Hospital Rotations Lesson 4: Destination Competency

flickr photo from Digital Explorer

At 70 mph, the hospital rotations are flying by.  8 weeks ago I was standing in the parkling lot, my head filled with nutrition theories, my arms loaded with textbooks.  But then I stepped from the parking lot onto the hospital floors, and that's when the journey began.
On this road trip I picture myself in a red '94 Jeep Wrangler (oh how I miss this car), driving through the practical lessons of nutrition care in a hospital setting.  With 4 weeks left, I'm keeping my eyes on the final destination.  Destination Competency.

Two thoughts.  (Thankfully a blog is both a journal and an information space!)
1. Embrace the U-Turns
Four weeks ago I got pulled to the side of the road and gently informed that my performance on the hospital floors needed to improve.  In particular, I was mistakenly pushing myself to see more patients per day, but failing to properly tailor my nutrition notes for each individual's specific care.  Increased quantity, with decreased quality.  Yup, time for a U-turn.
I didn't cry in that meeting (although later I smeared a patient's medical chart with a few watery sniffles).  In reality, anyone can take a wrong turn, but we are thankful for the roadsigns that guide us.  A change of direction can be a blessing.
2. Drive Solo 
Sometimes I get distracted by the other cars on the road.  I compare myself to other grad students, med students, dietetic interns, and friends.  Although I love my trusty Jeep, it has a broken tapedeck and no air-conditioning; I get easily discouraged when flashy BMWs and cute mini-Coopers whiz by in the left lane.  "How come I'm such a slower learner?"  "I wish I was a witty communicator so that patiens would like me."   Hush hush.  This is when I repeat to myself:  "Girl, just learn what you are supposed to learn.  Be earnest, be wholehearted.  Be thankful for the opportunities God has given you.  Accept criticism, embrace the U-turns.  Keep your eyes on the destination, and chug ahead."
With this attitude, I'm free to take off the hard top (convertible!), turn up the music, and enjoy the ride.

Update: 4 weeks left of adult inpatient!  This week I'm finishing the General Medicine and Oncology/Hematology/Bone Marrow Transplant floors.  I absolutely loved these floors and will be sad to leave them.

New Read

Better: A Surgeon's Notes on Performance

by Atul Gawande (author of Complications and The Checklist Manifesto)

published 2007

Insightful and amusing.  I'm enjoying a new understanding of insurance battles, a new appreciation of hand sanitizer pumps, and a new view of patients as human beings rather than a mere diagnosis.  

Check out Gawande's latest article in The New Yorker about the use of modern medicine in terminal illness.  This sobering article gives me new zeal as a future clinician!

Thanks for listening.

Happy Thursday,
Rach

Three Friendly Beets. One Pot of Soup.

Confession: I used to be an avid beet-hater.  In my defense, I think we all agree that beets are alarmingly red.  They stain the cutting board, they stain your fingers, and they most certainly will stain your favorite white shirt.  In grade school, I had one unpleasant encounter with the canned variety that left me cautious and wary for years to come.
However a few months ago I had my first taste of fresh beets, lightly steamed and tastefully scattered over a spring salad.  Redness!  Sweetness!  Delicious softness!  I was charmed.

The story gets better.  Last week I received three beets in my weekly CSA veggie and fruit delivery.  (This summer I signed up for a Community Supported Agriculture share through New Entry Sustainable Farming Project.  For a whopping $55 I get to share a small delivery of weekly produce from local farms in Massachusetts.)  As you can imagine, I was excited to receive these three friendly beets, and even more joyous with the beautiful pot of soup that soon followed.

(The kale and chives are from the CSA share too!)

Ukranian Red Borscht Soup
Modified from Original recipe at Allrecipes.com

1 package (16 oz) chicken sausage
3 medium Beets
1 cup baby carrots, sliced
2 medium potatoes, cubed
1 Tablespoon vegetable oil
1 medium onion, chopped
1 (6oz) can tomato paste
3/4 cup water
1 cup chopped kale (originally cabbage)
1 (8oz) can diced tomatoes, drained
4 cloves garlic, minced
salt and pepper, to taste
1 teaspoon white sugar, to taste
Top with plain nonfat yogurt (original recipes calls for sour cream)
Garnish with minced chives (original recipe calls for parsley)

Directions: 

• Cook sausage in a skillet over medium heat.  Remove and set aside.
• Fill large pot halfway with water (about 2 quarts).  Bring to boil.  Add sausage.  Add beets, and cook until half-way soft.  
• Add carrots and potatoes.  Cook until tender, about 10 minutes.  Add kale.  Add diced tomatoes.
• Heat oil in a skillet over medium heat.  Add onion and cook until tender.  Stir in tomato paste and water to blend with onions.  Transfer to the pot.
• Add raw chopped garlic to the soup.   Cover and turn off heat.  Let stand for 5 minutes.
• Taste and season with salt, pepper, and sugar.
• Garnish with plain yogurt and fresh chives.

This sweet soup is best enjoyed with a hunk of crunchy bread, something with a dense crumb useful for sopping up plenty of bright red broth.  I am a new enthusiast for the Whole Foods Bakery, which has turned into an expensive habit since I always find myself meandering from the bakery to the cheese counter.  This week I paired my beet soup with their hearty Seeduction Bread, pictured below.

I dedicate this recipe to my dear childhood friend Ashley.  From my earliest memories in grade school, she has been a faithful beet fan, a remarkable charateristic that I never appreciated until recently.  Hey Ash, I've finally converted!  I can't wait to eat some beets with you.  

Love beets?  Hate beets?  
What do you think about beet soup?
Happy Monday,
Rach

Veg Out for Breakfast!

One of the blessings of the blogosphere is mingling with new friends and colleagues.  These past few months it has been my pleasure to meet Carlene Helble, a dietetics student at James Madison University and fellow blogger.  I am excited to feature her as my first guest on Coconut Crumbs.  Check out what she has to say about Veggies for Breakfast! 

Veg Out for Breakfast!
Written by Carlene Helble, Elite Nutrition Intern 
“Here’s your wake-up call: breakfast eaters tend to be leaner and more successful at maintaining a healthy weight than people who miss their morning meal.”  This quote from Ellie Krieger’s website says it all!  Breakfast is extremely important, but even those who are on track with breakfast sometimes get stuck in a menu rut: cereal, perhaps a banana?  How often do you throw some nutrient dense veggies into your morning meal?

National Public Radio recently published a fantastic article on the lack of American vegetable intake at breakfast, comparing it against some delicious options across the globe that did contain vegetables. Here are some easy ways to make changes, and even ‘go global’ in the morning:

Omelets can be good.  But for a more filling meal with less calories plus a serving or two of veggies, try some scrambled eggs with chopped spinach, mushrooms, and tomatoes. Think of the egg as a ‘topping’ and let the vegetables shine. The great thing about this idea is the vegetables are interchangeable. Feel like some asparagus? No problem! A vegetable scramble can be easily personalized.

Another great way to get more vegetables at breakfast is with smoothies; perfect for an on-the-go meal. One smoothie that seems to be a favorite is the ‘green monster’, which consists of kale or spinach, blended with fruit, milk, and sometimes chia seeds. (Check out this website dedicated to green monster smoothies!)

One suggestion NPR gave was for a traditional Argentine dish: a breakfast tart with summer squash, red peppers, and a basil crust. This is definitely on my ‘to make’ list, especially with summer produce on the way!

Sources: 
Ellie Krieger http://www.foodnetwork.com/healthy-eating/the-best-start-to-your-day/index.html 
NPR http://www.npr.org/templates/story/story.php?storyId=126911529

Carlene is a senior dietetics student at James Madison University, and the president of the student dietetics association.  This summer she is interning with an inpatient RD and a private practice RD, while also continuing to write about nutrition and health.  This next spring she will be applying for dietetic internships!

Check out more of her writing (and obsession with food) at the following sites:

HerCampus

Balanced Health and Nutrition

All Access Internships Blog

Thank you Carlene!

What do you think about veggies in the morning? 

I'm inspired to try this greenmonster breakfast smoothie!

-Rachel 

Rajma, The Indian "Chili"

My roommate is back from Washington D.C., and The Indian Diaries are in full swing!  Today's special is Rajma, a traditional North Indian dish made with kidney beans.  Rajma's spunky spicy flavor makes it the Indian version of American chili.  Or more likely, our hearty stew is probably the American version of India's Rajma. 

Rajma, The Recipe
1 cup kidney beans*

1 small yellow onion, finely chopped

1 large tomato, pureed (in blender)

1 tsp chopped garlic 

1 tsp fresh ginger, chopped

1.5 tsp turmeric powder

1.5 tsp coriander powder

1 tsp chili powder

½ tsp garam masala
1 tsp cumin powder 

salt to taste

2 Tbsp oil

*can make with canned kidney beans (no cooking required) or with dried beans.  The following recipe uses dried beans, soaked overnight, and cooked in a pressure cooker.

1. Pour 2 Tbsp oil into the pressure cooker.  Once hot, add garlic and ginger. 
2. Lightly stir for a few seconds and add onion.  Cook onion on medium heat until transparent, but be careful not to burn.
3. Add tomato.  Add spices (turmeric, coriander, chili, garam masala and salt).  Cook down and stir until the mixture becomes a spicy paste.  
4. Add 1 cup kidney beans and 3.5 cups water.
5. Cover pressure cooker and cook on medium heat until you hear the cooker whistle.  This may take 20-30 minutes.
6. After the whistle, turn off heat but let beans cook for another 10 minutes.  Once pressure has decreased, take off the cover and evaluate.  Kidney beans may need more water if you want a soupy consistency.  Beans may need more cooking if you want a chunky consistency.

Eat with:

Rice, naan, or roti

Optional: Sliced persian cucumbers (smaller than English variety)

Optional: Plain yogurt.

Rajma is a hallmark of Indian cuisine, a suitable componant for any social gathering.  My roommate states, "It is loved by everyone.  You won't find someone in India who doesn't enjoy this dish."  It is served with basmati rice, all year long.  

Very yummy.  All the credit goes to my rommate! *Applause*

Feel free to leave a comment telling her what you think!

Thank you.  Happy Friday!

Rachel

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,
Rachel

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!
Rachel
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
Bye,
Rachel
(Photo from The American)