Jab 10 times daily for better results.

Am back in PG! Was actually a bit weird to be back at first - I was only here for a couple weeks, and then I was gone for almost 2 months. Will have to get some pictures up of my lovely neighbourhood and the hospital here; bear with me, PG seems less novel than the northier north. In fact, to most people in BC, PG is positively southern.

So right now, I'm starting Clinical 2. Sounds impressive, yeah? I'm doing diabetes ed - something I did quite a bit of in my last two rotations by total fluke, so I figured this would be a snap.

Right?

WRONG!

Don't get me wrong, some parts of it are much easier. For example, on my very first day, I got there at 8:30, and was putting on a group class on eating for diabetes by 10:30. Sort of badass, don't you think? I was pleased with myself. I'd never even seen the PowerPoint before, but I admittedly tend to do better in group settings so I breezed through it. Naturally, there were things I could've done differently, but then I gave a class the following 2 mornings and am starting to feel I've got the hang of it. There was a group for brand new type 2 diagnoses, an impaired glucose tolerance group (pre-diabetes!), and a Senior's Survival group. I enjoyed the crap out of it. To be fair, it was partly luck; if you have a lousy group, you could be the awesomest awesome who ever awesomed, and your class will still bomb. My groups were awesome and talkative and at least half of them really wanted to KNOW. You must realize how rare that can be. So many people are just shunted off for diabetes ed by their doctor when really, they have no interest. So what if they should eat more fibre? Changing eating habits is one of the harder habits to change, and sometimes the results are so subtle (man, my kidney feels WAY better today) that it can seem pretty thankless.

That said, type 1 diabetes was still a bit of an enigma at the beginning of this week.
A) You have no insulin. No matter what I tell you to eat, you will still have no insulin. Dietary changes can only go so far.
B) The vast majority of the clientele are kidlets, and all the ones I've seen  are about 10-14. It's an...interesting age.
C) Teenage boys. Ugh.

I think I'm starting to get the hang of it, though. It seems like the hardest part is really for the parents. I mean, yes, the kid is getting poked with needles several times a day (I have one of the pens! See previous post!), but mum and/or dad is worrying CONSTANTLY. Kid, for the most part, at least in a lot of cases, is not overly concerned with their blood sugar level. I don't know if you can really grasp potential nephropathy at age 10.

Think about it. How many foods can you think of that DON'T have any sugar?

Even things that don't taste sweet converts into sugar in the body. ALL carbohydrates - that includes some veggies, mes amis! Bread, cereal, fruit, potatoes, rice, pasta, yogurt, milk, granola bars, chips - that doesn't even include the really sweet stuff. (Don't even get me started on some of the myths, 'organic potatoes don't have sugar.' PLEASE.) Counting carbs, poking your kid with insulin or getting them to do it 4 times per day PLUS the blood glucose checks before AND after supper. SO MUCH POKING.

This is a pretty good video for just a glimpse of how much of an ordeal it can be. It takes 6 minutes just to explain how they figure out breakfast for this little nipper.

Kids will be kids. We had a teenage boy who ate...well...like a teenage boy. Fibre? WHAT? WHERE? And vegetables: you've got to be kidding. Ridonculous amounts of protein and refined flour without a carrot in sight. Another problem especially with older kids is missing meals *guh*. This is one of the worse things you can do, since your body runs a lot better if it has regular energy and carbohydrate coming in.

***Feel an eating-breakfast-sermon coming on? DAMN STRAIGHT. DO IT. For reals, just have a smoothie or something, it doesn't have to be the whole shebang with eggs and pancakes and so on. I don't care if you have diabetes, I may just poke you until you get my drift. Also the first thing we recommend for weight loss, just saying!***

Anyway, back to the kidlets. Sometimes, you get one in who is rather depressed. Think of sending your kid to school every  day, coming in 2-3 times to check their blood sugar if they're little, or them having to check their blood sugar before and after meals. They probably don't have all the stuff the other kids have; not like I think kids SHOULD have chocolate bars and chips in their bags, but it's got to suck a bit being the odd one out. And having your parents fuss about your sugars and nag you constantly about them, and always having to analyze everything you eat until you're not sure a 2nd helping is even worth it? It's not like it's ever going to go away, either. If you're lucky, you'll get on a pump so less poking, but you still have all the other hassle. Sometimes the kid just says 'I don't want diabetes today.' They don't want to check or inject, and they just want to eat every doughnut and chocolate bar in sight. Burnout is the sort-of technical term for it, when the person is just so tired out of the counting carbs and calculating insulin and insulin pens or beeping pumps that they hit a wall. Even if you let them take a day off (not recommended, for the record), it'll still be there tomorrow.

Bit depressing, this, isn't it? One of my very good friends is coming to visit this weekend, so will try to get out and take some pictures so I can talk a little less :P.

Just flipping EAT!!!

How many of us generally have a problem with that? Just eating? Actually, more than one might think; a lot of geriatric patients have no appetite. A lot of cancer patients feel appallingly awful (plus the fact that a lot of cancer meds cause taste changes.) People in dialysis sometimes have to choke down their food because they feel too lousy to eat.

It's often frustrating. We know the patient needs to eat. How can they ever get better without enough energy and protein? How can the cancer patient keep up their strength when lean body mass (muscle!) is slipping away on them, yet all meat tastes like metal? We try all kinds of weird things to make it work. For cancer patients alone, I've seen and tried cold food only (less smell), white food only (it was the only thing that didn't trigger vomiting for this guy), endless amounts of hot cereal, ice cream and popsicles (comfort food from when she was a kid), and dry food (toast, rice krispie squares, that sort of thing.) What works for one person is completely way off for someone else. It can be so aggravating when every method you've ever tried JUST DOESN'T WORK.

The frustration with this is nothing, NOTHING compared to an eating disorder. Eating disorders are just...ridiculous. Not in a 'haha, that's so funny' way, but in a 'I don't freaking know what to do' way.

It seems like this should be straightforward. You need to eat. You KNOW you need to eat. Everyone's bending over backwards to help you eat. You get to eat whatever you want! WHAT'S THE FREAKING PROBLEM?

It is simply that, for whatever reason, you can't.

It's hard for us to understand. What do you mean, 'can't'? The swallow reflex is there. Your GI tract is still intact, which is more than can be said for a lot of those cancer patients. All systems go, yeah? But you can't. I'm not just talking about anorexia nervosa - the stereotypical disorder which is essentially when someone starves themselves to be thin. I have learned there are other reasons to intentionally or unintentionally starve yourself. Sometimes, the patient may not even be doing it on purpose. Which begs the question: what the #%&@ do you do with someone who is maybe subconsciously intentionally restricting?

I was venting to boyfriend one day about how frustrated I was that we couldn't 'prove it' either way. Why prove it? he wondered. It's not court. Good point. It's really not about proof either way - it doesn't really matter in the context of our job. But to not know, is this person or aren't they trying to restrict/control their intakes, is a huge mind warp. How can you work with them, help them to eat, if you don't know if they're working with you or against you? And where do you start, if you don't know if they just need a high calorie diet plan or a psychiatric assessment? Where do you even start?

I read an amazing book called Brave Girl Eating. It's the story of a young girl who has a brutal battle with anorexia nervosa as told from her mother's point of view. The way she describes it, 'every bite she took was like jumping off of a cliff.' (You can see a preview at Excerpts from Brave Girl Eating. A really good but intense read.) It made it feel more real to know the mother herself didn't/doesn't understand. And yet, she MAKES herself think along the same wavelengths as her daughter, so she can premeditate what she's going to need and when.

Most of us can't even come close to fathoming the twisting and turning of a brain that isn't working the way it should. I am especially bad at this sort of thing. For example, I have a really hard time understanding depression. Some of my good friends have had long-standing issues with this, but it's only because I KNOW better, not because I understand, that I don't say 'Go pet a kitten and eat some ice cream and get over it!' So not helpful, right? But I've never been depressed, I can't imagine waking up feeling like the world was crumpling around me and not knowing it would get better. Even when I graduated university and was finding myself unprepared for the real world, I got up earlier so I could spend more time looking for jobs rather than struggling to get out of bed. I've got a very bouncy and happy personality - ask boyfriend, your average storm blows over in a couple of hours. If something doesn't work out, I can always find an alternative. If I've had a bad day, a cookie makes everything sunshine and daisies. I've had many a comment about bottling whatever my chemical make-up is, because it's awesome. I can't seem understand why everyone isn't like that. Just get up! What's the big deal? Everyone knows, that is NOT how this works. The same goes with an eating disorder. For most people, there's a simple solution. Too skinny? Eat more. Eating too much? Stop! It doesn't work that way for anyone suffering from an eating disorder or disordered eating. It's like telling a depressed person 'Just cheer up.'

I don't have any amazing insights into this. I still don't really know what to do in this sort of situation, really. I used to think I might be interested in eating disorders one day, due to my fascination with psych and neurological disorders. Still might, but I'm thinking I'd better work on empathy and patience a bit before jumping into the whirlpool that is disordered eating.

Why bad hospital cafeterias are good.

I don't mean what the patients eat (they usually have a separate kitchen), I mean the cafeteria where the employees eat. Tim Horton's is becoming a staple at hospitals in BC - every other hospital seems to have one. The doughnuts are tasty but boring, the coffee is bad, and the smoothies never change, so it really doesn't do too much damage. The FSJ hospital has an independent coffee shop for  a cafeteria, right on the main floor so I walk by ALL THE TIME. Their sandwiches are good, the soups are good, the muffins are amazing and usually still warm in the morning, and they make a MEAN soy chai latte. I love spicy tea, my favourites at present are Hot Lips (it has pepper in it!) and Cinnamon Hearts (so cinnamonylicious) from David's Tea. The chai lattes here are fantastic, they're super spicy. I may or may not have had three this week. Thank goodness I only paid for one (seriously, this has been a good week for me, spoiled rotten), because they're Starbucks-priced. I can't actually afford $5/day for a drink. I almost never eat out if left to my own devices because I'm too cheap. I really need to start making these at home, sick expensive plus so much sugar from the chai syrup. I could probably make a london fog with chai tea, yeah? Is that the same thing? If so, why am I paying so much for it?

Eating out up here is different, for sure. There simply isn't really anywhere good to do so. The best place I've come across is Whole Wheat & Honey, a Vancouver-esque coffee shop off the main street. Sadly, it is also expensive (so now I really feel at home :P). Not ridiculously, but enough. I went out for dinner with a friend of a friend to another place in town, Roustabouts, which was actually pretty good. And because it was some special Thursday, the lights were dim, the beer was cheap, and the food was 15% off. WIN. Most of the food around here is very diner-ish though, and not particularly exciting. You can find the list for FSJ restaurants that have merited any sort of rating here: http://www.urbanspoon.com/n/85/49244/British-Columbia/Fort-St-John-restaurants. That't not all of them, but it's pretty close.

After dinner, I walked home in the snow. Apparently this is a bit strange; I've been told by several people now that I have a strange indifference to cold. Anyone who knows me quite well knows I'm always boiling hot, and have been known to shop for clothes based on how thin the fabric is. It was about -9 C, but I had a hat and mittens and winter coat, so I don't think it's THAT weird.

How can anyone not like it here? I don't understand! I'm starting to find that a large number of the residents here are from the south, and they're here for the same reason I am. Who wants to compete for casual jobs at home and pay ridiculous rent when you can come up here and jump into something full-time and with better money?

Well, there are a few things. Of course, the snow is hard for some people. It is harder to find things here. You like Indian spices? TOO BAD. People who are used to that sort of thing apparently often bring an extra bag on any travels and stock up on spices and condiments. I can't find Pantene conditioning mist (my LUXURIOUS CURLS!) There's only one movie theatre so far as I can tell, although it's playing 6 movies (I don't know if it's all at once.) I have no idea where you'd go to buy a pair of jeans. There is a Walmart, a PriceSmart, and a Safeway, as well as a Shopper's Drug Mart. There are probably more, but not much, I don't think. The closest big town is Grande Prairie, Alberta, which is about a 2 hour drive.

There's also the small town thing. Everyone knows everything about everyone else. It can be a little strange. There is also more racism than I'm used to - not in a 'DARN FURRENERS' way, but there simply aren't a lot of non-caucasian people here. A few times I've overheard something that to me seems so off-colour, but no one else seems to notice. It is improving, I'm told, as more people come up to work in the mines and oil fields, but it's a bit off-putting. Homophobia is another thing; not in a 'GET OUT YOUR PITCHFORKS' kind of way, but I certainly wouldn't want to be a gay person in this town. A - there isn't exactly a gay 'scene' here, and B - you couldn't keep it on the DL if that's what you wanted, your neighbour's aunt's friend's sister's acquaintance would know about it pretty quickly. In short, there are some hick-ish qualities to FSJ. Not everyone is like that, of course, and with so many people moving north the accepting population is increasing at the same time as the somehow-perceived-as-scary population is, and people are getting more used to it. Come on people, we're still Canadians. Politeness overcomes fear in most of us :-)

Here are some fun Canadian stereotype comics from Kate Beaton at www.harkavagrant.com just for fun!

Oh right, the reason I'm here...

...is to learn ALL THE THINGS and become super smart. Piece of cake, yeah?

So the happy background for all this brain-expanding is Fort St John Hospital. It's brand new. Like, BRAND new. As in, only a couple of months old. They're still finding very silly things that people forget about when they're building a new building, such as methods of access during off-hours. A pt's family actually couldn't get into the building when the pt was passing away, it was horrible, because all they could do is page the nurses' desk, and who's likely to be around to pick up the phone at bedtime? Also the hilariously slippery entrance to the long term care building: Smooth, guys. The old building, however, is in such disrepair that apparently the cheapest thing they can do is tear it down. And by cheapest I do NOT mean cheap.

The old hospital was this super cute old brick building, but the wiring was sketchy and it was about 60 years old.

Sorry it's fuzzy, tis a google picture.

And now, the NEW one!!

Acute side

Peace Villa (long term care)

Thought it was only fair to include a snow picture,
since that's kind of a regular state for it.

The street in front of ze hospital.

So the acute side only has something like 55 beds + maternity, but the LTC side, which is attached, has I think 10 'pods', or units. There's the tree side, with Birch, Pine, Spruce, etc, and the flower side including Marigold, Sunflower, Bluebell, Tulip, etc. There are at least two locked wards for wandering patients. It's pretty nice, too. Pretty sure I'd be okay with living there when I was old although it's not as nice as Rotary Manor in Dawson (seriously, so nice. It makes ageing look a lot better.) I've seen everything from stroke victims in their 40's to a few patients in their hundreds and counting. I find the ones who SEEM totally normal and functional, but then turn around and do something completely bizarre, the most interesting.

I do a lot of spying during meals to see if patients can swallow okay and the like. Today I sat down with 3 ladies during their lunch and had a good gab fest for half an hour while they ate (it was super cute, they were waiting for me to get lunch before I started, I had to assure them I already ate.) A lot of people don't much like having you stare at them while they're eating - I'm starting to learn it's a hugely personal thing. Sitting down and shooting the breeze isn't always an option either, if you're watching their throat closely to see if the reflex is still in place, or if they're completely out of it. Mind you, just because they look out of it doesn't mean they are; one lady who generally is a bit out to lunch saw us watching and gave us a definite shoo. I sort of get that, I think. I remember in high school for a while I was just bringing juice boxes for lunch because I didn't like eating in front of other people. Thank goodness I grew out of THAT, but it went on off and on for about a year. As I've said before, it can be so easy to forget the personalities of people that seem to be long gone. Just because we can't see it, don't mean it ain't there, homeslice.

I also do some diabetes ed, although it's not as demanding time-wise as it was in DC. There, you're LUCKY if you get a break. The demand here just doesn't seem quite so high. I've also gotten to do some community stuff, which is neat. By that, I mean visiting patients in the community, sometimes group homes and sometimes private residences. One place had 5 dogs and a cat - I was thrilled! Naturally, I paid very little attention to what was going on in that one, too distracted by the promise of fur (and also allergies. There were good reasons for me to switch to dietetics from my original career plan as a vet.) It's interesting to see people in their homes; they're a bit more relaxed, a bit more comfortable, and then you have a way better idea of what they're up against when it comes to everyday life. It can be daunting; hemiparesis and still trying to run around after kids; trying to commute with a tube feed bag hanging in your car; gradually losing your ability to swallow. Yeesh. I don't know how some of these people do it.

It is starting to pick up here, which I like. I also have a  coffee date with a friend of a friend (we met by accident today) this week, am seeing an old friend from 1st year dorms, and possibly more. I would SO WELCOME any sort of non work-related social interaction at this point. It's a bit isolating, not so much because I don't meet anyone but because I'm leaving so soon. Makes it very hard to cultivate some sort of relationship. Here's to having much less time to work out this week, amirite?

Alright, FSJ: You got me.

I've been waiting for this to happen. I have loved everywhere I have ever lived; there's always something to love. In Langley, it was berry farms and lots of animals. In Chilliwack, it was the river, the beginning of a new relationship, and being able to walk everywhere. I loved Vancouver for the lights, the beach, and getting distracted by my favourite dress boutique on the way to the grocery store. I loved New Westminster for the view and nutella and bananas on toast, I loved Burnaby for our ghetto apartment and the proximity to Hastings for its butchers and fantastic produce (and not least for fresh-baked biscuits and watching Glee!). I loved loved LOVED Coquitlam for living with my fantastic boyfriend in an adorable house with a yard, and being close to everything. I loved Dawson Creek for being friendly and compact and surrounded by hills of farms.

Yeah, I've kind of gotten around.

So I was waiting for Fort St John to click. I knew it would happen, but I've been moving so much lately perhaps that it took a little longer.

Finally, finally, it did. I had a good weekend - went to the community centre fish-bowl-of-a-gym (the only community centre I've encountered in the north with reasonable drop-in rates. GAH.), went for lunch to a little coffee shop, wandered around. I had a good day at work on Monday - busy with a care plan meeting for one of 'my' patients, lots of assessments, and lots of finishing up with interventions. I felt productive, which is pretty well my favourite way to feel. As per usual, when I got home I went for a run. There's a running trail here that I hadn't used before, and it's about 5 k - PERFECT. And that, my friends, is when it happened. This is my run (ran it again today with camera in tow.)

If you're not half in love after those pictures, then there's probably something terribly wrong with you. It is GORGEOUS. And I can walk to everything, and it has some cute little shops, and a nice community centre, the people are nice, and it's sunny and lovely even when it's cold. I understand the whole dry vs wet cold thing now; you can walk around when there's snow on the ground wearing a sleeveless shirt. 5-10 degrees up here is reasonably balmy. It's also sort of surrounded by farmland, although it's harder to see it, and it's a bit bigger than Dawson so it's a bit more convenient with a downtown that is more than a couple of blocks.

I could totally live here :-)

Okay, really seriously, next post will be more on hospital-y things. Seriously. I already have pictures and everything!

Baby's First...Tube Feed

That's a bit misleading, actually. I didn't tube feed a baby. That said, I did  do my first very own tubefeed and observed my first TPN. SO COOL.

For those not in the know, an enteral or tube feed is when liquid formula is fed straight to the stomach or intestine via a tube through the nose or through an opening in the abdomen. TPN is known as total parenteral nutrition, so the actual elements of nutrition: amino acids, dextrose, and fatty acids, are put via IV right into the bloodstream. It blows my mind a little bit that we can even do this. Anyway, the acute care RD emailed my preceptor to say she had a new TPN and a new tubefeed, AND they were both at risk for re-feeding syndrome. Basically what happens here is that the person is malnourished to the point where electrolytes can go pretty haywire if you give them too much too quickly. My preceptor was like 'Yeah....you probably won't get to see too many of these. Howsabout we lend you to her?'

I don't have much to write about the TPN because as it's still technically beyond my scope in clinical 1, I just watched. The patient had an ileus, so basically their colon wasn't working temporarily. Ergo, tube feed won't help much since you need a working gut. There was pretty well a whole page of calculations, if not two, because one of the problems with the north is they don't stock all the nice convenient products you can get in the south, so the dietitian was frantically trying to figure out SOMETHING that would work. You have to try to get the right ratio of everything, but in this case you couldn't have too MUCH of fat, liquid or carbs because of the refeeding. Oi.

But the tube feed - my FIRST tubefeed. This patient was having a very difficult time with weight gain, so they decided to give them a continuous tube feed and still allow some oral foods as possible. Basically, the dietitian gave me the patient's chart and the enteral feeding form, and said 'I'm going to go talk to the patient. Write her up a tubefeed prescription.' Oh. Em. Gee. So after sitting stunned for a couple minutes, I just...did it. Just like that! I had the formulas, I had the guidelines for refeeding, it was just a question of walking myself through. Protein, carbohydrate, fat and fluids: how much do they need vs how much can they have.

Here's what all those calculations look like. It's too bad I can't show the finished form, but that's rather confidence breach-y.

I should frame this.

If someone is that malnourished, you actually start out by feeding them only about half of their estimated requirements for calories. You also only get 2 g carbs/kg (not much, considering most of us easily eat 200 g of carbs in a day, I imagine), and 1 g of fat/kg (which in this case can actually seem like a lot, almost 50% of their calories coming from fat!), and only 1L of fluid (for most people you need around 1.5 L, but in this case you're worried about messing up electrolytes.) I also got to order the required labs - daily labs for glucose and electrolyes, and weekly iron studies, etc. Electrolytes has to be daily for the 1st 3 days because you MUST correct them if they're really off. Anyone know what having messed up electrolytes does? Basically, your nervous system is not appreciative if anything is off. Google it for gory details if you're feeling nerdy.

I felt very smart, especially after a nurse leaned over and said, 'Whoa. I had no idea there was that much calculation involved.'

So we did get some snow shortly after my last post, although it's pretty warm now. Here are some pictures :)

Walking to the main street (that traffic light is actually
the main street)

Ze neighbourhood

Houses right by the hospital

More sort of neighbourhood

On the main street, facing out of town

Walking along the main street to downtown

SO MANY LEETLE BIRDS. Chickadees?

Downtown! Although not the downtowniest part

These weren't the best icicles I saw, but it was parked.
Rather easier for picture taking.

Next post will be more about the FSJ hospital! It's very nice and new and shiny.

Don't go for a run in FSJ if it's winter and overcast.

It's a bad idea, trust me.

'Why?' You ask. 'You call yourself a Vancouverite and you're afraid of a little precipitation?'

Allow me to explain. It was about 5 degrees when I got home for work, so I figured perfect, time for a run! I have a lovely baggy sweatshirt which I borrowed/accidentally stole from my last host family in Dawson (I think she meant me to keep it, but I meant to check). I have my iPod. I have reasonably flat roads (this is big, for anyone who has EVER tried running in Coquitlam. Oh em gee.) RUNNING TIMES.

It started out well, super windy but I don't mind that at all. Was happily running around exploring the place for about 35 minutes, when I reached PriceSmart. I thought to myself, 'how convenient! I will pick up some post-running snacks, i.e. peaches and cookies.' So I went in and merrily grabbed a couple bags of stuff, was delighted to find it was cheaper than expected, and skipped out the door.

This is where the problem begins.

It is much, much colder than when I went in, or so it seems. I'm not running anymore, and I've cooled down a lot. There is also very, VERY strong wind. Okay, it's unfortunate that I'm only guessing my way home since I've only been in Fort St John for like 24 hours, but I think, I can do this. No biggie.

So, I'm about halfway when my face starts to sting. It's like little teeny pins are pricking me in the face. This is where that dratted precipitation comes in. FROZEN precipitation. Plus wind. Ergo, I have freezing rain essentially jabbing my face at rather high speeds, and it does NOT feel nice. This is around the time when I start realizing I'm a bit farther from the house than I thought. Okay, just keep moving. I ended up either tucking my chin RIGHT in (my throat felt like an ice cube, of course my sweatshirt is very loose around the neck and my hair is back, no protection at all. May regret that tomorrow!) or turning my face away from the wind because I keep quietly shrieking curse words in the general direction of everyone and everything every time I feel a new handful of pinpricks. May have to invest in actual gym time while here, it's supposed to snow tomorrow too. Eep!

So Fort St John is about twice the population of Dawson Creek, apparently, although it's not that much bigger in size. The hospital is nice and new, and an absolute labyrinth of hallways. There is no WAY I'l be able to sort out where the heck I'm going before I leave. Looks like here will be LTC 2.5 days per week, DEC 1 day, and community health (YAY!) 1 day per week. Bit different from Dawson, which was inpatients on Monday, outpatients on Tuesday, DEC Wed/Thurs, and long term care (LTC) on Friday. Bit more LTC, which I'm less excited about as it can be a bit slow, but will actually be able to address a few things we couldn't really do in DC. When you're that busy and your week is that varied, it's really difficult to do any kind of follow up. Today we started by reviewing 3 LTC patients, and I also did the assessment (first) half of a one-on-one diabetes ed session. My preceptor said she thought I did pretty well (kudos to my DC preceptor, if she's reading this! It's all you!) As always, the dodgy questions are weight related; she suggested I dance around it a bit more (whereas I'm quite direct, usually.)

My goal for FSJ is to get better at the 2nd part - actually coming up with recommendations. Usually I do come up with at least most of the things my preceptor does, but I'm still really hesitant to give a client suggestions in case I'm wrong, so I let the RD take over. Looks like I just need to get over that, I don't think I've really ever come up with anything my preceptor wouldn't agree with, and I'll only really start to see which things I'm missing when I start making recommendations and the RD can correct/adjust them. Dietitian SUIT UP.

No pictures today, maybe this weekend. I also found the gloves my last host family lent me in my purse - may have to send a care package at this rate. They would be a huge help in the picture-taking if it does snow, though...