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by Celina Caetano

The senses of a medical student are heightened from day 1 of a clerkship. You try to see everything your attending, your resident, and your patients are doing. You hear new things like the beep of a ventilator or the alarm of an IV pump. And, sometimes, you even smell interesting things.

During rounds of one of my third-year clerkships, my nose sniffed it for the first time. On the first floor, with the step-down-unit patients, you only smell the fibers from the N-95 and other masks you are wearing. On the third floor, in the general wards, the smells range from any imaginable body odor to the unique stench of the rubber from catheters and IV plastics. On the sixth floor, hematology/oncology, sterility generally consumes the air and nothing has a scent.

However, one day was different. When turning into a patient's room, something gave my olfactory receptors an interesting surprise—sweet honey-barbeque chicken on freshly made vanilla waffles! It was not what I was expecting but it was certainly a divine change. After I got over this scent indulgence, my first thought was, “When did the hospital cafeteria start serving that?” Soon I realized there was more to the story.

The patient in the room was a 34-year-old woman with a past medical history significant for sickle cell disease who initially presented to the hospital for a suspected pain crisis triggered by an upper respiratory infection. She had been admitted seven times to the hospital within the last year alone for pain crises. She came in knowing exactly what medications at what dose and at what rate she needed to get through her 10-out-of-10 pain. Today was hospital day 4 for her. The resident on the team began the conversation with the typical, “How are you feeling today?” She told us her pain decreased to an 8.5 and (very happily) told us that she felt well enough to eat, so she ordered some chicken and waffles via DoorDash.

I was very perplexed on how this could even be permitted. Maybe it was my naive, medical-student brain, but I was fixated on what the patient said. She had been in and out of the hospital enough times to know that the hospital food is not Michelin-star quality, and she was able to have food delivered to her bed without ever leaving the hospital. I asked my team their thoughts as we left the room. Overall, they agreed that this can be dangerous for some patients, but in certain situations (like this patient's case), it is benign. So…should it be regulated?

My inquires come from a place of concern and not of judgment. Many patients are provided food by the hospital tailored to their specific medical needs. Approximately half of all patients admitted to the hospital are put on a “nothing-by-mouth” (NPO) diet at some point (1) for their safety during their hospital stay and/or procedures. Others are limited in what they can order from the cafeteria given their comorbidities. Imagine if this patient had diabetes with renal failure: I am sure that all the sugar in the waffles and salt in the chicken would not align with the carbohydrate-consistent, renal diet. Indulging in such restricted foods can exacerbate a patient's present disease when their primary goal should be healing. During my next rotation, I saw a patient at a different hospital prolong his admission for heart failure exacerbation after having Uber Eats services deliver an anchovy pizza to his room. Another patient with chronic kidney disease at yet another hospital experienced a dangerous rise in her potassium level after Grubhub delivered some rice and beans from the local Mexican eatery. Ultimately, these examples highlight a significant threat to our patients' health in the hospital.

Now reverse the roles in the situation. You are the patient I saw. Would you have done the same? Imagine being admitted to the hospital for the seventh time in a year and experiencing 3 days of wrenching, consistent pain so deep that you are frozen in discomfort. When you feel better, would you not want something that brings you happiness? For this patient, it was enjoying one of her favorite meals.

How about those patients who remain NPO for days during their admission? I agree that having nothing by mouth is of utmost importance for many processes that occur in the hospital. However, there are some instances in which the patient's medical team prioritizes the fear of a complication over the patient's comfort. For example, one study found that patients with ulcerative colitis were given unjustified dietary restrictions for fear of bowel compromise (2). This chronic condition plagues patients' lives daily. So when they feel better in the hospital, but are not medically cleared for discharge, how harmful would it be if they had their favorite pasta dish delivered from their local Italian restaurant?

With 100% certainty, I believe that NPO should mean NPO. Nevertheless, it is worth asking whether patients like the one I had on service, or the restricted patient with ulcerative colitis, or even the new mother who just delivered a baby, deserve to choose their meals if they are willing to pay for DoorDash, Uber Eats, Grubhub, or any other delivery platform. As such self-serving businesses become more prominent, hospital administrators should be better prepared to ensure that patient health is maintained throughout hospital admissions. I find that many patients do not know why they are put on certain diets, and the solution may all come down to educating the patient about the impact of their dietary choices. Nonetheless, health care providers should be aware of this “secret” hospital food bypass and do the best they can to maximize all patients' health.

References

1. Sorita A, Thongprayoon C, Ahmed A, et al. Frequency and appropriateness of fasting orders in the hospital. Mayo Clin Proc. 2015;90:1225-32. [PMID: 26355400] doi:10.1016/j.mayocp.2015.07.013
2. Gallinger ZR, Rumman A, Pivovarov K, et al. Frequency and variables associated with fasting orders in inpatients with ulcerative colitis: the audit of diet orders-ulcerative colitis (ADORE-UC) study. Inflamm Bowel Dis. 2017;23:1790-5. [PMID: 28906293] doi:10.1097/MIB.0000000000001244

Celina Caetano
University of Connecticut School of Medicine
Graduating Class of 2023

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