Army dietitian part of COVID-19 fight

Captain Melissa Shaffer is a registered dietitian and certified nutrition support clinician at Blanchfield Army Community Hospital. Recently Shaffer had to create a specialized diet plan for a patient who was sedated and on a ventilator for a month battling COVID-19. Since ventilated patients cannot swallow Shaffer used enteral tube feeding to provide the patient a continuous feed of a no fiber, high protein formula, with supplements to meet his nutrition needs. Once the patient improved and came off the ventilator, he had lost the ability to swallow and eat and needed to relearn those skills. A swallow study determined the texture of foods he could tolerate and Shaffer used a combination of thickened liquids and mechanically softened foods to help wean him from tube feedings.

She doesn’t swab nasal cavities to test for COVID-19 or administer COVID-19 vaccines to military health care beneficiaries, but one Army dietitian in the fight shared her experience contributing to the COVID-19 response mission.

Captain Melissa Shaffer, a registered dietitian-nutritionist at Blanchfield Army Community Hospital, oversees the nutritional needs and special diets of patients admitted to the hospital.

Shaffer also is a certified nutrition support clinician, specifically trained to work with critically ill patients. She was part of the hospital treatment team for a critically ill COVID-19 patient. Air Force retiree Gino Garcia spent about two months in Blanchfield’s intensive care unit where a team of health care professionals worked together to help him recover from the deadly virus.

“The last thing I remember was that I had COVID and that I went through [the hospital] doors to be taken care of like any other patient,” said Garcia, who is now in recovery. “After that I don’t have any other memories.”

When Garcia first arrived, his doctors noticed he wasn’t able to oxygenate his blood so they decided he would benefit from being intubated and placed on a ventilator. A ventilator is a life-support machine that uses a tube inserted into the trachea through the mouth or nose that forces air into the lungs, artificially breathing for a patient who cannot adequately breathe on his or her own. Ventilated patients cannot swallow or talk and may be sedated.

Shaffer was responsible for the nutrition care needs of Garcia, which she coordinated with other medical specialists involved with his care.

“Nutrition plays an important role with the recovery of critically ill patients. Since Mr. Garcia was ventilated and sedated he couldn’t eat on his own,” she said. “You have to feed critically ill patients who are ventilated with enteral tube-feeding and you have to consider the formula, the rate and the type of feeding you are going to give them.”

Shaffer used predictive equations to calculate his energy needs and started Garcia out on a continuous feed of a no fiber, high protein formula to meet all of his nutritional needs. She gave him additional protein supplements so he wouldn’t lose a lot of lean body mass while he was hospitalized and also evaluated his medications.

“We screen all the patient’s medication for nutrient/drug interactions,” she said. “There are certain things you have to watch for if somebody is on tube feedings because certain drugs can deteriorate the tube.”

Each morning Shaffer would attend morning report with other members of Garcia’s treatment team that included doctors, respiratory therapists, intensivists, social workers, clinical pharmacists and physical and occupational therapists. The nurses responsible for his care would brief Garcia’s condition and any changes since the day before.

“I’m interested in things like how the feeding tube is working, is the patient tolerating the feeding, the patient’s bowel movements because you want to make sure everything is moving properly,” Shaffer said.

Garcia’s case was extremely critical but after nearly a month on the ventilator he began to improve and became aware of his surroundings.

He was very weak from the toll the virus took on his body but ready to begin the recovery process with the help of his Family and care team.

Shaffer was responsible for making sure Garcia had the nourishment to aid his recovery which presented some challenges.

“After such a long time in that position I forgot about eating,” he said. “I forgot the taste of food, color and aroma. So, I had to kind of rearrange my brain … and go through the learning process like a baby learning to eat.”

When a ventilator tube is removed some people may have issues with eating and swallowing. Shaffer said. Patients sometime have to relearn those skills and with ventilation they are not using their muscles so they may lose muscle strength.

Once he was able to breathe on his own, Garcia’s ventilator feeding tube was replaced with a thinner feeding tube through his nose. This tube would allow him to begin the process of learning to feed himself again. Shaffer continued tube feeds to meet his energy needs until Garcia was able to meet them through eating on his own.

The treatment team used a multidisciplinary approach for Garcia’s nutritional and self-feeding rehabilitation.

A speech pathologist performed a swallow evaluation to determine the texture of foods Garcia could tolerate and provided the information to Shaffer so her team in nutrition care could create foods he could consume. Shaffer did daily calorie counts to assess how much Garcia was eating by mouth. As that improved, she began taking him off tube feeds and protein supplements.

Garcia started with thickened liquids and after his first swallow study he was able to have pureed foods and mechanically softened foods like applesauce, as well as puddings and gelatin.

“A lot of times a patient will want a specific food, but you have to change the texture of it, so our patient food service team would blenderize or modify it to get it to the right texture,” Shaffer said.

Once Garcia progressed to scrambled eggs and ground meat with gravy, he no longer required tube feedings.

Meanwhile the hospital’s occupational therapy and physical therapy personnel also played a large part in helping him regain his self-feeding skills.

“Many times it was like turmoil because you would expect that I could [feed myself] very easy, but it wasn’t,” Garcia said. “I didn’t have the strength in my hands. I didn’t have the balance in my hands.”

Little by little he was able to grasp on to a spoon, hold a fork and become confident grabbing a cup.

“He was a very strong guy and he worked very hard because he didn’t want to be on tube feeds anymore,” Shaffer said. “He wanted to eat by mouth.”

After several weeks off the ventilator, Garcia was healthy enough to transition to a rehabilitation facility where he continues to regain strength and the daily living skills he had before contracting COVID-19.

“Our whole team was rooting for him and his recovery,” Shaffer said. “So, it feels great to know he’s improving and that we played a part in it. I am so incredibly proud of him.”

In the Army, the field of nutrition is vast and Army registered dieticians can do a number of different jobs, from clinical to food production and humanitarian missions. Army dietitians also work closely with Army physical therapists through the Army’s Holistic Health and Fitness Program to educate Soldiers on performance nutrition to meet the physical demands of field training and combat.

Army dietitians must have at least a bachelor’s degree in nutrition, dietetics or institution management from an accredited institution, complete a dietetic internship and be a registered dietitian through the Commission on Dietetic Registration.

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