RDs in the ICU. It is tough. Having a CNSC now helps so you do not go out of your scope of practice, although in many places, the unit will welcome the expertise of the RD. The RD where I worked who did ICU and trauma has been there over 20 years, and the doctors fully trusted her judgement and she helped write TPNs, which she could do better than doctors. She is also a CDE.

One thing you hate about the ICU, I loved. The patient CAN NOT complain about the food. True, you can't talk to them, but sometimes that means you can see the patient in half the time, sometimes twice as many patients a day, especially if you round because you can take notes and already know what adjustments you plan to make. I like all units, but sometimes I welcomed the peace and quiet of a day in the ICU (minus the actual beeping of machines...hopefully you have a quiet corner to sit in).

Emily said...

I didn't like the NICU/ICUs as much because of the reasons you stated...little patient interaction. I think the doctors relied on me and my preceptors to determine if TPN was adequate, but at the same time, we couldn't always go up on feeds r/t high blood glucose or other problems. It is super fast-paced, though, and you really have to stay on your toes as pt condition changes daily.

I think that rounds are really helpful in finding a medical and nutritional plan that is most appropriate. If there was something I felt should be done, that was the best place to catch all of the residents and attendings and nurses at once (although it was scary at times!).

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Disclaimer. I am not a Registered Dietitian yet. I provide nutrition information intended for the general public, not for the treatment of a specific medical condition. I try to use scientific research and reliable sources when forming my opinions and messages.
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