CCU and Step Down CCU

Today, I shadowed a dietitian who has only worked at KMC for two months.  She mentioned to me that her pay is about 7,000 rupees per month.  This is so crazy to me, still! I make 7,000 rupees in a day or two, and I do not even have a degree, yet! Apparently, the head dietitian makes around 10,000-15,000 rupees each month.  One admirable thing that this dietitian told me is that she has only two months of experience in a multispecialty hospital because she used to work at a gym focusing on weight loss and gain.  She was actually paid more at that position, getting 12,000 rupees per month.  However, she was bored!  She said she was not learning anything, so she came to KMC despite the fact that her pay would be cut in half.  I would really have to be bored and hate my job to move to another job with half the pay.  It is wonderful that she moved in the pursuit of knowledge and contentment.  Anyways, considering the fact that KMC just hired a new dietitian last week and that they are implementing a hospital kitchen soon, it seems like they are drastically expanding the nutrition program, which is good news!  Unfortunately for me, the dietitian I shadowed today speaks very little English. It is unbelievably lucky that the country I was born in has citizens who speak a language taught all over the world, but it is learned to varying degrees!  This dietitian did things that were very different from the head dietitian, Gayathiri.  There were two problems with this for me: I was in the CCU, which I rarely visit, and this dietitian is very inexperienced.  Combined with her present, yet poor, English skills, I was left confused frequently.  Despite this, I will now report to you the common threads between each cardiac patient.  In general, these patients are served only liquid or soft diets, are prescribed much lower calorie and protein allowances than I would expect, have fluid restrictions, and take food orally with few tube feedings.  An extreme example of the limited food prescribed is one patient with cardiovascular disease who had a heart attack.  She was given 18 kilocalories and 0.6 grams of protein per kilogram of bodyweight.  The standard values for anyone are 23 kilocalories and 0.8 grams of protein.  I have no idea why these values are lower than I would ever expect.  One explanation given to me before is that most cardiac patients are overweight because the same diet that produces heart problems usually causes overweight or obesity.  Macronutrients will, therefore, be restricted to promote weight loss.  However, malnutrition is very common in hospitals here, and this is dangerous even for patients who are overweight.  I need to ask more about this. 

Something I saw today, which I have not seen before, was an Acitrom diet.  Acitrom is a blood thinner, and a special diet goes along with it.  Vitamin K and fat rich foods were to be avoided.  The patient was not served cauliflower, cabbage, any other green leafy vegetable, or coconut. 

After lunch, we visited the “Step Down CCU.”  This is where cardiac patients are moved to after their condition improves.  This ward acts as the intermediary between the CCU and general wards.  The most interesting patient I saw had a BMI of 41 kg/m² (the cutoff for obesity is 30 g/m²).  He had an aortic aneurism and left leg cellulitis.  He was to eat a normal soft diet today, but tomorrow he would begin a high protein diet because he required surgery on his left knee.  His leg was HUGE.  He had a high BMI in addition to the cellulitis.  His skin was peeling and he had ulcers all over.  The dietitian was unsure about what to do with the doctor’s orders.  They prescribed a high protein diet post-surgery, but the man had a urea value of 141 mg/dL and creatinine level of 3.80 mg/dL.  The normal ranges for these blood components are 7-20 mg/dL and 0.6-1.2 mg/dL, respectively.  These values are very high, and excess protein is often broken down, producing ammonia that is turned into urea.  With high urea levels, and with a high protein diet needed to support recovery after surgery, what is a dietitian to prescribe?  She stuck with the high protein diet, but I need to ask Gayathiri more about this tomorrow. 

The last thing to mention about today is that I finally learned to make tea, the South Indian way.  I watched Madhan, our chef, as he prepared tea.  The process goes as follows.  First, you bring milk to a boil over low heat.  This takes about three minutes.  You then add tea powder, one spoonful per cup, and allow it to simmer for a minute or two.  You then turn the heat up and down three times.  Each time, the milk will slowly boil up, nearly coming out of the pot.  Right before this happens, you turn the heat way down low and allow the milk to simmer down.  In a separate cup, you add two spoons of sugar for each cup of tea that you are making.  After the third time that you allow the milk to boil down, you pour it through a strainer into the cup with the sugar.  You proceed to pour this back and fourth between two cups to thoroughly mix the freshly brewed tea and sugar.  The result is a frothy, delicious cup of tea.  It really was more of an art than simply brewing tea.  I will have to practice many times before I can do it nearly as well as Madhan.  Tomorrow morning, he will show me how to make sambar!