Sunday, 29 April 2012

Outpatients, interpreters and FODMAPS

Building with clean white lines and blue sky beyond
Leamington Spa's 'Justice Centre' Jan 2011
I am starting to enjoy my outpatient clinics. One of the main reasons for this is that I am no longer scared of them, no longer worried that I won't know the answer, or won't know what to say. They are still difficult and tiring: three and a half hours on a Tuesday morning, with slots for up to three new and eight follow-up appointments. I would be very surprised if any Dietitian has actually managed to see eleven patients, though, because usually fewer are booked in, or at least one patient doesn't turn up. This is actually the only thing that makes a clinic manageable - I don't quite know how I could possibly cope if all the scheduled patients did turn up. Last week one of my colleagues had ten patients, and she had a student with her. She deserves a medal.

I have also had an unusual number of patients who require interpreters. Neither of the other junior Dietitians have needed any interpreters at all, but so far, in about ten clinics, I have needed interpreters for Punjabi (twice), Persian, Kurdish, French (North African), and English (Sign Language for a deaf patient).

Up to now the system has worked in that nobody has turned up without an interpreter, and I have been given extra time for a consultation that includes an interpreter - except last week when I had only fifteen minutes for what was effectively a first appointment, which should have been allocated thirty minutes, even without the need for interpretation. Luckily, the patient didn't turn up. Unluckily, the interpreter did.

Using an interpreter is slow and difficult, especially when there is something complicated or sensitive to discuss, such the foods that do or don't contain gluten (how do you say 'rye' or 'buckwheat'?) or the workings of the bowels. Talking about the consistency of poo with a stranger is difficult enough without having someone else you've never met and who has no health qualification involved in the conversation as well.

Irritable Bowel Syndrome, or IBS, is one of the most frequent conditions that I see in my outpatient clinic. It's not really a disease, it's what's left when all the other likely diseases have been eliminated. If you have chronic bloating, wind, diarrhoea or constipation and you don't have a malignancy or tumour, or coeliac disease, or inflammatory bowel diseases like Crohn's Disease or Ulcerative Colitis, then IBS is what's left.

Treatment: well, there isn't really any treatment other than trying to identify what's causing the symptoms and eliminating that. It could be stress rather than anything physiological, or an intolerance to a food or ingredient, or not enough fluid or fibre, or the wrong type of fibre. A recent innovation is the FODMAP diet, where foods are eliminated that contain Fermentable Oligo-, Di-, Mono-saccharides and Polyols. These are short and medium chain length carbohydrates (compared with the long chain polysaccharides that comprise starch and cellulose), and it is thought that trying to digest them may cause some of the symptoms of IBS for some people.

Digestion takes place mostly in the small intestine, where transit time is relatively brief and enzymes excreted by the pancreas, liver, gall bladder and the gut chop up the food into its constituent parts so they can be absorbed through the wall of the intestine into the bloodstream or lymphatic system. A lot of fluid is needed for this task, so when the undigested remainder of our meals passes into the large intestine, the main job is to recover all that fluid so we don't dehydrate (which is the main problem with diarrhoeal diseases like dysentery and cholera).

But quite a lot of potentially digestible material still remains, such as these FODMAPs. The huge number of bacteria that colonise the lower intestines can perform this function on our behalf, chopping up the FODMAPs, allowing us to absorb potentially useful molecules, but generating gas as they do so. Eliminating FODMAPs from the diet might bring relief to someone who suffers with wind, bloating or diarrhoea.

Unfortunately, it's no easy thing to eliminate FODMAPs, which are present in many different foods. It takes a lot of effort and creativity as well as time to remember lists of foods, read food labels and avoid many social situations that include eating, for six to eight weeks. If there is no relief, then either FODMAPs are not to blame, or else the task of achieving their exclusion is too hard. If excluding FODMAPs is of benefit, then there is a protracted period of re-introduction, to try and ensure that foods are not unnecessarily excluded from the diet.

If all this doesn't work, then there is the Exclusion diet, where you cut down to a very few foods and gradually reintroduce things one at a time. This is almost as hard as the low FODMAP option, and takes just as long. In the end, IBS is not like Crohn's or coeliac disease, because eating foods that cause symptoms does no underlying damage to the body, it's just a matter of deciding how much effort you're prepared to put in to identify troublesome foods compared with the pain or discomfort of the symptoms.

Sunday, 22 April 2012


River, barges, trees, blue sky
Barges on the river Cam, July 2011
Posting has been late; I haven't been inspired. I had a long week, not a particularly difficult week, but nothing inspired me to write. That's when I tend to press 'Publish' on my 'What I've been reading' posts, which are always waiting in the wings.

Last weekend was a busy one, down south with the family. It was supposed to be Lola II's birthday weekend with me and sister D, postponed from the end of February when her birthday actually takes place, but then sister D couldn't make it after all, and I didn't finish setting up dad's computer last time, and Lola II had one of her Great Ideas about me coming down for the weekend anyway. Mum got in touch to say that her new computer was completely messed up (even though it was fine when I'd left it two weeks earlier), and dad got in touch to say that his old computer had died, and Lola II got in touch to say that she was back from Japan.

There was lots to do on Saturday - mum's computer was straightforward to sort out, so that didn't take too long. Setting up dad's new computer didn't got well: the monitor had arrived, but not the converter for his keyboard, so we had to borrow mum's keyboard, and he couldn't remember his email password or his Skype password, and Andy tried to set up a new email password but it didn't work, so we couldn't access his email to retrieve the Skype password, and because the old computer wasn't driving the screen I couldn't transfer any of his old files across. So he's sharing mum's computer until I can spend a bit more time to sort his new one out. And for some reason I can't see his computer over the remote access link, so I'm having to work blind like in the old days.

The remote access has been a mixed blessing. It has created a (two-headed) monster, in that I can now be called upon at any time, day or night, to hook up and solve some parental computing problem. But most problems are relatively trivial and take only a few minutes to sort out, so it seems a shame to postpone a remote access session and hold back progress. I'm sure we will find a happy compromise.

Over at Lola II's house on Sunday I performed my usual role of prison guard to ensure that she tidied her office - Mr M was still in Japan last week, so I didn't have to combat the usual undercover jailbreak operation on the side. We had food, fun and all our usual activities, but the most exciting thing for me at the weekend was to find that Lola II is on the brink of entering the ideal 'weight for height' category. She has been losing weight consistently since August last year and has lost more than two stone (that's 28 of your US pounds, or nearly 13 kg). I think she's amazing, and the weight's still coming off.

She's been attending WeightWatchers, and religiously counting 'ProPoints', and tracking everything she eats, and staying within her allotted number of Points, and steadily losing weight, pound by pound, week after week (because what do Points mean? Pies-es!) I cannot tell you how impressed I am with the progress she has made - if she stands sideways I can hardly see her. She can hide behind telegraph poles and lolly sticks. Well, nearly.

My own weight loss efforts have been converted to weight maintenance, and I haven't put anything back on, so I'm still where I was last summer. This is absolutely fine by me, even if it would be quite nice to see another couple of pounds drop off. I doubt it will happen while I'm still buying chocolate.

This weekend is very different - Mr A is away on a biking trip, and I spent Friday night cleaning and tidying rather than playing badminton as I'd planned. I played on Saturday instead, at an informal tournament organised by another badminton club (not either of the two I regularly play for), with a partner I'd never met before, and somehow we came second, which was nice, and my friend who plays with them regularly and invited me along came first with her partner, so that was nice too. Today I have been buying vegetables and cooking them for tonight and the coming week.

With any luck, the post I've commissioned from Lola II about her holiday will mature soon (she was even talking about a series of two), giving me time to recover my writing inspiration.

Thursday, 19 April 2012

What I've been reading

Image of the book cover

To Let
by John Galsworthy

"Soames Forsyte has built a good life for himself with his second wife Annette. And he has a new focus and purpose; his beautiful, beloved daughter Fleur. But when Fleur, a vibrant and impetuous young woman, catches the eye of warm-hearted and idealistic Jon Forsyte at a chance meeting, it seems fate is determined to torture them all with the hurts of the past."
Unusually, I didn't write about this book straight after I read it; I don't know why, because it was just as good as the previous two. We have reached the end of the lives of all the second generation Forsytes, and have lost a few of the third generation too, but I imagine there is plenty more in store for these fourth generation children who are now entering the 1920s with their short dresses and wayward behaviour.

Image of the book cover
The Secret Scripture
by Sebastian Barry

narrated by Stephen Hogan
"Nearing her 100th birthday, Roseanne McNulty faces an uncertain future, as the Roscommon Regional Mental Hospital where's she spent most of her adult life prepares for closure. Over the weeks leading up to this upheaval, she talks with her psychiatrist, Dr. Greene, and their relationship intensifies and complicates."
Another random choice from Audible, but somewhat better than previous selections. Set in Ireland, the ancient patient in the 'mental hospital' is being assessed for release into the community in the present day, but the psychiatrist realises he has never investigated the circumstances of the patient's actual committal. I should have seen it coming, but the twist took me by surprise, although more detached readers would have put all the pieces together long before I did.

Image of the book cover
Small Gods
by Terry Pratchett

"Brutha is a novice with little chance to become a priest - thinking does not come easily to him, although believing does. But it is to Brutha that the great god Om manifests, in the lowly form of a tortoise."
I can see now why I never managed to read one of Pratchett's books in print rather than audio - it started so slowly that I thought I would never reach any coherent narrative. But it accelerated wildly to the point where I started skipping paragraphs just to find out what happened next, and enjoyed his little touches with language, like Djelibeybi, which is a place that slaves run away to for two weeks a year. I still prefer these books in audio, I think, but thanks to Hugh anyway for lending me three of them in print!

Image of the book cover
To Say Nothing of the Dog
by Connie Willis

"Ned Henry has been shuttling between the 21st century and the 1940s searching for a Victorian atrocity called the bishop’s bird stump. Verity Kindle, a fellow time traveller, inadvertently brings back something from the past, and now Ned must jump back to the Victorian era to help Verity put things right — not only to save the project but to prevent altering history itself."
This is one of my all-time favourite books ever, given to me by sister D when I moved to Coventry 12 years ago. To this day I don't know why she chose it, I have never remembered to ask, because it's by an American author who isn't well-known or much published over here, although Coventry Cathedral does feature tangentially within the story. The title comes from the subtitle of Jerome K Jerome's book "Three Men in a Boat," and it has a similar style; it is funny, witty and a cracking story. I can wholeheartedly recommend it. Lola II loves it too, and has even read the whole thing out loud to Mr M.

Saturday, 14 April 2012


Velvety stellated leaves
Leaves, Wisley, August 2011
My presentation on Re-feeding Syndrome (RFS) went very well, although if I were to do it again I would make a few changes. The audience was small, and all were doctors. Last week was when all the junior doctors changed to a different department on rotation, so there were five brand new doctors in attendance, with their consultant and clinical educator who is one of my favourites. To be honest, any doctor that knows who I am is one of my favourites, but this one has been particularly helpful and welcoming.

The consultant kicked off by giving the new doctors a bit of information about how their placement was going to work, and then I was introduced by the registrar as a Senior Dietitian. I had to explain that despite my appearance I am actually a very Junior Dietitian, only two months old in Dietitian Years.

I embarked on the presentation, which I had been given ready-made by one of the senior Dietitians in the department, saving me no end of time in putting something together. I'd tweaked it a little bit, but not much. It wasn't designed for such a medical audience, so I had to supplement it with some hard facts about treatment, and then we talked a bit about how to manage ward procedures to cope with any patients who actually were at high risk of RFS.

So what exactly is Re-feeding Syndrome? It's "a potentially lethal derangement of blood electrolytes (potassium, phosphate, magnesium and sometimes others) caused by a switch to carbohydrate metabolism from fat and protein metabolism."

What that means in ordinary language is that in normal circumstances we use mainly carbohydrate for energy, adding to or removing from fat reserves if carb intake doesn't match energy expenditure. We don't store a whole lot of carbohydrate - I believe that when marathon runners hit the 'wall' it's when their stored glycogen is used up. For normal people, it would take about two days. After that, our metabolism switches to using mostly fat for energy, which works pretty well as a substitute, as you might expect. When the fat is gone (and to some extent, before the fat is gone) we turn to protein for energy, turning muscles into fuel.

The problem in RFS happens when carbohydrate intake starts up again, and metabolism switches from burning fat/protein to carbs. If the interruption was only a few days, and the individual was not underweight or malnourished to start with, then there's no problem. If it's a particularly thin person who hasn't eaten for more than 5 days (and there are a few other more obscure risk factors) then the risk rises with the rate of feeding. What actually happens is that energy generation using glucose starts up inside cells, which sucks the materials it needs out of the blood to make ATP for energy. The concentration of these electrolytes and vitamins in the blood drops, leading to potentially fatal consequences.

There are not many acute life-threatening conditions that a Dietitian encounters, so there is a good deal of emphasis on RFS in the Dietetics degree. I assess every patient I am asked to see, and if RFS is a possibility I will indicate it in every way I can - in the medical notes, nursing notes, and to the medical and nursing staff on duty.

The main approach for prevention of the Syndrome is to take great care not to feed the patient too much too quickly, and provide them with vitamin supplements. Monitoring the success of the approach is generally by way of monitoring levels of potassium, phosphate and magnesium in the blood, and replacing these if they drop. It is highly unlikely that someone will succumb following ordinary eating and drinking, but much more likely if they have had a period of no oral intake followed by tube feeding, as in the case of a stroke that has disrupted the process of swallowing, for example.

The way we manage tube feeding is that I write down the rate of delivery of the feed and the number of hours it should be given. On each successive day my regimen shows a slightly increased rate of feeding, and in someone at high risk, it is important to check blood results before the rate is increased. The main issue we face is that while I produce the feeding regimen, the nurses actually control the delivery of feed, and the doctors order blood results and review them. At the point when the rate of feeding increases, I definitely won't be there, but the nurse setting up the feed should check that a doctor has reviewed the blood results and approves the increase in feed rate. I wonder if this has ever happened. Mostly, I imagine, we've been lucky and nobody has died.

At the meeting, after I'd done my lecture, I presented this problem and asked for suggestions. The best that we could come up with was the liberal use of a highlighter pen in notes and other records to ensure that the risk is not overlooked, and checkboxes to be ticked to try and ensure that blood results are reviewed appropriately. I have two potential re-feeders at the moment, so we'll see if it makes any difference.

Wednesday, 11 April 2012

Reducing the workload

Yellow flower on cactus
Wisley, August 2011
My workload reached the point last week where one of my colleagues (who only has an outpatient clinic every two weeks) offered to help out, and I accepted gratefully, handing over six patients who really needed reviewing. That relieved the immediate pressure, but we had another discussion and agreed that I would hand over my three outlying wards to the other two Band 5 Dietitians. Since then, I have felt so much better that I actually told someone that I'm enjoying my job now.

I have felt slightly guilty about this transfer of work - maybe I'm just not doing as well as the others, maybe I'm too slow? But then I think - there's a new Dietitian starting in May who's only going to be looking after one of my wards as a full time job. While she will be able to address aspects of care that I don't have time for (e.g. why aren't patients routinely weighed once as week as protocols dictate?) I have four other wards to look after. Or I did have, and my colleagues insist that they are able to manage with the extra workload, which actually only came to two or three patients each. My main wards each have between about ten and twenty patients on my caseload, on average.

Then there was the Nutrition Nurse, who asked me why I hadn't applied for the more senior job when it came up. Nutrition Nurses are part of a team that make the strategic decisions about nutrition - whether a feeding tube should be surgically inserted, for example, or whether IV feeding is appropriate - and also do some hands-on nursing relating to the tubes. They are in charge of making sure there is no infection at the tube site, and no other complications with the tube components, and will pass nasogastric tubes if the nurses can't manage it, and help to unblock tubes in appropriate ways, and are responsible for a specific type of tube called a nasal bridle. I also discovered recently that they also assist with the endoscopic and surgical  insertion of gastrostomy tubes (feeding tubes into the stomach).

The main problem with nasogastric tubes is that they are designed to be temporary - easy to insert, but also easy to remove. Patients routinely cough them out, or pull them out, because who wants a tube going up your nose and down your throat, especially if you can't understand where you are or why you are there? I expect that some patients have specific and ethical objections to being fed, but often we can't ascertain whether this is case, if communication has been seriously disrupted by a stroke. So decisions are made by the Nutrition Team according to their assessment of the patient's best interests. If a patient repeatedly pulls out an NG tube, one of the options is the nasal bridle.

This is an NG tube that is not just passed up the nose and down the throat and fixed in place with tape, but a 'bridle' is also inserted behind the nasal septum. This just means that the tube can't be pulled out easily, and pulling on the tube may become painful, preventing all but the most determined patients from removing it.

Getting back to my Nutrition Nurse, I told her that I wouldn't have been given the more senior job because I've only been working as a Dietitian for two months. She was gratifyingly amazed, which made me feel great: someone who doesn't know anything about me other than my interaction with the patients thinks I'm doing a good job. My Dietitian supervisors and managers don't actually see as much of my day to day work as the Nutrition Nurses. So that was a very good day at work.

When the new Dietitian starts in May I will hand over the largest chunk of my work, and responsibility for all the other wards will be re-allocated between us three junior Dietitians. So the workload will be even more manageable, and I may have a little bit more time for thinking and planning, which hardly happens at all at the moment. I'm looking forward to it, and actually enjoying my job in the meantime, now that the workload is more manageable.

Sunday, 8 April 2012

Home life

Garden in Norfolk, July 2011
Outside work all is well, although you may have notices that my reading time has been reduced almost to vanishing point. Before work started: seven books in a month. After work started: just three, and that's been while I'm working only four days a week. I've had time to go to the dentist and the hairdresser and the optician, where I've been investigating a return to contact lenses. Their records show that I stopped wearing contact lenses nine years ago, which surprised me. I've enjoyed the feeling of being rid of glasses during a test phase, and the badminton didn't suffer too badly, with only a few complete misses, so I'm going to give it a try for a while.

Mr A: in brief, he has been working hard on his Open University course, doing some interesting website work including with the publisher of an online magazine, and dealing with his mother's dementia deteriorating to the point that his father has actually asked for help. He has also been running the Lola Towers Catering Department very effectively indeed, except at weekends when I do the cooking.

Meanwhile, Lola II and Mr M have been off on an overseas holiday. There is an Irish saying I've heard, when someone is extremely hungry, that "the stomach thinks the throat's been cut." In a similar vein, I've started to think that my mobile phone is broken - it hasn't rung for more than a week. On the bright side, I've had a couple of Skype conversations with Lola II - this new hi-tech world is extraordinary. I've commissioned a blog post on their return, so we may hear more.

In other family news, I have delivered two new (refurbished) PCs to mum and dad, although I have only set one up, since the other cannot drive dad's ancient monitor which is currently being driven from a PC card that is too big for the case of the new machine. And his keyboard has a PS2 connector rather than USB. And it took me more than 12 hours to get mum up to speed on the new machine, and I need a rest before doing that again. The computer now takes a blink of an eye to boot up a browser, rather than about 5 minutes; it felt like most of the 12 hours was spent sitting watching the little hourglass revolve on the screen.

I have installed remote control software on both machines, although I still have a small problem because all the sound from the remote machine is re-routed to me, which means that as soon as the remote control is initiated, the remote machine can no longer hear me using Skype. Which is jolly annoying, and I can't find a setting to stop it happening, and the software Help website is down for maintenance. But it is generally wonderful to be able to sort out little problems at a distance.

Thursday, 5 April 2012


Geese on a river bank
I know, geese don't say 'bleep'
Now that I work on hospital wards, I am deemed important enough to be given a bleep. In theory, I can be contacted any time, any where, by anyone needing urgent dietetic input.

This is a slightly absurd statement, seeing as there is virtually no situation where dietetic input can be considered urgent. We generally don't work evenings, weekends or on public holidays, although I think one senior dietitian may be on call for Intensive Care. Even if no nutrition is given, a patient will most likely suffer no side effects for at least four days, unless they were at the point of death to start with, in which case they would probably appreciate medical or surgical input a great deal more than someone advising on their nutritional intake. In a crisis, I cannot imagine a call going out asking: "Is there a Dietitian on the plane?"

But never mind, I have a bleep. At the point when it was given to me, the spring clip fell off so it couldn't be attached easily to my person. For a while I carried it in the bag I take around with me, but sometimes that is on a table while I am across the room, and the bleep is not that loud, so I missed most calls. Then I found a kind of wrist band with a clip on the end, which I can attach to my belt loops, although the bleep then dangles around my hips in an annoying fashion. But I could hear the bleep when it went off, and found that most calls were for a different dietitian who used to have my bleep number.

The latest trick the bleep played on me was the failure of some of the LCD bars in one of the characters on the display. I started to find that the bleep displayed numbers that were unobtainable, or where the person answering thought it was most unlikely that the Assistant Manager of Human Resources would have bleeped a dietitian. Eventually I worked out that the failure was in the lower left side of the third digit of five, so generally I only had to try three or four different numbers to discover who it was that actually bleeped me. Even then, I sometimes couldn't trace the call.

I tried to the get the damn thing fixed at the start, when the clip was broken, but was told that the damage had to be a good deal more serious before they would consider spending any money on repairs. I had a much better case now that the clip was broken AND I couldn't tell what number had bleeped me. So at the end of the working day I trudged over to the Switchboard department, which also manages bleeps, in a building in the middle of one of the car parks. I showed them the problem with the unintelligible characters. And that the clip was broken.

"Has it been dropped?" they asked. If you have dropped a bleep, then your department may be charged for the repair. If you have damaged your bleep by negligence, your department may charge you personally for the repair or replacement. I said no, it hasn't been dropped. The clip was already broken when I got it.

This lame denial was accepted at face value, and another bleep was produced and 'programmed' so that it became my bleep, with my bleep number. It was a newish looking bleep, with an undamaged clip, so I skipped off joyously at the thought of not having a bleep dangling off me any more, and being able to answer a call the first time by dialling the actual number shown in the window rather than having to guess the number on the basis of the balance of probabilities.

Except that next morning I was in my outpatient clinic at the start of the day, and the bleep went off. "Hooray, it works!" I thought. I dialled the number shown, and reached the switchboard. "Did you bleep a Dietitian?" I asked, confidently. "No," they said. "We didn't."

Well, this was no better than before! Just an error typing the number, I thought. It could happen to anyone.

In between patients later in the morning, the bleep went off again. I dialled the number, and reached the Labour Ward. "Did you bleep a Dietitian?" I said, not so confidently, because the chances of a lady about to enter the throes of childbirth requesting the services of a Dietitian is about a trillion to one against, at a conservative estimate.

"No, I bleeped the On-Call Obstetrics Registrar." That seemed a whole lot more likely.

"Out of interest, what number did you bleep?" I asked.


Well, now this started to make sense, because my bleep number is 2141. Through the morning, I would guess that the On-Call Obstetrics Registrar was quite a popular person, because that bleep made more noise than it had done in the previous two months, including a very shrill interesting noise that I can only assume meant there was some sort of obstetric emergency going on. I was closeted with my clinic outpatients throughout, and could only apologise to them about 'my' bleep going off all the time.

After clinic was over I made my way over to the building in the car park, and it was raining this time so I got cold and slightly wet, where apologies were proffered and the correct number programmed into the unit. Of course, it hasn't gone off since. But then, nobody really wants an emergency Dietitian, do they?

Monday, 2 April 2012

Continuous Professional Development

Close up of purple flowers on our rosemary bush
Rosemary flowering in the garden, March 2012
The lecture last week was one of a weekly series held in a side room off one of 'my' wards, covering aspects of elderly medicine. Following a recent incident, one of my favourite doctors suggested that it would good if I gave one of the lectures about re-feeding syndrome, which is a potentially fatal condition that may arise when someone who has had little or no dietary intake for more than five days starts to eat (or is fed). At the time I was less twitchy about my workload, and conscious of the need for evidence of CPD (continuous professional development), so I agreed.

Every two years, all professionals regulated by the HPC (Health Professions Council) are required to re-register. To ensure that professional standards are maintained, 5% of the registrants, selected at random, are required to submit a portfolio of evidence to demonstrate that they are engaging in CPD and keeping up with the latest developments in their particular field. CPD might consist of attending a professional meeting or a training course, a written piece of reflection on a particular case or condition, or researching an aspect of practice, and as in this case, delivering a lecture about it. If a Dietitian is unable to produce a satisfactory portfolio then registration may be withheld, meaning that he or she is no longer allowed to practise as a Dietitian. Loss of job and livelihood ensues.

The week before my lecture I thought it would be useful to see the room and hear someone else talk, to judge the kind of thing that might be expected. In a tiny room with space for no more than about fifteen chairs squashed together we were offered supermarket sandwiches, crisps, fruit and chocolate by a rep (I would have written 'lunch' but thought you might imagine something more lavish). The first part of the lecture (which is all I could stay for) was about admissions to hospital and mortality of stroke patients in the local area compared with a different local area, an English region and England as a whole. It was mostly attended by doctors, from the most junior Foundation Year trainees up to the senior consultants. The senior consultants asked many detailed searching questions, and I am now thoroughly apprehensive. But it was nice to mix with the doctors off-ward, where it is possible to converse on a social level - two lanes out of three have been closed on a main route into the hospital; that part of our journeys, normally less than 5 minutes, took 45 minutes. We talked quite a bit about how late each of us had been that morning.

Clinical Supervision is an opportunity for us three newly-qualified and newly-appointed Dietitians to have some scheduled time with a more senior colleague, and can also be used as evidence of CPD. In my first supervision we talked about the generalities of the job and about specific patients, where there is some ambiguity about the treatment, the patient or our role.

For example, one of the main things we all seem to experience is how much we should contribute to the overall holistic care of the patient. For example, patients who have the capacity to make their own decisions are entitled to make decisions that we think are unwise, and we have to deal with the consequences. A patient for whom swallowing has been deemed 'unsafe' (i.e. food or fluid is at risk of entering the lungs rather than the oesophagus), may refuse to have a tube placed, in which case the lead consultant usually allows the staff to offer food and drink on the basis that this is better than allowing the patient to starve.

In this situation, the Speech and Language Therapists will not advise on the 'safest' texture of food or thickening of drink, on the basis that their professional opinion is that the patient should not be eating or drinking anything. The lead consultant generally rules that the patient should then be offered thickened fluids and a puree diet, because these will probably cause the fewest problems. The patient's nutritional requirements will almost certainly not be met without supplements, but should Dietitians similarly withdraw from the situation, or continue to recommend nutritional supplements that may cause harm if taken?

The consensus in the Clinical Supervision meeting was that we should recommend that supplements are offered, since it is in the patient's best interests to have a sufficient dietary intake, and if the patient has capacity and chooses an unsafe route of ingestion, then that is their right. Our discussion also concluded that we should challenge the consultant's ruling on puree diet and thickened fluids, because this form of intake is generally unpalatable and limiting, and if a patient chooses to eat unsafely rather than be tube-fed safely, they might as well be offered an unsafe appetising menu, rather than gloop which is also unsafe.

In future Clinical Supervision meetings we hope to invite experts to talk about various aspects of practice, such as how much we should know about diabetes on the wards, and what might influence our choice of feed regimen. I'm hoping we'll also plan some more evenings out, because last week's night out was great. I had two drinks (double my usual intake) and reached home well after normal bedtime.

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