Here I am in end-stage renal disease management, providing nutrition care to patients receiving hemodialysis and peritoneal dialysis. With kidney failure, there's a lot to know: get lab values for electrolytes and protein metabolism markers (e.g. urea, albumin), interpret the labwork and prioritize patients based on who is at the most nutritional and/or medical risk, and create individualized nutrition care plans and education for each patient based on their labwork and current intake, modality of treatment (hemodialysis vs. peritoneal dialysis), and other issues like fluid restrictions, medication/nutrient interactions, concurrent disease management like diabetes and heart disease, financial constraints, amputations, etc, etc, etc...
This rotation has certainly been the most challenging yet. Being my last rotation, expectations are high. Preceptors expect that you've developed certain abilities and skills and can pull together a patient education plan with ease. Normally, this would be fine and good, but nutrition in dialysis is a whole different monster than anything I've dealt with before. I've had to understand specific lab values before (like in diabetes, we would gain and interpret fasting blood glucose, A1C, and serum lipids), but I've never before had to understand the finer details about why someone's potassium would be high (which can be very dangerous and cause heart attack) -- is it really just that they're eating too many bananas, or are they also on antihypertensive medication that's jacking up their potassium? Are they on a diuretic? What kind of K bath do they have in their dialysate? Are they diabetic - if so, are they hyperglycemic? Has their labwork been showing a trend up or down, is this high potassium unusual for them? If it really is dietary, do they need to be on a dietary potassium restriction? How many mg or mmol of potassium do they need to bring the potassium back down? Are they constipated - if so, what high fibre foods can they eat that are also low in potassium? Are they also on Warfarin? Watch that Vitamin K, and by the way, many foods with Vit K also have potassium. *sweating* Go ahead. Make a nutrition care plan and educate your patient in a way that they'll actually understand what's happening.
Within the first few days of the rotation, I knew I was in way over my head.
My preceptor was very tough on me. She would ask super challenging questions that I'd never encountered before and want me to think through the process to come up with a plan. Unfortunately for me, I struggled a lot with figuring things out, and my preceptor did not help my struggle or provide assistance when I was clearly not getting there, rather, left me with homework every night to research and deal with it. I became very frustrated and upset, because I could not for the life of me come up with appropriate answers to her questions. I felt dumb on a regular basis, because I felt completely incapable of answering things that it seemed to her to be easy enough questions for an intern in her 3rd day of a rotation. And then I remembered how I'm here for not just a 4-week rotation, but also expected to take over her job for 3 weeks as an independent practitioner.
And so, I had a complete meltdown.
It was epic, and awful, and ridiculous and humiliating. I managed to hold it till day 4 - I even succeeded in holding it while our practice leader and two senior level RDs were hanging out in our office chatting (kept my head down, didn't say a damn word for fear I would explode). Almost the minute they left, I burst into projectile tears. Preceptor admitted that she had been a bit harder on me over the previous couple of days in order to make it clear to me that I had a ways to go - I wasn't at the level she expected for my last rotation, I wasn't grasping the concepts and specifics of renal disease management, and I knew it. Our discussion only served to confirm everything I already knew, which really only upset me more. I cried in the office for an hour. I cried the whole subway ride home. I cried at home for another hour. I don't think I've felt that terrible about my performance, skills, or education in nutrition since, well, ever.
I took that weekend, which was the long weekend for Canada Day, and studied harder than I ever have before. I reviewed notes from university, read articles recommended for the internship (which I had kind of skimmed before, but decidded to buckle down into it), researched medications, nutrient/medication interactions, labwork interpretations. I practiced assessments, calculations, diet recalls with super specific detail needed for dialysis, and practiced education delivery for all kinds of different issues I might come across.
By the end of week 2 (now), I'm feeling more comfortable, but I'm not quite to the level of independence that I was in my last couple of rotations. Also, my preceptor has adjusted her teaching style drastically, and I no longer feel stupid all day long :) I'm feeling better about asking questions, knowing that there are some questions I'll just have to look up myself and take the initiative to figure it out or ask someone else before asking my preceptor. It's getting better, but I have to admit, I'm not feeling the awesomeness of "FINAL ROTATION!!!" like I thought I would at this point. Hopefully in the next couple of weeks, the comfort level will continue to increase and I'll feel a bit more competent.
Meanwhile, back to my neverending homework and studying.
Meanwhile, back to my neverending homework and studying.
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