Week 4: Rose Park

6/03  

This week at Rose Park hospital has been quite a transition back into modern health care. I had to stop myself in the pediatric ward from rubbing a baby's head and playing with him because I realized that I was no longer in a government hospital. Private practice is a lot like the county hospitals in the US; the pulse monitors on fingers, televisions in every room, computers with Internet, windows in tact, a more responsible nursing staff, electronically adjustable beds, the use of medical gloves, etc. I think the most significant difference between private and public hospitals were the rates of certain types of diseases and procedures. I saw maybe one or two patients with HIV at Rose Park, and almost no cases of severe acute malnutrition. Meanwhile, Botshabelo, Universitas, National, and Pelonomi had so many cases of HIV, TB, and SAM, it was no longer alarming for me to see patients looking like skeletons. I can't say that the quality of care in government hospitals was nearly as shocking as everyone described it, but it definitely did not meet American standards of medical care. It was assuring to see that most of the patients in the public sector experienced improvement in health status. Though I know that obesity is indeed associated with poverty, I have also witnessed obesity strongly correlate with all demographics and socioeconomic statuses, the only difference being the existence of malnutrition among the impoverished. Tristi, the head dietitian at Rose Park, sees a lot of bariatric surgery patients, specifically gastric bypass surgery patients. In case you are not familiar with the procedure, basically a large portion of the stomach is removed to hold about 80 ml and the duodenum is detached from the stomach where the jejunum is stapled. The result of the surgery is an unnaturally small stomach, malabsorption of nutrients, and an obsolete, dangling duodenum. Patients must have a BMI over 40 and no other comorbidities to qualify. Obviously no dietitian is in support of the surgery; it is incredibly unhealthy for the long-term yet is an irreversible long-term alteration. Yet, it is very important for Tristi to maintain a stable relationship with the surgeons, otherwise they will not refer patients to the dietitians before and after the procedure, despite the imperativeness for a successful operation. Many patients view the surgery as an easy solution, but if there are no permanent dietary changes post-op, weight loss may be minimized and re-hospitalization is inevitable, whether it be due to gastric tearing, sepsis, gastric obstructions, or major deficiencies. This is why Tristi and the surgeons collaborate by requiring the patient to lose at least 10% of their body weight before the surgery through dietetics counseling, usually over 6 -12 months. One would think that after losing 10% through only diet modification, the patient would decide against the surgery and rather pursue a health lifestyle, but many patients believe that the surgery is the only way they will be able to lose 100+ lbs. Tristi counsels all of the outpatients in the hospital, a model significantly more relationship-based than the public sector. When patients actually pay for a visit, they are far more likely to come and listen than if the same service were free. She is really spectacular at helping people develop healthy lifestyles in order to lose weight, rather than offering them a "diet" that will eventually be neglected after a few months. Fad diets work well in the short term, even the Banting diet that is so popular in South Africa right now, however, fad diets can have seriously harmful effects if made into a lifestyle. The only reason you don't hear the negative side effects is because participants ditch the diet after a couple of weeks. The best way to become healthy is to maintain a healthy lifestyle, it truly is as simple as that. One of Tristi's patients so observantly said, "My wife's friends are always dieting. I know that because they're always complaining and I never see them getting any skinnier."

My observations were certainly not limited to beriatric surgery patients; I saw countless diabetics and renal failure patients. Carika (another dietitian) said that she thinks the high rates of renal failure are due to a combination of high uncontrolled diabetes rates and frequent consumption of meat in Afrikaans culture, particularly red meat. Protein has its advantages, but an abundance of it can definitely have detrimental effects on the kidneys. I also saw quite a few cholecystostomy and hepatotomy patients. Those patients are started off with NPO post-op, then they transition to clear fluids, fortijuice, and finally a regular low-fat diet.  Sometimes you get a patient with only one medical condition, which allows for less complex nutritional formulation. The patients who suffer from multiple diseases require more careful consideration. The most complicated case I saw was in the multi ICU. This poor man suffered from hepatitis B, cardiac failure, renal failure, hypertension, and diabetes. I honestly would have no idea how to feed a patient like that. Low protein, low carbohydrate, low fat - what is there left to eat? Carika just put him on a NG tube of the 2kcal at 70 ml/hr over 18 hrs. We also saw a 96 year-old with renal failure, bronchitis, oedema, and hypotension. Carika put him on a renal soft diet supplemented with supportan. We saw a man who was experiencing organophosphate poisoning, likely from pesticides, and a young guy with a laparoscopic nissen fundoplication (a gastric hernia). I've noticed that dietitians in South Africa supplement with glutamine quite frequently to support wound healing, a practice that is a bit less common in the US. I didn't get to sit in on many of Tristi's counseling sessions, which was unfortunate as I have heard that she is a really motivational dietitian and all of her outpatients love her. From what I did gather, it seems that her secret is just encouraging patients to make minor dietary alterations until the new habits become a lifestyle. I very intentionally used the word 'encouraging.' I did learn a bit more about low-residue diets from one counseling session, and I learned loads more about renal diets from taking on case studies of patients that the dietitians assigned me to work out. I was already pretty familiar with the numerous foods that renal patients are not allowed to consume, high potassium, high sodium, high phosphorus foods, but I was always curious as to what renal patients actually can eat. One thing I need to inquire about during Advanced Nutrition II next semester is the biochemical pathway and function of glucophage (metformin) in preventing glycogen release from the liver and reducing insulin resistance. I looked it up on the web, but it seems like the biochemical pathways are only generally understood (it activates AMPK, but how?). A lot of pre-diabetic patients are prescribed glucophage to promote insulin reception. One theory I was totally astounded to discover today (Thursday) was that the application of ketogenic diets for some epileptic patients may reduce the prevalence of seizures. I did some research to make certain that what I was being taught was evidence-based, and I found that Tristi was right on. It actually was a bit frustrating to know that I had never been taught this information before now, and I was an epileptic from age 9 to 15. I didn't dwell on it though; I've been so abundantly blessed in healing, there is very little I can reasonably complain about.

-Jordan