Diary of a Mad Dietitian

Accepting

2011-07-22T21:04:00.000-04:00

I have been concerned about this blog and how I am going to have more topics to discuss. I don't not want to disclose issues from my current employer simply because I want to keep my job. Bad-mouthing an employer could not only cost a person their job. In addition, I could be violating HIPAA. I don't think there hasn't been a person in the United States who has not heard of HIPAA. But just in case, let me explain what it is.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104-191) [HIPAA] was enacted by the U.S. Congress in 1996. Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.

OK, enough of all of that mumbo-jumbo...moving on....

I have a couple of Facebook pages I maintain about food and nutrition. I posted something today about USDA regulations regarding meat regulations.

I was surprised by a comment from someone today. This someone is representing an organization. That pretty much tells me either this organization is bogus or this person is closed mind, feeling it is appropriate to comment for the entire organization. The comment clearly indicated that this person is a vegetarian and has aversion to any animal product.

I could not believe it. How narrow minded can a person be? And everyone should learn at least one culture other than their own. As a dietitian I have to have a fairly decent working knowledge about other nutritional culture. What I like to eat is undoubtedly different to what another may eat. But I do not try to be judgemental in something I do not care for in eating. I have little or no tolerance for others who are judgemental.

Everybody's an expert

2011-04-26T22:02:00.000-04:00

With the increasing admissions of patients who are obese, there can be trying times in healthcare. I recently overheard a conversation between two occupational therapists. They were reading the admission history of a resident.

Body Mass Index (BMI) is a relationship between WT & HT associated with body fat & health risk. Health risks associated with a wide range of BMIs (both high and low values). Acceptable range for BMI standards: 18.5 to 24.9. This particular patient had a BMI that was more than twice the higher number of the acceptable range for BMI standards (24.9 x 2 - 49.8).

The two occupational therapists were lamenting about the size of this patient. One said to the other: "The BMI listed isn't correct. When the hospital lists they don't use the calipers." I stopped and politely interjected, asking: "I am sorry, but calibers?" The reply was "you know one of those things to pinch the fat in your arm. That is true way to determine a BMI."

I paused for a minute....then I replied: "Could I help you understand BMI better?"

They replied yes. I explained that the calibers they were referred to skin calipers. I further explained that skin fold calipers take skinfold measurements which is a common method for determining body fat composition. Accurate measurement technique is important. A standard technique that is used. That measurement is not the BMI.

I further went on to explain the BMI equation.

Needless to say, they seemed surprised they were incorrect.

Inner-Professional Organization Prejudice

2011-02-01T22:37:00.001-05:00

As a Registered Dietitian with more than 20 years of experience within the field of dietetics and nutrition I have seen a lot of events occur within our professional organization of The American Dietetic Association (ADA).

Some of these events have been positivies for the general membership, some many not have been so positive for the general membership.

People who know me, can readily affirm I am not a person who goes along to get along.

For years I have felt our professional organization has inner-professional organization prejudices. There is more than one prejudice within our professional organization, but for the brevity of this installment of my blog I am focusing one inner-professional organization prejudice. Our professional organization suffers from educational elitism.

Let me enlighten you a bit. In this case elitism is the belief that professional organization should be governed by a select group of gifted and highly educated members. There is a concept within our professional organization that only those in elected offices should have a master's degree ore better.

The American Dietetic Association has mandated the qualifications for a Registered Dietitian to be: Qualifications of a Registered Dietitian

A registered dietitian is a food and nutrition expert who has met academic and professional requirements including:
•Earned a bachelor’s degree with course work approved by ADA’s Commission on
Accreditation for Dietetics Education. Coursework typically includes food and nutrition
sciences, foodservice systems management, business, economics, computer science,
sociology, biochemistry, physiology, microbiology and chemistry.

•Completed an accredited, supervised practice program at a health-care facility, community agency or foodservice corporation.

•Passed a national examination administered by the Commission on Dietetic Registration.

•Completes continuing professional educational requirements to maintain registration.
source

If the Educational Task Force had it their way, all dietitians would have a master's degree. That has not come about yet. Yet is the operative word. Hell, even getting published within our professional organization's journal does not even get considered, UNLESS you have at least a master's degree.

I know I am a damn good dietitian. Would having a master's degree making me a better dietitian? We do not know that. What I do know is I know my profession. I also know that I would not receive any additional increase in my salary if I had a master's degree.

Where am I going with this?

The American Dietetic Association is beginning yearly elections. I was extremely pleased to see that a dietitian who has a bachelor's degree has worked very hard to break the "educational elitism" glass ceiling. We have a dietitian who running for the position of "Speaker of the House of Delegates" on the ADA national ballot. This is the first stepping stone to a dietitian breaking the "educational elitism" glass ceiling to hold the position of President of The ADA. Just because a person does NOT have a master's degree, does NOT mean they would NOT be an excellant elected official of an organization. The elitist of The American Dietetic Association need to realize this. Because about 59% of the membership of my professional organization has a master's degree or more, it is often felt as if those of us who have less than that, are the bottom feeders of our profession. Inner-Professional Organization Prejudice is NOT acceptable and should NOT be tolerated within ANY professional organization.

This is why I am endorsing Becky Dorner for Speaker of the House of Delegates on the ADA national ballot. ADA National Candidacy Announcement .

You can view the entire ballot, including candidate bios, qualifications and
campaign statements at Elections. Please take a few moments to vote between February 1 and March 3, 2011.

Ironic Diagnosis....(again) and interesting allergies

2010-08-18T19:33:00.000-04:00

Recently had a couple of new people admitted from the hospital with interesting diagnosis.

One had a diagnosis of "recent fall with floor fracture of femur." Really? The floor fractured its femur? Now that I would like to see.

Another had a diagnosis of "recent fracture motor vehicle as a result of being passenger in truck." Really? A motor vehicle had a fracture and it was a passenger in a truck?

Had an admission who claimed to be allergic to mayonnaise. When probing questions revealed the person was not allergic to eggs, mustard, vinegar, sugar, or lemon juice. Interesting, those are all the ingredients of mayonnaise.

Had an admission who claimed to be allergic to tomato sauce, but no problems eating canned, fresh, stewed tomatoes.

Had an admission who claimed to be allergic to white bread, but had no problems eating hamburger buns and hotdog buns.

Working with people and satisfying their food preferences is a challenge....

Diabetics

2010-05-16T17:47:00.000-04:00

After I graduated in 1988 I didn't like to deal with diabetic diets. That was simply because I found them tedious to plan versus spending time with the patient. That seems like a lifetime ago. I experienced a new found interest with diabetic diets and patient education when I helped launch a diabetic educations program at a local hospital in Palm Beach County. In launching this program I learned to much about the absorption of sugars (carbohydrates) from different foods, the timing involved with the absorption of the different foods and the effects on the blood sugar, the different personalities of younger diabetics versus older diabetics, and how to implement nutrition plans with insulin pumps.

In 1993 the American Diabetic Association launched the results of the Diabetic Control Trials. This changed the landscape of nutrition plans and nutrition education.

About six weeks ago a friend came to me casually asking about her mother-in-law, who was currently in the hospital as a newly diagnosed Type II Diabetic. I am hopeful the dietitians in the hospital were actively educating her. My friend told me her mother-in-law was checking her blood sugar about 9 to 10 times daily and all she would eat was cheerios because she said everything else caused her blood sugar to rise. I encouraged my friend to get in touch with the hospital dietitian and ask for education - let's hope she did.

These are the kind of patients that can evolve into a nightmare - it is just a perfect example of why nutrition education for medical nutritional therapy of diabetics is essential.

Is "Food For Fifty" a Good Cookbook?

2010-04-27T21:55:00.002-04:00

Today I got a surprising question from a Registered Dietitian who is on the corporate level and oversees many different food service facilities. This dietitian has several years experience - writing menus, writing recipes, work flow procedures in food service, etc. This dietitian asked me, on the telephone, asking for advice.

The dietitian asked me: "Is Food For Fifty" a good cookbook? Does it have food handling procedures and safe meat handling procedures? Does it have step by step cooking and recipe procedures?"

I cannot tell you how taken back by this question. A foodservice cookbook standard since 1937 and this dietitian was asking me if it is a good cookbook. As I was listening, trying to give her a decent answer without laughing out loud, I wondered what planet was this dietitian on and where has she been? She has the position she has, but is not versed on "Food For Fifty?"

I suppose I should not be surprised, but there are times....there certainly are times....

Not Documenting Carefully

2010-01-23T18:41:00.001-05:00

We all have seen them, errors in documentation in the medical record. Some times these errors are so funny, you just have to laugh. There recently has been a discussion on an email list I subscribe. This discussion just gave me the idea for this posting.

Here are some examples. If the contributor is known, I have acknowledged them with their initials.
-----------------------------------------------------------
J.S. contributed:

"The pt. has 2 teenage children but no other abnormalities."

Doctor's note: "She is numb from her toes down".

"The pt. has pain when lying on his left side for over a year."

"The pt. has left his white blood cells at another hospital."
-----------------------------------------------------------
S.S. contributed:

Nurses note: "resident is totally continent of bowel and bladder with frequent episodes of incontinence"
----------------------------------------------------------
B.C. contributed:

"Pt vomited x 4 prior to tx on hosp room floor"....hmmm no beds available?
---------------------------------------------------------
M.F. contributed:

In a transfer note from a hospital MD........"the patient was found in a weekend condition"
--------------------------------------------------------
L.C. contributed:

Found an interesting social note today: "no visible family members present". (hahaha - maybe ghosts?)
--------------------------------------------------------
C.C. contributed:

A recent readmission who is a bilateral amputee. The history and physicial from the hospitalist stated: "No notable edema of lower extremities."
--------------------------------------------------------
J.K. contributed:
"Resident has had a 20 lb. weight loss. Will request re-weight. Nursing reports resident had a large bowel movement this morning."
-------------------------------------------------------
Unknown contributors:
"Patient isnonverbal, noncommunicative and offers no complaints”

"Patient had irregular heart failure”

“The need to maintain dialogue with the family regarding the appropriatenss of limiting futile care to the patient is noted”

“His Hemacrit is stable but dropping”

Patient states “I don’t want to be incubated again”

"Patient is experiencing increased worriation”

“Patient was apprehended and guarded”

“Patient pulses are fixed and dilated”

In asking about code status - “do you want your wife to receive artificial insemination”

“Findings compatible with ileus. Bladder is still in colon”

Orders include: “Be sure to check eyes and nose” [should have said I's (Input) and O's (Output)]

Reason for leaving AMA - “pt wants to live”

“I had a kiwi on my chest” (keloid)

“dictated home O2, transcribed homo too”

“I have hemorrhoids & the Fitzgeralds”

“that bacterial virus is a doozy”

“noncompliant smoker”

“homodynamic compromise”

“denies any rectal breeding”

Indication for an EGD (written by a physician) - “stomach hurt, swallow face in the morning, her poop is black & diabetes”

“spucus”

“fireballs in the uterus”

Reason for office visit - “Follow Up chest rumbles”

Nursing notes in the ICU - “MD at bedside attempted to urinate”

Indication for flex sig - “blood when whipping himself”

“chicken pops”

“if she wants children, think about recommending birth control pills”

“holy systolic murmur”

“Patient expired and was discharged home”

“My back has been hurting ever since they gave me that cauterizer.” (Foley catheter)

discharge dx=nephrolithiasis; discharge instructions=”drink plenty of urine”

“She did not lose control of her rectum”

Plan - “gently dehydrate”

“essentially tremors”

“nursing home called for paient acting lethargic”

“Patient is 95% blind”

chief complaint - “bazaar behavior”

allergies - “yes” (really? what are they)

Patient said “They took a 50 cent piece out of my colon” (hemicolectomy)

“She has encephalitis of her right leg.” (Encephalitis is a liver diagnosis nothing to do with legs)

“The surgical team was contracted for a cecal mass.”

“This is a 981 YO female with a host of medical problems.”

“hyperglycemia toe” (hyperglycemia is high blood sugar - nothing to do with a toe)

order - “Discharge home when strong”

“Patient was given a banana bath”

“This is a 75 year old type 2 hypertensive” (there is no such thing about type 2 hypertension, they probably meant type 2 diabetes)

Order “Please feed patient only when awake.”

“Check orthostasis while on the floor”

“She is to wear STD stockings” (STD stands for Sexally Transmitted Disease)

“nonaudible wheezing noted”

When asked if she had a discharge, the patient said “No, but I have Blue Cross Blue Shield.”

“Yes, I just met the Infectious Waste doctor.”

Nurse to doctor: “I just want to let you know that this lady has had decreased urinary intake.” (Doctor aware)

“He is allergic to wives.”

“Renal insufficiency. IV Lasix was used to perfuse the kidney.” (Lasix is a diuretic)

order: “Incentive spriometry Q 1 hour until awake.” (scary way to wake a patient up?)

“Pleasant man lying comfortably in bed. Appears somewhat uncomfortable”

“Her stomach showed 3+ edema up to the knees.”

“Will hold glyburide for now because of reverse hypoglycemia.” (reverse hypoglycemia is hyperglycemia or high blood sugar)

“pneumonia left femur” (pneumonia of the leg bone?)

“2-4 packs of whiskey QD" (QD means every day)

Want to read more funnies? Go here: http://gigglemed.com/

You Just Gotta Laugh...

2009-11-10T20:28:00.004-05:00

I decided I would blog about this even though this incident involves a sales representative for a leading nutrition supplement company versus the public or colleague healthcare professional.

All of us can have a love/hate relationship with sales representative. That being said, my telephone rang today - the caller identification was not disguised and for some reason I impulsively answered the telephone.

On the other end of the telephone call was a polite caller, a man. From the sound of his voice, I could tell he was young. We conversed for a while. In our dialogue some facts were exchanged. I learned the caller's age and facts about my mailing address was verified. I was asked if I was interested in continuing education teleconferences. I asked the fee involved, promptly being informed it was free. He further told me one teleconference was starting in a few minutes.

He wanted to give me a website to register, I explained I didn't have a computer on my desk. He gave me a telephone number to call to register. I said my good-byes, hung up the telephone, and called the number to register. I called the number only to be told that I had to register on the internet. I explained that I didn't have a computer on my desk, so there had to be another way to register. The answer was there was not. I became a little insistant, but with no positive result. I hung up the telephone.

I called the sales representative back. I explained who I was and immediately said, "That sucked, that didn't work." I immediately heard nothing on the other end of the telephone. It occurred to me that this young man (younger than my son) had no idea who I was. He did not know about my brashness, my out spokenness. I could tell he was taken back, not knowing how to respond to me. I knew I caught him off guard. I immediately apologized saying "I apologize, I am very frank, sometimes too frank, and I have a tendency to cut to the chase."

I realized right then and there that this young man was a mere baby, only 23 years old. He was dealing with a curmudgeon who is a rogue and often can get her own self in trouble all by herself. This poor young thing has no idea who he has gotten himself into being the sales representative that has to deal with me. I don' know if I should have pity on his soul or suggest this young thing beg for mercy.

Talking over The Dietitian NOT the Fence...

2009-11-06T18:56:00.003-05:00

Today we had a resident care plan meeting for a young long term resident at our facility. The resident was not at the meeting, however the resident's mother was there. The resident and the resident's mother has had a long term professional relationship with the physicial therapist at the meeting.

The routine protocol is for each discipline to briefly discuss how the resident is doing. I was the first person to have the opportunity to discuss the resident's status. As I was discussing the resident the phyisical therapist decided to talk over me giving her input regarding the resident's nutritional status and weight. I spoke up and explained where the resident's weight was and where it is now.

It bothered me all day. I have some tendencies to speak over people, I have had all my life. I am working on this flaw intently. As I do, I am now realizing more when people do it to me. The incident kept festering. I have difficulties standing up for myself sometimes as well. The reasons for this are multi-factorial and I prefer not to go into details.

I do not talk about people behind their backs. If I have an issue with someone, either I let it go or take it right to the person I have the issues with of concern.

Today I decided to "man-up" and talk to this physicial therapist. I explained my point of view. I was professional and courteous. I explained of my endeavors to work on my flaw of talking over people and how this has made me more aware of when people do it to me.

She stated she only remained positive and reinforced what I had said. I explained that I appreciated her relationship with the mother and her responsibilities to the therapy of the resident, but I didn't appreciate her talking over me.

I decided to blog about this for two reasons:

It still amazes how we continually encounter these "nutrition experts" that are not Registered Dietitians. I know it shouldn't amaze me, but even with other professionals I just don't know when these people are going to get it.
This incident was a personal victory me. I stood up for myself. While it was extremely uncomfortable, I did it, I stood up for myself where normally I would have been quiet and not said anything.

School Food Service - the Expert vs the Wannabee and Quality Nutrition vs Profit

2009-08-28T20:33:00.003-04:00

For one year I had a position as Nutrition Services Director for a very small school district. The first thing I did was try to make the menus more wholesome with less processed foods. I also added a vegetarian entree daily as well as increasing fruits and vegetables.
In working with public school nutrition often you recent subsidies from the USDA. I found that was a welcome benefit on a tight budget. Other influences I encountered was the active input form the Parent Teachers Association and student advocacy group.

As a registered dietitian I attempted to add nutrition education into the classrooms. This was met with mild to moderate success. I encountered territorial teachers who felt I was stepping out of my element and coming out of the kitchen. I shared my credentials with these teachers and the principals with only mild success. I heard rumors and talk that I was less creditable because I was not a "certified teacher."

I also attempted to meet with the superintendent. This person was not the person who hired me for the position. I was hired by a committee consisting of two teachers, one principal, and the committee chair - the business office manager. The superintendent was a retired superintendent from another state education system. The superintendent was Ivy-leagued educated. Being a true Midwesterner, I have never really met a stranger. But this superintendent was a tough nut to crack. Nothing I did, none of the positive contributions to the school nutrition program was ever satisfactory in this person's eye.

Additionally, I was told that I was expected to make a profit (without increasing lunch prices) for the school system so computers could be purchased. Any registered dietitian who has had experience in food service management and working in the school nutrition program knows the potential for profits from the operation is not very likely.

About half way through the school year I heard rumors that one of the secretaries in the front office was an acquaintance of mine. Her husband had worked with my husband, until they retired. This acquaintance worked in another town's school nutrition program as a cook. It was brought to my attention that the secretary in the front office provided this acquaintance with the menus I wrote.
Critiques ensued with them trickling to me. Because I knew this acquaintance, I decided to call her asking her what issues she had with the menus I wrote and what credentials she had to analyze them. Simply she replied: "Carol, this nutrition is different. THIS is school nutrition. All you know is health care nutrition." I asked her what she meant by this. Now this is the icing on the cake. Her reply was "Well I am an LPN, although I have not worked in health care for many years, I have attended numerous training seminars and I have taken two classes at college level on nutrition. I think you need to step back into health care and handle health care nutrition, leaving school nutrition up to the experienced personnel."

I was speechless. I thought about what I wanted to say before I exploded. I replied something like this: "While I can appreciate your concerns, as a LPN who has not worked in health care for a number of years, perhaps you might like to learn a little about my experience and my education." Finally she replied, "I don't have a college degree in nutrition, but it is clear to me you do not know what you are doing in school nutrition."

Just WHO is the Nutrition Expert

2009-08-05T21:26:00.017-04:00

Background:

90 something year old male, diagnosis include:
Congestive Heart Failure
Hypertension
Disease of chronic anemia
Splenolmegaly with pancytopenia
Duodenal ulcers
Cirrhosis

Hyperlipidemia

Recurrent bilateral lower extremity edema

World War II veteran with the Veteran's Adminstration contractually financially responsible. As part of the Veteran's Adminstration services, the case manager and social worker are responsible to review and provide suggestion for resident care.

Resident was originially admitted 4/25/09 for rehabilitation and possible long term care.

Height 69 inches

Weight 195.8 lbs

BMI 29

Diet at admission was 2 gram Sodium, Low Cholesterol

Medications include:

Lasix, KCL, Flomax, Folate.

Edema progressed to lower extremities the point of Zaroxlyn being added to medications. As another method to help control edema the medical doctor ordered Unna Boots. Resident has had a long history, since 4/25/09 of refusing medications, including Zaroxlyn. He also began refusing Unna Boots. While resident was taking Zaroxlyn, weight decreased, through diuresis to

176.9 lb and BMI 26. He has consistently consumed 75% or more of his meal. No signs or symptoms of dehydration.

On 7/17/2009, after a week's time of resident refusing medications and Unna Boots weight ballooned up to 199.5 lbs with edema increasing to +3 and progression to acute congestive heart failure.

Resident was re-admitted 7/31/09 after stablization. Weight at the time of re-admission is 182.7 lbs and BMI 26.8. Little or no evidence of edema at the time of re-admission.

Yesterday I met with the RN Case Manager. I explained the resident's history of cycle weights related to edema.

Today, I had a telephone conversation with the RN Case Manager:

Me: Hello, this is Carol

RN Case Manager: I am XXX and I spoke with you yesterday. I am calling about Mr. XX. He has had about a 8 pound weight loss since he was since to the hospital to current readmission of 7/31/09. I am calling to find out what plans you have to intervention with this weight loss, to prevent further loss, and how to get his to regain some of this lost weight.

Me: As I explained yesterday, Mr. XX has a history of refusing medications and the Unna Boots that the physician order. When he does this his weight balloons up.

RN Case Manager: I understand the potential for weight fluctuations, but there it is unlikey it will account for all this weight change.

Me: As I explained yesterday, there was a point that Mr. XX's weight was down to 176 lb due to him being more compliant with medications and treatment. At initial admission in April, his weight was 195.8 lb with his BMI in the overweight, close to obesity range. His weight in April was sckewed due to the edema he was experiencing in his lower extemities. I do not feel this 8 pound weight loss is a reason for concern and with no need to implement goals for him to regain this loss. As weight gain would be undesirable.

RN Case Manager: Have you had a recent albumin or prealbumin laboratory result?

Me: On 7/30/09, while in the hospital, the albumin was 2.1 However, with albumin being synthesized in the liver and his diagnosis of cirrhosis, using albumin as an earmark of his nutritional status is not appropriate.

RN Case Manager: Oh an albumin of 2.1, that is close to within normal limits. So how do you propose to "resolve" this weight loss and what are you going to do as interventions to stablize his weight.

Me: On the contrary, albumin of 3.5 is the lower limit of normal. Using an albumin level, especially in this case is not a fair earmarker of nutritional status due to the diagnosis of cirrohsis. We are monitoring his weight weekly. We monitor for signs and symptoms of edema and acute congestive heart failure. We monitor meal intake after every meal. I honestly am not worried about "resolving" this loss, because it was a desirable loss through diuresis.

RN Case Manager: But you still have an 8 lb weight loss. In my eyes, this places the resident at increased nutritional risk. There should be interventions place, i.e. nutrition supplementation, to prevent and intervene regarding the weight loss.

Me: Well, recommending a nutrition supplement is not warranted at this time. I agree to his nutrition risk, but current interventions are appropriate, without adding a supplement. At this point it is be more concerned about the weight gain from resulting edema which could result in recurrent congestive heart failure.

RN Case Manager: Why not?

Me: The supplement is fluid. This would add to his overall fluid intake. The resident is consuming greater than 75% of his meals. His edema is labile at this point. Adding additional fluids could be contradictory to resident's history of edema and could even exacerbate his congestive heart failure.

RN Case Manager: So you aren't going to do anything about this loss? In my professional opinion I feel additional interventions are warranted because of this 8 lb weight loss. How are you going to resolve the loss and stablize his nutritional status? I don't know if I agree that a nutrition supplement is not necessary.

Me: That is not the case. We are providing a low sodium diet. We are monitoring weekly weights. We are monitoring, every shift, for any evidence of edema returning. We are monitoring the percent the resident eats at each meal. We are providing medications as ordered. We are providing treatments as ordered. We are elevating the resident's legs. We are monitoring intake and output as possible. I feel all of the interventions we have in place are appropiate at this time. Furthermore, as I have explained, in my professional opinion, I feel this 8 lb weight loss is a positive for this resident. He is breathing better, he doesn't have an edema, and he doesn't have any symptoms of congestive heart failure. He has a good appetite and does not have any sign or symptoms of dehydration. I feel it is important to look at his current situation from potential for edema. Right now he is probably close to his dry weight AND a BMI within satisfactory range. Goals for weight gain or re-gain would do more determint to the resident.

.....long pause at the other end of the telephone....

RN Case Manager: OK, thank you for talking with me.

Me: I do appreciate your concerns and their validity. But to feel that the interventions in place are the most appropriate ones at this time. I would like to invite you to contact me anytime should you have any further questions.

Just another case of a professional who is NOT the Registered Dietitian thinking they know MORE than the Nutrition Expert.

**Point of clarification** The weight loss is desirable from the edema and congestive heart failure potential, but the Case Manager RN, couldn't seem to get that through her head**

Everyone is a Nutrition Expert

2009-07-01T17:48:00.007-04:00

Working healthcare for all the years I have worked, I have learned not to be surprised by anything. Sure, sure, there are times I get aggravated. With the multi-discplinary approach to patient care there all these nutrition experts that come out of the woodwork. Here are 3 of these interesting suggestions these "so-called" nutrition experts.

1) A 80 year old patient diagnosed with multiple chronic diseases. The family was insistant that the patient receive Monavie Juice. The family was concern this was going to cure all of the ailments the patient had and increase their loved one's life span indefinitely. The Fountain of Youth.

2) An Occupational Therapist comes to the kitchen requesting that patient with chronic urinary tract infections be given Guava juice at every meal. Their explanation was that is was extremely high Vitamin C. This will make the patient's urine acidic causing them to urinate more and thus decreasing the incidents of urinary tract infections. The perfect filter for prevention of the urinary tract infection.

3) One morning several years ago when I was a Food Service Director, a new Physical Therapist came to the Dietary Department. This Physical Therapist was a vegan vegetarian and had been for many years. She was outraged the facility menu was not vegetarian. She wanted to share her expertist from being a vegetarian for so many years. She felt she could made a positive impact on making the facility menus healthier by converting all of them to vegetarian. She had no regard for the Registered Dietian on staff - ME. She felt she was more of a Nutrition Expert that the facility Registered Dietitian.

Needless to say, in addition to doing all of our required job responsiblities, dealing with all of the these so-called "Nutrition Experts" adds spice and sometimes more aggravation than many Registered Dietitians - the true Nutrition Expert - likes to experience.

Trying to Get More from Public Assistance

2009-06-22T22:03:00.003-04:00

As part of my Coordinated Education Program while earning a bachelor's degree in South Florida, I had to have at least one rotation of working in the public health department. Part of my experience was working in the geographical area associated with sugar cane fields and migrant workers.
Part of my experience was working directly in the Women, Infant's and Children program.
This was quite an experience - an eye opening experience to say the least. I had helped coordinate WIC vouchers for an African American woman who had a 3 month old baby. The supply for baby formula she received was more than ample amount to feed her baby until her next appointment which was approximately 3 weeks time.

After one week from her receipt of the baby formula vouchers she was back in the office stating she had no more formula. She had the baby with her. We were being as delicate as possible questioning her. I could not help notice how she was slinging her baby around, not to be disrespectful, but all I could think about was primal mammal handling of the baby. I offered to cradle the baby, which I did until the baby started crying. The mother was sitting in a chair. She took the baby, placed the child on her lap, stomach down, and began shaking her knee. The next thing we knew the baby was spitting up. It was clear that the baby was not spitting up formula. The clear of "spit-up" was green and orange.

We knew exactly what had happened. The mother sold the formula she had recieved vouchers for the earlier week and was feeding the 3 month old baby food from that found in the grocery store in jars. At this point my preceptor tactfully admitted the woman. She admitted what she had done. The mother stated she needed the money she was able to make from selling the formula in the community.

This experience is one of the many experiences I will never forget from my experience in the public health department.

Making The Best of a Less Than Desirable Situation

2009-04-18T18:47:00.011-04:00

When I graduated from the Coordinated Undergraduate Program I was enrolled in South Florida, I needed to take the Registered Dietitian test. At this time it was only offered every 6 months and it wasn’t computerized. I have always had test anxieties. Because of this I had to take the Registered Dietitian test more than once. Additionally, at this time, the status RDE (Registered Dietitian, Eligible) was acceptable to use.

I had a family I had to help support. I needed income until I take the Registered Dietitian test again. Considering the Coordinated Undergraduate Program was located within the driving distance of South Florida’s three most populated counties, sometimes getting a job wasn’t always easy. I was growing desperate. I saw a position opening for a Dietetic Technician, Registered. I decided what the heck; I needed to apply, I NEEDED TO WORK!

I applied. I got the job. I worked in this position as a Dietitian, even though technically, it was a Dietetic Technican position. I lobbied my supervisor to change my assigned duties until I was the Dietitian assigned to the ICU/CCU department. I took care of all the critically ill patients. For the non-dietitian readers, this means I was in charge of patients in a varying range of nutrition care to receiving nutrition via a tube or nutrition fed directly into a big vein in the clavicle area. This was very technical work and since I had just gotten out of college not too long ago, I loved this work. I tend to be very technical. I was learning so much. The caveat was, I still getting paid the same rate as a Dietetic Technician, Registered. I was NOT a Registered Dietitian. Prior to passing the Registered Dietitian test, I was a Dietetic Technician, Registered. So technically I was getting paid for what I was credentialed, but I was performing the duties of a Registered Dietitian.

Finally the day came; I passed the Registered Dietitian exam. I was a happy girl. I approached the powers that be, presented my qualifications and my credentials, and asked for a raise and change of my job title. That didn’t happen. I started looking for a new job as a Registered Dietitian.

During the period of working in the ICU/CCU department, I was around every time a CODE BLUE was called. Everyone, I mean EVERYONE – except me – responded to the CODE BLUE with a crash cart. What could a dietitian do in a CODE BLUE? Nuthin. I would always joke around with the medical director that I always felt left out during CODE BLUE’s. I would always say, just what could I do? Would it help if I showed up with graham crackers and milk saying to the patient, “Eat this, it will make you feel better?” He would always laugh like crazy when I would say this.

Finally the day came; I had given my notice of resignation. I was successful in getting hired as a Registered Dietitian in a different position. The ICU/CCU department hosted a going away party for me. I was opening the going-away gifts and I got to one from the medical director of the ICU/CCU department. I opened it and started laughing immediately. His gift was a blue square lunch box with Wonder Woman on the front. Words encircling Wonder Woman was “Carol, the Registered Dietitian, NUTRITION CRASH CART.” I looked inside to find a small box of Animal crackers and a full juice box of juice. Both had labels on them, “Open only in Emergencies.”

Making No Bones About It

2009-04-16T15:40:00.006-04:00

I am a Navy veteran and darn proud of it. The GI bill it how I entered my college degree. I am from the midwest - farm country. I have Irish and some English and some German ancestry. I have never, ever been thin. I think in boot camp I weighed the lowest I have ever weighed.

That being said, I have experienced prejudices based on my stature and my military experiences. Let me explain before there are any hot heads out there.

I started my career in the field of dietetics as a dietetic technology. I was in the very first group of Dietetic Technician, Registered. Being the first born, I have always been an over-achiever. Because of this and because I was older than many of my college students, I seemed to have an allegiance with many of my instructors and department head advisors. I was enrolled in a Dietetic Technology program. The department head advisor appointment me to the advisory committee. I was honored.

That feeling of appreciation and gratitude disappeared when fellow advisory committee members (who were also Registered Dietitian) came up to me in private saying something like: "Carol, you are very smart, but you will never been an effective dietitian because of your weight" or "Carol, you will never been successful in this field, because you do not look like a dietitian." I was floored and my ego was bruised. Being who I was and enjoying this profession, I didn't give up. I tried and tried to lose weight. I continue to try. I had fellow advisory committee members come up to me and actually successed fasting, following an 800 calorie diet, and even one suggested that I binge and purge. I could not believe it. I approached my department head advisor to share what had happened. She shrugged off, as if she agreed. Shortly after that I graduated and got a job as a Food Service Director of a long term care facility.

A few year later, after I graduated from the Coordinated Undergraduate Program, I got a job as a Registered Dietitian in a high income area. The Dietary Department was ran by this older woman who was a Registered Dietitian. She was not the Chief Clinical Dietitian who hired me. The Dietary Department head was surprised of my prioritizing, my goal setting. Every day she would comment to me of her surprise. I learned in the military to no question a lot. I continue that today - I just do. One day she looked at me saying, "Carol, you are very militaristic." I was surprised and I didn't know what she meant. I asked her as courteously as possible. She said that I am regimented and I say things that need to be done in an orderly manner. I queried her further. She said, "Well Carol, this community is not used to this. They need to be stroked. They need to be coddled. They need to be treated as if we are subserveant to them." I was floored. I had learned a long time ago thatI was no better than anyone else and no one was better than me. I had the most difficult time with this idealogy.

My 90 day review period finished and I had to have my evaluation completed. I was reading my evaluation. I was younger, I was naive. I didn't do anything about it, I regret it to this day. This Department head dietitian included in my evaluation that I did not look like a dietitian. My skills were excellant, I was very well versed in my profession. I was effective in my job to the point, except I didn't "look" like a dietitian. I didn't take any course about this, this was my fault. But I will never forget.

This is will be the last time I ever discuss these prejudices. But at least it is out there. I won't be addressing these issues again.

Stay tuned for more eye-rolling adventures....

Intentions Waylaid

2009-04-13T16:35:00.007-04:00

I wasn't going to write for a few days. I was mentally formulating what I wanted to write. I do this, I contemplate, I plan, I organize, and some how I remember what I want to say when I actually decide to write. But something happened today that caused the plans that I am making in my mind to be put on the back burner. I had no idea the ideas for this post would rear its head today.

I continue to learn how territorial I am about the topic of food, nutrition, and medical nutrition therapy. For those who are reading that are not dietetic professionals, the American Dietetic Association defines medical nutrition therapy as: Medical Nutrition Therapy is an essential component of comprehensive health care. Individuals with a variety of conditions and illnesses can improve their health and quality of life by receiving medical nutrition therapy.

Perhaps my territoriality stems from the years of our struggles as dietetic professionals to be recognized as the experts we are, Nutrition Experts. We are well educated and we have a well-rounded education. Our struggle for acknowledgement in the healthcare field is a suffrage of sorts. A suffrage of acknowledgement for our value by healthcare professionals, our communities, and more.

We are more than just menu writers. We are more than cooks. We are more than just servers of food.

We are scientists in the fields of dietetics, food science, culinary arts, chemistry, biochemistry, biology, physiology, and pathophysiology. We are educators of nutrition and culinary arts. We are mediators and negotiators between all levels of people and professionals. We are analysts of nutrition content, physical assessment of people, and processes. We are public speakers and media liaisons. We have made strides, but the level of acknowledgement for dietetic professionals is still in its infancy.

Today, as I struggled to get through a typical Monday, I was at work. I discovered Pat (gender neutral name change) received nutrition education information from Dusty (gender neutral name change) in another department. Externally I remained calm and read the information. Inside I could feel my territoriality fire being lit, quickly escalating from smoldering umbers to a controlled full blown fire. I questioned Pat why not come to me about nutrition education and the related medical nutrition therapy. The reply was something to the effect that Pat knew Dusty for a long time and this was just a discussion about the treatment of this condition. Dusty took this situation one step further to provide printed education to Pat for the family member. As I reviewed this education information it was clearly nutrition education information.

I have had interaction issues with Dusty in the past. Dusty is of the impression they are the nurse, doctor, expert in their specific field, and the dietitian. I purposely avoid many interactions with Dusty because our personalities can be compared to trying to mix oil and water. I have not spoken to Dusty. I do not know if I will. I have not decided yet. I voiced my concerns to Pat. I will see where that goes, if anywhere.

If is just very frustrating. I know that I am territorial, but keeping it under control and confronting those who cross the boundaries of my territory is a challenge for me. I am not a confrontational person. It just frustrating I have to nurture these traits that are not innate to me. I also have to learn which battles to choose, when not to get my feathers ruffled, and is it worth it to even say anything about these kinds of situations.

Memorable Experiences

2009-04-12T11:52:00.014-04:00

As a sophmore in college, I was a student in a Coordinated Under Graduate program of a dietetics and nutrition program. Many of my experiences were in large healthcare facilities in South Florida.

Jumping through all the required hoops to meet the academia requirements included numerous patient interactions and nutrition education. As a dietitian it comes to a point that nothing surprises you. But as a dietitian student, not being exposed to many experiences, there were those times you were caught off guard, left scratching your head.

I had a task of nutrition education for a cardiac patient. This patient was a woman in her late 40's. She had elevated cholesterol, low HDL's, high LDL's, and elevated trigylcerides. This was during the early 1980's, statin (cholesterol lowering) medications had not been introduced, and at this time, the American Heart Association and the American Medical Association were endorsing only three eggs a week.

During my interview with her I learned she was from the midwest, a farmer. Since I grew up in Missouri and deep in the farm community of the midwest, I had some ideas of her eating patterns - they were mine (in the past) also. I proceeded to take a diet history. I learned she was eating scrambled eggs - at least two of them - daily. I continue to talk with her. I explained the American Heart Association guidelines about changing her eating habits and egg consumption. She was having the most difficult time accepting what I was saying. She looked at me, in all sincerity saying, "But when I cook my scrambled eggs, I mix them water." I asked her why? She replied: "The water dilutes the cholesterol so I can have twice as many, right?"

It was all I could do to keep from laughing out loud.