Hospital Rotations Lesson 3: A Poker Face

Lesson 1: Alphabet Soup
Lesson 2: The Humility Pill
Lesson 3: A Poker Face
I think I could use some tips from Lady Gaga.  Here's the story.
Last week I saw a patient with both liver and kidney failure; he had been in the hospital for over a month before transferring to my floor.  I knew something was terribly wrong when I stepped into his room and noticed an eerie yellow glow.  I soon realized it was the sheen of his severely jaundiced skin reflecting off the white bedsheets and absorbing into the white painted walls.  Blinding.  (Jaundice, a symptom of excess bilirubin, gives body tissues a yellow tint and usually indicates liver disease.) Suddenly the man looked up at me, and his voiceless mouth started to speak (he couldn't talk because of a tracheotomy).  I'll never forget his eyes.  I saw no white, only two black pupils on balls of blood red, unblinking saucers of pain boring into my own paralyzed profile.  I attempted my best poker face, however I couldn't maintain eye contact, and I pretended to fiddle with his IV before stumbling out of the room, deeply shaken.  Those red eyes have been on my mind ever since.

What is your strategy for death?  What do you say when it looks you in the face?  My dad reassures me that I'll soon get used to such hospital sights, a thought equally disturbing.

On that sober note, The End (for now)!  Thanks for reading my three-post series about my thoughts on clinical rotations thus far.  There are many more lessons to share!  Yesterday I was overwhelmed to receive all the encouraging comments, and I am grateful for your kind words and advice to me.

With thanks from the bottom of my heart,

Hospital Rotations Lesson 2: The Humility Pill

Lesson 1: Alphabet Soup
Lesson 2: The Humility Pill
Someone once warned me that the dietetic internship is 99% awkwardness.  This is absolutely true, and I'm having a little trouble integrating with the medical team.  Even after reading through a patient's medical record, I find that there are many gaps and holes to be filled in, which requires talking with the doctors.
It takes a daily dose of humility, for I confess that the attending physicians, the residents, the interns, and the nurses intimidate me!  Most times I feel like a little child sitting at the grown-ups table, listening to the adult conversation.  But then I tell myself, "Hey girl, remember you have a job to do!"  So I spank myself on the bottom, stand up, and speak my mind, saying, "Excuse me Dr. ABC, what's the care plan for Patient XYZ?  When do you plan to advance his diet?" And away we go.
Epiphany: "Interns" are actually first-year residents.  This confused me at first, but I have since realized that interns are much more approachable than the older residents or attending physicians.  Thank you Interns!

Coming soon...Lesson 3: A Poker Face 
Once again, Happy Monday!
PS-Sometimes I feel like this picture!  Hehe.  (Photo from Kswpgoodfriends Blog.)

Hospital Rotations Lesson 1: Alphabet Soup

Was it only three weeks ago that I was ironing my white lab coat, desperately trying to smooth out the starchy wrinkles and my own flustered nerves?  Now three weeks later my original anxiety about working on the hospital floors has subsided, and I'm enjoying the fast-pace clinical experience.  I'm thankful for the dietitians who are teaching me, and I have some lessons to share (look out for several blog posts).
Lesson 1: The Game of Alphabet Soup
Reading the medical charts is like playing alphabet soup; it's a hot mess of swirling letters and abbreviations.  The physician notes are rarely legible, making each spoonful a game of translation and decoding.   Can you guess what this means: "Pt. p/w CP, c/o SOB with PMH of CAD s/p OHTx in 2008."  On my first day on the cardiology floor it took me several minutes to learn that, "Patient presented with Chest Pain, complaining of Shortness Of Breath, with a Past Medical History of Coronary Artery Disease status post a heart transplant in 2008."  It can be very discouraging, but I am finding that with each day I'm getting better.
I spent two weeks in cardiology, but now I'm on the surgical floors.  Each new service is a fresh bowl of soup, a new mix of letters, and the start of a whole new game.  Slurp!

Handout I made.  Heart disease leads to fluid accumulation.  Taking medications and limiting fluids helps these patients decrease the extra fluid and swelling in their body. 
Happy Monday!
Do you have any thoughts on the hospital?
Coming next...Lesson 2: The Humility Pill
(Photo from The American)

A New Library. A Full Book Basket.

The Cambridge Public Library
Who doesn't like a pleasant surprise?  I feel smug when I pull out a forgotten $10 bill from my pocket, or when I slide back under the covers on a Saturday morning after the alarm accidently goes off.  I love pleasant surprises, especially when it involves the unexpected discovery of a beautiful public library.
Here's what happened this weekend.  I traipsed out of my apartment intending to walk to Harvard, rashly decided to take a new route, swerved a sharp left on Broadway Street, and skipped merrily along for seven minutes.  Then hello!  I stumbled upon the Cambridge Public Library.  It was an emotional afternoon that ended with a shiny new library card in my wallet.  Well, enough about my library fetish (now that I've confirmed my nerd status).  Here's what I've been reading.
From the Book Basket
The Reason for God, by Timothy Keller.  Published 2008.
Do you believe in God?  Can all religions be true?  Why does a good God allow suffering in this world?  This New York Times best seller tackles these tough questions and more.  Timothy Keller is a pastor for Redeemer Presbyterian Church, a large urban church in Manhattan.   I just started this book for a church study, and I'm excited to examine my own convictions.  Recently it seems that my Christian faith has become a mere label, a lifestyle of habits.  This summer I'm seeking sincerity.
Little Bee by Christ Cleave.  Published 2008.
"Most days I wish I was a British pound coin instead of an African girl.  Everyone would be pleased to see me coming. [...]"  Are you intrigued by these opening lines?  Let me tell you, this British author has an enchanting way with words!  Narrated through the spunky yet innocent voice of a Nigerian refugee who starts her new life in England, this tale is amusing and sobering.  I'm only a few chapters in, but I'm ready to recommend it!
A Thousand Splendid Suns, by Khaled Hosseini.  Published 2007.
A tale of two women in Afghanistan.  Poignant.  Compelling.  Informative.  It's times like these that I wish I could shed tears easily.  Truly splendid.  I predict a movie.  I'm sure most of you have read this, but if not, please do! It's completely different than The Kite Runner, which I did not care for.
 The Tipping Point, by Malcolm Gladwell.
Just finished this non-fiction book by Malcolm Gladwell, writer for The New Yorker and author of more recent books such as Outliers, Blink, and What the Dog Saw.  This was my first taste of Gladwell, and I'm fascinated by his research and presentation on the theory of social epidemics.  While I flipped the pages, I kept thinking, "How can we make fruit and vegetables a social epidemic in America?"
Medium Raw, by Anthony Bourdain.  Published 2010.
This new book, sequel to Kitchen Confidential, is on hold at the Boston Public Library!  Oh dear, I think I'm #47 on the waitlist...
The Cambridge Public Library
What can you say about these books?
What's in your book basket this summer?

New! 2010 Dietary Guidelines for Americans

On Tuesday June 15th the Dietary Guidelines Advisory Committee released their report for the 2010 Dietary Guidelines for Americans.  Public comment will be accepted from June 15 to July 15, 2010.  The final report is due at the end of the year.
This is old news, however my head has been stuck in medical records and clinical rotations (more on this  in the future) so I just found out this weekend!  Here's more info on the Dietary Guidelines:
Published every 5 years by the United States Department of Agriculture (USDA) and the Department of Health and Human Services (HHS), the Dietary Guidelines represent science-based nutrition guidance for the general public.  Their mission is to promote health and reduce risk for major chronic diseases through good dietary habits.  First published in 1980, Congress mandates that the guidelines be reviewed and updated every five years.  The Dietary Guidelines set the standards for all Federal food and nutrition education programs.
Read the press release.   
Check out the USDA's Nutrition Evidence Library to see the supporting research.
Read what Marion Nestle thinks on her Food Politics blog.
Wall Street Journal reports on the Advisory Committee Report.
Blog love!  Read a brief recap from my friend Emily at The Health Nut.  She offers a soon-to-be dietitian's perspective, and her blog is super fun!

Have you read it yet?  What do you think?  I have to find time this week to go over it.
Happy Monday!

The Secret Garden of Cambridge

Unlike Burnett's classic children's tale, Mount Auburn Cemetary is not literally hidden behind a locked ivy-covered door.  Nope, this National Historic Landmark sits beside the Charles River just a few minutes west of Harvard.
My friend was the first to discover its beauties, and several weeks ago she took me for a visit.  We enjoyed strolling the solitary paths, hiding underneath the weeping birches, and quietly treading among the resting places of Henry Wadsworth Longfellow and Isabella Stewart Gardner.  For those few hours, we completely forgot we were in Cambridge.

What a view of Boston!
The inside of this magnolia flower looks like a pineapple!  
Resembling a garden more than a graveyard, Mount Auburn Cemetary is one of the best kept secrets of Cambridge.  I want to proclaim its excellencies from the rooftops, or rather, from this blog into the echoes of cyberspace.  So call me if you're ever in the area; we will unlock the door, push back the ivy, and step into a green garden paradise.
Hope you have a great Friday!
(Here in Boston, our hearts are still healing from last night's game. Go Celtics!)

Singing with the Beans

The Sweet Vinaigrette Bean Salad started as a simple duet.  Somehow black bean's deep bass combined in melody with navy bean's light soprano.  Gradually the other players arrived: red onion brought his biting percussion, sweet corn came with her sugary chimes, cherry tomato sang a snazzy solo, and fresh cilantro tried to blare his bold tune over it all.  A dollop of plain greek yogurt added the perfect ending note.  Encore.
Sweet Vinaigrette Bean Salad
1 cup Black beans
1 cup Navy beans
A handful of cherry tomatoes, cut
1/4 red onion, chopped
1/2 can corn
Handful fresh cilantro, chopped finely
1-2 Tablespoons Sweet Vinaigrette Dressing
Mix all ingredients.  Change amounts to your taste.
Modified from The Joy of Cooking.

Sweet Vinaigrette Dressing
1/4 cup canola oil
3-4 Tablespoon sugar
1 tsp salt
1/2 tsp pepper
4 Tbsp white vinegar
Bring ingredients to a boil and then cool.
Recipe from my mom!
These days I come home tired and in no mood to cook.  A bean salad is the perfect no-fuss, protein-packed, fiber-filled light dinner that softens my mood.  Also, a friend recently informed me of Rancho Gordo, an online store specializing in heirloom beans!  I just received my first taste, delicious!
Any thoughts on beans?
And yay for the World Cup!

Coconut Milk Yogurt

My expedition to find coconut milk yogurt began last week with an article in the LA Times.  While explaining the recent explosion of yogurt options, the writer mentioned coconut milk yogurt.  I was intrigued, and thus the search began.
Fortunately Turtle Mountain heard my desperate plea on Twitter, and directed me to their So Delicious dairy-free products.  In their generosity, they also sent me coupons to purchase some free products! Thank you!

I finally found the Coconut Milk Yogurt at Whole Foods.  These dairy-free, soy-free yogurts were quite expensive.  A glance at the ingredients list shows that they are fortified with calcium, B12, and some fiber.  Though available in 9 flavors (pina colada!), I was feeling like a purist and chose Plain.  I was surprised by the initial sweetness, but reassured with the sour aftertaste.  The mouthfeel was nearly the same as regular yogurt, and overall the taste was good.  I added sliced banana and unsweetened coconut flakes to the yogurt.
The Coconut and The Cow
  • Saturated Fat.  For those trying to limit their saturated fat and lower LDL cholesterol (the Lousy cholesterol), coconut milk's 6 grams in 6 ounces might not be the best choice.  I chose to compare So Delicious with a whole milk yogurt so that the saturated fat content would be comparable (a plain 6 oz skim milk yogurt contains less than 1g of saturated fat).   
  • Protein.  I confess that I was a little disappointed with the 1 gram of protein.  Yogurt is often touted as a low-fat, high-protein food that can serve as a satisfying snack or meal component.  Perhaps adding a handful of crushed nuts to the coconut milk yogurt can boost the protein for a filling snack!  
  • Dairy-free.  Soy-free.  Coconut milk yogurt is a great option for those who cannot tolerate lactose and may not like the taste or texture of soymilk yogurt.
  • My opinion.  Coconut milk yogurt may not provide the best nutritional quality for a limited budget.  However this was a great splurge, and I love trying new products!  I hope you will take the time to try this too. 
Happy Monday,

On Hairnets and Temp Logs

I have a clipboard in my right hand, a thermometer and temp log in my left hand, and I'm rockin' out in the oh-so-attractive hairnet.  A cart of dirty dishes clatters by me, while shouts and yells of "Next order UP!" bounce off the tiled walls and absorb into the slip-proof rubber floor mats.  Can you guess where I am?
The Tufts Medical Center kitchen!  For the dietetic internship I am required to learn production and management skills in a large food service setting.  So for the past three weeks I have been hanging out in the kitchen listening to stories [and songs!] from the cooks, exchanging meal trays and friendly banter with the kitchen staff, walking the hospital floors with the meal passers, and observing the inner workings of the kitchen management.  Tufts has contracted its hospitality service with Aramark, and like many hospitals it has set up a "room-service" infrastructure in order to give provide high quality individualized meals for their patients.
View of the trayline from behind.  I was usually stationed at the very end on the right, and would check the meals before they went to the hospital floor.
I was really nervous about taking pictures in the kitchen.  I wouldn't survive as a stealth photographer.
What did I do in the hospital kitchen?
Under the supervision of the Assistant Director of Patient Services (who is also a Registered Dietitian), I have been learning about management roles in the context of large-scale food production.
  1. Help assemble and check meals on the trayline.
  2. Performance Improvement measurements in the kitchen (accuracy of meal trays, timing of room service delivery, temperature compliance of the food, protocol compliance of the meal passer employees).
  3. Brief research report on sustainability in foodservice.
  4. Observed the call center, where patients place their room service orders.
  5. Sanitation and safety audits in the kitchen.
  6. Test tray...testing for correct food temperatures once the meal reaches the patient's room.
  7. Paperwork for payroll.
  8. Observe the head chef in food purchasing and inventory.
  9. Attend various meeting with my manager.
  10. Inservice with the cooks.  The topic was the gluten-free diet.

Here is the half-page inservice handout I made for the chefs!
Tasty [and Sustainable] Links to Share
While researching the concept of sustainability within foodservice institutions, I came across several informative resources.  Just want to share!  Enjoy. 
Healthy Land, Healthy Food, and Healthy Eaters: Dietitians Cultivating Sustainable Food Systems By Angie Tagtow and Alison Harmon.  Published 2009.  Eight page handout explaining the dietitian's role in approaching food, nutrition and health from an ecological standpoint.  

The Food Climate Relationship: The Registered Dietitians' Balanced Approach to Postivie Change Published 2010.  Handout published by Health Care Without Harm and Hunger and Environmental Nutrition (dietetic practice group of the American Dietetic Association).

Buyer's Guide for Sustainable Seafood.  By the Monterey Bay Aquarium, as part of their SeafoodWatch program.  They characterize fish by "Best Choice," "Good Alternative" and "Avoid."  Also check out their archives of Sustainable Seafood Recipes for amazing dishes like "Grilled Oysters with Wasabi and Miso."  Ouch...that sounds good.
Gotta love those homemade choc chip cookies.
The kitchen feeds me well!  I have hardly gone grocery shopping in 3 weeks.
Next week I start clinical rotations with the dietitians on the adult inpatient floors!  Cardiology is first up.  It's time for real patient contact, and I am so nervous.  Any tips for me??
Bye bye!

PS- My last day in the kitchen is Friday.  I won't miss the hairnets, but I will sincerely miss the kitchen family.  Thank you for welcoming me into your loud and crazy, but friendly world!  
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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