A little over a week ago, I finished up my fourth clinical rotation – Nutrition Support.
It was a challenging rotation, which is why I loved it. My preceptor would give me an EN calculation to do, then ask me why I picked the formula I did, or alter the scenario and have me redo my calculations to fit the new scenario. When figuring out tube feeds, I had to make sure I double checked the patient’s medications to see if any of them provided calories or if any of the medications required tube feeds to be stopped at certain times. My preceptor and I talked a lot about some of the circumstances that arise in Nutrition Support, such as: how do you figure out a transgender person’s calorie requirement when BMR calculations are based on a binary sex system? How many times do you attempt EN before giving up and switching to TPN? What do you do if your formulary doesn’t contain any formula you think is appropriate? (Use kcal/kgBW if the transition isn’t complete, focus shouldn’t be on number of times tried but on how many hours/days the patient has gone without nutrition, and work with the pharmacy to get something appropriate.)
Nutrition Support is done mainly in the ICU. (We had some of our patients move out of the ICU so we followed up with them once they were stable and in the wards.) Patients in the ICU can change status rapidly, so we rounded every day with the interdisciplinary teams. Every morning, the doctors, the nurses, the social workers, the pharmacist, the chaplain, and the dietitian (with me tagging along) would discuss each patient and the plan for the day. And even though we rounded every morning, we would also check in with each other in the afternoon to see if anything had changed since the morning. For example, we had one patient that we expected to get a Dobhoff placed so I did the EN calculations, but complications arose so I had to get TPN recommendations done right away. Nutrition Support was a non-stop rotation and I was busy every day.
Patients in the ICU can also be more dangerous than patients in the other units. Some patients are coming out of medically induced comas and can react unpredicatably. Some patients are suffering incredible amounts of pain and may unintentionally grab whatever (or whoever) is right next to them. We had one patient lash out at staff during rounds, so we had to immediately back away and had a discussion with just the healthcare team. (When possible, we always involved the patient or their family during rounds so they could understand what was going on.) You don’t want to withhold care just because a patient is violent to staff, but you also don’t want to endanger the staff, so it’s not uncommon for patients to be sedated so they can get the care they need.
Nutrition Support is “short-term,” especially when compared to hospice, nursing homes, or psychiatry, so you don’t get to see the long-term effects of nutrition counseling or MNT such as sustained weight loss or A1cs reflecting well-managed diabetes. Instead, in Nutrition Support, you get instant gratification because you can see how quickly patients respond to and improve with tube feeding. It really is amazing.
I also got to learn the random fact that back in the old days of tube feeding, lipids weren’t provided in the tube feeds. Patients who were on long term tube feed would develop essential fatty acid deficiency in 7 to 10 days. So the remedy for that was to rub safflower oil on the patients. Seriously. I found a lot of papers from the 70s and 80s about the topic and they showed mixed results. Since TPN formulas now include lipids, it doesn’t look like a whole lot of research has been recently done about topical use of safflower oil to reverse EFA deficiency. Still…Pretty cool stuff.
Now, Nutrition Support is definitely not for everyone. There’s probably more math in Nutrition Support than there is in any other rotation. The patients are in a more critical state so you don’t really do much counseling. (It’s kind of hard to counsel someone on the benefits of a healthy diet when they’re in a coma.) The critical state of the patients means that nutrition requirements can change the next day or even sooner than that. Constantly re-assessing patients and re-doing recommendations can be frustrating for some people. Patients will code and crash carts will be used. There will be tears, sadness, and hopelessness – from patients and family members. There can be death. There will be unpleasant sights and smells.
Still, I found Nutrition Support to be an extremely rewarding rotation. I really felt like I had an important role in the care of critically ill patients. I definitely plan on being able to put “CNSC” after my name someday.