Wednesday, 2 May 2012


Two brown ducks
Norfolk, July 2011
I am getting to know my wards now, and I can even remember some of the names of the staff nurses and Health Care Assistants (HCAs) and therapists and doctors. Some of them know who I am, and a very few even know my name. This is good, because it improves the working environment no end, but I do get extra work because patients are referred just because I'm there.

There has also been some work behind the scenes, possibly because I mentioned to the Dietetic Manager that one of my wards was particularly bad at weighing their patients. Admittedly, many patients are too ill, but it is very difficult to make an assessment of whether someone is eating or being fed enough if you cannot tell whether they are gaining or losing weight. As I came onto the ward the other day, I heard the staff nurse was enumerating all the patients in her area and whether their weights had been recorded or not. As a patient was referred to me in another area, the staff nurse hurriedly checked the paperwork and said. "...and there is a weight recorded here..."

Because of the difficulty in weighing very unwell patients, for the first time I have resorted to what is generally referred to as 'Anthropometry'. This essentially means making various other measurements in order to assess nutritional status. The method I chose was the 'Mid Upper Arm Circumference', which is fairly straightforward. Combined with the Tricep Skinfold Thickness measurement, and appropriate use of formulae that include pi, it is possible to work out the relative amounts of muscle and fat in the upper arm, but I didn't bother taking it to that level. There are centile reference ranges for the MUAC depending on the patient's sex and age, but in this case I knew the patient was underweight. I'm just hoping for an increase in the measurement, even though this will mostly mean additional fat reserves rather than development of muscle mass.

[Interesting note: a friend who is blind once commented about someone's weight gain or loss, and I asked him how he knew. He reminded me that when he is being guided, he holds the guide's upper arm, and I had to acknowledge that this would be a good marker for body weight, especially combined with the height of the upper arm being held!]

I am now partly responsible for the 'Consolidation' period for a B placement student, which is three weeks long. My own B placement went pretty well, and was not so long ago that I have forgotten how it felt. I feel sorry for this student, who is not having such a good time, but I am not sure how to help her without adding to her stress levels, which are pretty high most of the time. I have also been given another student's case study to review because the case in question was one of my patients. I have taken a brief look, and have not been impressed, so that may constitute a fair amount of work.

Things take longer with a student who cannot be left to get on with seeing patients and report back when she has finished. One of my colleagues has also given back two of the wards that I gave her, so my workload is a little bit greater too. The week before last I managed to squeeze in half a day in the office, tidying up and doing a little bit of research to find things like the evidence for the health benefits of losing 5% or 10% of your body weight (if you are overweight). There has been no more spare time since then.

We have done a little bit of CPD as a group, including the training session where I learned all about FODMAPs, and a fairly depressing discussion about the ethics of feeding, palliative care, end of life and the role that we might play within the multidisciplinary team. I have even gone on to use that information on the ward, questioning what the purpose of inserting a feeding tube is for a patient who is not eating well but has no physical barrier to eating.

Before long the new stroke Dietitian will start, and there will be a general reallocation of workload again, and I will probably lose my two biggest wards and move on to something new. It will be a shame to leave the people I've started to get to know on the wards, and a challenge to get to know new people, but I'm enjoying the work more now and am looking forward to such challenges.


  1. appropriate use of formulae that include pi. Is this your formula for putting weight on patients? What sort of pie?


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