Discharge

Pump Room Gardens, May 2012

Today is Friday, the last of my pointless days off, without which I would have felt cheated, but after which there is always twice as much work to do. So yesterday was my last full day in the week, trying at least to see every patient who hadn't been seen the previous week. Yes, I'm struggling to review longstanding patients once a fortnight now.

While I was thus engaged, every colleague in the hospital was conspiring against me. A patient is going home with a tube feed, and both colleagues in the Dietetics office who help out in this situation were on holiday. Another patient may be going home on a puree diet, and will need information and advice on how to achieve this at home. A doctor has specifically requested a Dietitian to see a patient with interesting blood results as soon as possible. A previously tube-fed patient is now able to eat, so the tube feed has to be adjusted or discontinued. A Ward Manager wanted to talk to me in her office about a specific patient, and I had a lecture to attend at lunchtime and my first clinical supervision after lunch.

Patients leaving my wards are almost as much work as patients who stay there. I am still trying to grasp all the different options and processes that need to be followed. If they are eating and drinking well when they go home I can put their Dietetic Record Card in a plastic basket in the office and relax (this is rare). There is a different basket for 'RIP' cards. If a patient is transferred to a different hospital, we have to contact the dietitians there and let them know what the situation is, especially if the patient is being tube-fed, and sometimes send the Record Card over as well (depending on whether the hospital is in our region or not).

If a patient goes home but is not likely to eat and drink enough, there are a number of options. I can write to the GP asking for supplements to be prescribed for a period of time and leave it up to the GP to review the situation, or send the patient an outpatient appointment with a Dietitian (there is a different basket for the Record Card if this is the case). If the patient is going to a nursing home, I can be fairly confident that their nutritional status will be monitored, but I can pass the Record Card to our Community Dietitian if there are any worries. She also looks after every patient who is sent home with a feeding tube, whether it is being used or not. Even if not used, the tube needs to be looked after, and eventually removed.

If a tube is being used for feeding into the stomach, there are many administrative and practical steps that must be taken before discharge. The patient needs to be sent home with enough supplies to ensure they are fed until further supplies are delivered. This means bags of feed (between 7 and 14 kg altogether), a pump, a stand, tubes to connect the feeding tube and the feed, syringes for flushing the tube with water, and sometimes a water container have to be physically taken to the ward in time for the discharge. There is a form that gives the patient and/or their carers instructions on how much feed to give at what rate over a specific period of time and how much additional water is needed. They need to sign a form to consent to their address details being given to the company that will be delivering the feed. The Dietitian has to register the patient with this company and provide all the same details and more, and then print a letter to the GP asking for the feed prescription to be arranged. Then all this is handed over with the Record Card to the Community Dietitian. Sometimes the ward forgets to mention that someone is due to be discharged on a feed imminently, so everything else has to stop until it is all sorted out.

More difficult is if the patient needs a modified texture diet, especially if they are elderly. Constructing a nutritionally adequate diet when everything has to be blended to a smooth lump-free puree is not straightforward, especially if the patient doesn't have a blender or liquidiser. If fluids also need to be thickened, then the choice of supplements is limited too. Chances are that the patient will lose weight, become dehydrated, and/or eat or drink something that goes down the wrong way and they end up with a chest infection or worse. There is a commercial company that will deliver pureed ready meals, a bit like Meals on Wheels, which can help a great deal, as long as the patient can afford it. It is likely that the patient will be on supplements long-term, and even need to be seen occasionally in outpatients.

There are different baskets for Record Cards of clinic outpatients who are going to come back for a further appointment, outpatients who have been discharged, and outpatients who didn't attend their appointments. There is another basket of Record Cards for upcoming outpatient clinics. There are probably more baskets that I'm not even aware of yet, perhaps for newly referred patients, and for IV feeders at home (Home Parenteral Nutrition).The Dietetic admin staff who manage all these baskets (and much more) are universally helpful, patient and good-natured, and don't seem to mind me asking the same questions multiple times. In fact, all the Dietetic staff seem friendly and supportive (have I mentioned that before? Probably). Tonight we have arranged a departmental outing in a local Indian restaurant, and despite my nervousness about large social groups, I think it will be fun.

Annual Leave

Surprise daffodils that I planted and forgot about until they appeared this spring

The end of the year draws closer, according to the calendar of Annual Leave. The amount of holiday entitlement within the NHS is generous, even for new employees, at five weeks plus public holidays. The difficulty comes when you try to actually take time off - in the acute dietetic posts, Ward Cover Must Be Maintained. Even though we don't work evenings and weekends.

So there is a process of applying for leave that takes into account everyone else who might be taking time off. Most of the time there's no problem, and the first person to apply for any particular period is given permission. At Christmas and New Year things are different, and everyone's preferences must be taken into account. Unfortunately, when I was asked if I had any holiday booked when I started the job, I didn't look as far ahead as the New Year, so now I'm in the position of having to ask very nicely for time off, and hoping that my colleagues won't get shirty that I've asked for a full week straight after Christmas.

There is an absolute edict that No Leave Can Be Carried Over to the following year, which starts on 1 April. Everything must be used up, but there must still be Ward Cover. When I joined, the peculiarities of the way that leave is calculated meant that I needed to use up just over five days before the end of March. In previous jobs, I have found that taking single days off suits me very well, rather than a whole week at a time, so that's what I booked. It also fitted in better with everyone else, because wasn't a whole week available that didn't compromise the essential Ward Cover.

The trouble is that when you take a week off, then some of your patients will be picked up by other Dietitians if necessary. If you take a day off, they don't. So since I've joined, I've been working four-day weeks, but still having five days of work to do, plus cover for other Dietitians who've most sensibly taken full weeks of holiday. This goes some way towards explaining the amount of pressure I've felt I've been under.

To make me feel better, Mr A and I have been working out what our holidays might consist of this year, and we're hoping for a week camping in May/June as well as the family holiday in October and the New Year holiday (as long as I'm allowed to take that week off), with two more weeks in hand. I won't be taking any more odd days, though.

What I've been reading

North and South
by Elizabeth Gaskell

"Set in the mid-19th century, North and South follows the story of the heroine's movement from the tranquil but moribund ways of southern England to the vital but turbulent north. An unusual love story shows how personal and public lives were woven together in a newly industrial society."

I enjoyed the descriptions of rural and industrial life at the start of the industrial revolution. Through the characters in the story, the author lays out the struggle between the owners and the factory hands alongside a modest love story, which is only really resolved on the last page. Much grittier and more political than Austen, but not as great as Galsworthy, which I'm going back to soon.

In Chancery
by John Galsworthy

"Separated from his wife Irene for some years now, Soames Forsyte has resigned himself to the fact she's never coming back. But as he grows older and richer, he yearns for an heir. When he confronts Irene, the raw wounds of his past passion are exposed."

Just as good as the first book in this first trilogy, easy to read, and fascinating. The predicaments of Soames and his sister (with a profligate wastrel for a husband) are as shocking as they are unfamiliar these days: each wishes for a divorce, but divorce is the ultimate public shame. So shameful that Soames tries as hard as he can to take back his wife, his 'property', for the sake of public appearances and the chance of an heir, despite the fact that she has stated openly that she detests him.

Major Pettigrew's Last Stand
by Helen Simonson

narrated by Bill Wallis

"Since his wife Nancy's death, he has tried to avoid the constant bother of nosy village women, his grasping, ambitious son, and the ever spreading suburbanisation of the English countryside, preferring to lead a quiet life upholding the values that people have lived by for generations - respectability, duty, and a properly brewed cup of tea."

This was unexpectedly good, considering that my choices at Audible are now quite random and mainly based on the synopsis and previous readers' reviews. This is the story of the Major, Mrs Ali who runs the village shop, the Major's son who's a bit of a snob, and Mrs Ali's nephew who's grappling with his Muslim faith. And quite a number of other well-rounded characters from their respective families and the village where they live. The narration was so wonderful that I shall now look out for other books narrated by Bill Wallis.

Outpatient clinic

Lakeside, May 2011

Outpatient clinics are stressful, from my point of view, anyway. I don't know whether the patients find them quite so difficult, since all they experience is the frustration of almost always being seen later than their appointment time. Although parking at the hospital is enough to make anyone feel cross when they finally reach their clinic waiting room.

My clinic runs from 9.00 a.m. to 12.30 p.m., at least in theory. New patients get half an hour, follow ups only fifteen minutes. Four minutes late and you might have lost a quarter of your appointment time, except I'll probably have to run late because there's no way I can complete any sort of sensible consultation in eleven minutes. Four minutes early and you're probably going to wait for half an hour because the people before you were late or were particularly chatty or had complex conditions that needed some extra time.

I sit in my clinic room with the patients' cards and the computer showing the clinic list. I have reviewed the cards in advance so I have an idea of what I'm going to encounter, and have a chance to research any conditions I haven't come across before (this is starting to seem pointless; see below). Every minute or so, I press the 'Refresh' button, which re-loads the list and shows if anyone has checked in at the reception desk.

It is 9.18, and it seems my 9.00 patient has DNA'd (Did Not Attend) and my 9.15 is late. I click 'Refresh'. The updated screen shows that at 9.17, the 9.00, 9.15 and 9.30 patients all turned up together. Oh boy. What a great start to the morning.

Or, it is 8.58 and my first patient is at 9.15. I click 'Refresh'. The updated screen shows that the 9.30 patient has already arrived, so I can see him at 9.00 and get ahead. What a great start to the morning!

Here are some examples of consultations, which have been changed from the real ones, but are close enough to give you an idea.

The referral states that the patient has IBS (Irritable Bowel Syndrome) with symptoms of diarrhoea. I'm a bit shaky on the guidelines, so I make sure I have copies ready for us to go through. The patient arrives: IBS is old hat, the latest diagnosis is colitis, which is what the subject of the consultation will be. And we discover that I don't know what you actually do with golden linseeds.

The referral asks me to advise on a diet that will help a type 2 diabetic reduce blood sugars. A typical day's diet history is faultless in terms of sugar, saturated fat and complex carbohydrate intake, and when I check the results on the computer the last tests were done in 2010 and show all blood results within the desired range. Both of us are confused.

The referral states the patient has a Syndrome that I've never heard of. I do a fair amount of research in advance into what it is - it turns out to be a relatively rare endocrine condition marked by excessive hormone production - and I fail to find any relevant dietary guidelines. We will have to work it out together. The patient DNA's.

The card shows that a very overweight patient wants to lose weight, having tried for ages without success. The patient arrives and announces that thanks to a support group, 5 kg has already been lost, and motivation remains to lose more. All I have to do is say thank you for taking the trouble to come and let me know! And write to the GP.

The card shows that the patient needs in-depth dietary advice, and only speaks Urdu. It is 30 minutes before the patient's appointment at the start of the clinic, and I have no idea whether an interpreter has been arranged, or what to do if there hasn't. The admin team arrives and saves the day, showing me how the system shows that an interpreter has been booked. We manage very well, although some concepts don't translate well - I was very confused about 'fish fingers' until it became clear it wasn't the conventional sort.

After the clinic, I have to make sure that all the notes are written up on the cards, and each patient is 'outcomed' on the computer (a nice example of verbing of nouns) so that follow-up appointments can be arranged. Letters are written to the referrers of new patients, if there has been a change in treatment and a new prescription is needed from the GP, or if the patient has been discharged. This week's ambitious target was to try to get all of this admin done on the same day as the clinic, and I managed it!

The manager of the department is very supportive, and encourages using pro forma letters. She didn't exactly say that we didn't have to write when a patient is discharged, but gave the strongest impression that it wouldn't be considered unacceptable. I am still suffering from having to take days off as Annual Leave or forfeit them altogether, meaning that I have to squeeze five days of work into just four, but I'm still writing discharge letters; I think it's the right thing to do.

Student

New Forest view, Feb 2012

The workload was so nearly under control the day before my long weekend.

I spent the morning on one of my wards and managed to review and discharge a handful of patients, a student Occupational Therapist had asked if she could shadow me at some point next week, a Speech and Language Therapist had just reviewed one of my patients and approved his return to solid food taken orally at last, and one of my favourite doctors was telling me his life story.

It was all going so well, and then a student turned up.

We'd had a departmental meeting the day before, my first. I've done my share of meetings, and this job seems to have far fewer than any job I've had before. We talked about which diet sheets need updating, the financial state of the NHS Trust in which we work, the policies around allowing people time off for courses and professional development, an update to the Bible of Hospital Dietetics (not its real name), and Students. We have three students in the department at the moment, all on their B placement, and the discussion was about their training plan, learning outcomes and how they are getting on. Among many other tasks, each student needs to write up a case study, which involves finding a patient who agrees to be the subject, and then researching their medical and dietetic treatment before presenting the results in written and oral form.

I should have kept my mouth shut, which I succeeded in doing for the best part of the meeting, but I feel enormous sympathy for the students, based on my own less than happy experiences. I may have mentioned that I had a whole load of patients with NG feeds on my wards, none of whom seemed to be going home, and some of whom might be good for case studies. It was this moment of loose talk that started the chain of events that led to the student turning up on my ward.

Normally a new dietitian has 3 months' grace before being expected to supervise a student - after all, I have only been there a month, and my confidence in my own abilities and knowledge is growing from a fairly slow start. Being observed by someone else and having to answer questions and justify my own practice is a little daunting so early in my career. And my workload is so nearly out of control all the time, and working with a student doesn't half slow you down.

Anyway, there she was, asking about the possible case study, and there I was, with a whole load of work. I remembered how wonderful my own B placement supervisor had been, and how she had made me feel as though I had her full attention and support for however long it took, and I tried to do the same. So now I am potentially supervising this case study, although I will try to see whether someone else with more experience could possibly do it instead.

International badminton

White Lions Badminton Club, 2011

I spent Friday and the weekend watching badminton again, this time much closer to home than the badminton in Wembley last summer. There were a couple of benefits to having international badminton in Birmingham: several of my friends were also there, and it's only about 45 minutes from home.

Friday was Quarter Finals day, when there were still some British players in contention. Two pairs made it to the quarter finals of the mixed doubles, but both were knocked out. Like cricket, rugby and other games devised by Brits, players from other parts of the world now beat us into the ground - in the case of badminton it's Far Eastern and South East Asian countries. China, Korea, Malaysia and Indonesia were represented in the finals, along with a lone pair from Denmark, the only European country apart from the UK that produces world class players. China tends to dominate - in the last 17 years, China has won the Women's Doubles in Birmingham in all but two years, when it was Korea that won. Nobody but China or Korea has won the Women's Doubles in this competition since 1981.

The event was definitely brought alive by plenty of representatives from those countries being present to support their teams, especially Malaysia and China. The Malaysians brought drums! The Men's Singles contenders have superstar status in their own countries and must find the anonymity of English streets a bit of a relief. The two men in the final produced interesting chants from my disinterested point of view, one having a name with three syllables equally emphasised within four beats (Lee! Chong! Wei! [rest]) and the other with just two, accompanied by three claps (Lin! Dan! [cha-cha cha]). Contrapuntal chanting from the crowd. Made me wonder about other people - Mr A's name has four syllables, which would work well with a football-style dotted rhythm, but my own name has three unequal syllables, so the emphasis would have to be iambic or something complicated. Funny what you think about when you spend six hours among strangers in a large stadium on a Sunday afternoon.

On Friday and Saturday one of my badminton mates was there too, and on Friday we sat together seeing as it wasn't full enough for ticket-holders to be filling every seat. I'd booked my tickets jolly early and had a fine view; she'd booked tickets without a very good view via Groupon for hardly any money but sat with me anyway (clearly, she got the better deal). We discussed many things as we sat watching, including the criteria for whom you support during a match. Obviously Brits are at the top of the list, followed by other Europeans, especially Danes. After that it is a complex formula that takes into account whether you've been to the country, played badminton on the street with the natives (she's done that, not me), whether the players are attractive, what they are wearing, how old they are (veterans often get my vote) and whether they play for China (they have enough advantages without our support).

On Saturday and Sunday I was surrounded by members of an Irish badminton club, who'd brought an Irish flag which they put on display throughout despite there being no Irish players in the competition at all. They conformed to every Irish stereotype, including the flag, the heavy drinking, the 'crac', the lack of inhibition and the catchphrases ("JAYsus would ya look at him!"). Every now and then they would randomly shout "Come on Ireland!" to no-one in particular.

Apparently, the weather over the weekend was positively balmy. I didn't see any of it.
 

Nutrition support

All Saint's Church, Leamington Spa, Feb 2012

The vast majority of the patients I have been seeing on the wards are one of two types: a) not eating well and requiring either food- or supplement-based prescribing, or b) needing to be fed through a naso-gastric (NG) tube to the stomach via the nose and throat, or percutaneous endoscopic gastrostomy (PEG) tube to the stomach directly through the stomach wall.

A regimen for tube feeding requires a calculation of the patient's likely nutritional requirements for energy, protein and fluid based on their age, sex, likely level of activity, a stress factor according to their clinical condition, and their weight (or more usually an estimated weight because they haven't been weighed as they're supposed to be). Other considerations may be taken into account, such as a prolonged high sodium level in the blood biochemical results, or impaired kidney function. All of this leads to the dietitian making a choice of a type of feed, the amount that the patient should receive, and the rate at which it should be delivered via a pump, which will start at a low level and then increase over a number of days. I document all this in the notes, and all the nurses have to do is follow the instructions.

Compared with drawing up a feed regimen, oral nutritional supplementation is much more complicated. Where the feed, fluid and pump settings are very much under the control of the nursing staff, when it comes to trying to increase a patient's intake in hospital by getting them to eat and drink, there are a whole lot more variables to deal with. The catering department, the food service staff, support workers and nurses all have to come together at mealtimes to provide appetising food and to help frail and sometimes confused and/or recalcitrant patients to eat it. In theory, snacks and drinks are available between meals, including such wonders as cheese and crackers (8g protein and 130 kcal), but the patients are more likely to get a couple of ordinary biscuits (negligible protein and about 70 kcal).

Worse still is if the patient has an impaired swallow, and cannot be given normal food and fluids because of the risk that it will enter the lungs instead of the stomach. Food with modified texture is usually preferable to tube feeding, but trying to maintain sufficient intake from pureed food and fluids thickened to the consistency of custard or syrup is difficult. The very thought of thickened water or tea is enough to put most of us off drinking as much as we should. If this situation persists and the patient is otherwise medically fit for discharge, it may be necessary to draw up a fluid-only plan for their full nutritional requirement of anything up to and sometimes beyond 2000 kcal. This will rely to a great extent on nutritionally complete supplements in order to ensure that vitamin and mineral requirements are covered, because ordinary everyday fluids rarely contain iron, for example.

Even more difficult are those patients who are eating almost nothing but are deemed unsuitable for artificial feeding through a tube. This may be because of a medical condition that makes the endoscopic placing of an NG or PEG tube inappropriate (e.g. oesophageal varices or abdominal ascites), or a condition where artificial feeding has not been found to improve quality of life or clinical outcomes (e.g. dementia). Or because the patient just doesn't want to eat, which is, after all, their right. A referral is often made to a dietitian, because not to do so might be considered neglectful, but a dietitian can't wave a magic wand and make patients eat if they don't want to.

Towards the end of life it is often the case that a patient will stop eating and drinking, and the evidence suggests that clinical dehydration is actually likely to make the process of dying less traumatic. But the ethical dilemmas that arise are no less intractable because of the evidence - what if a patient with dementia starts to have an impaired swallow? Is tube feeding indicated, contributing little to quality of life and likely to cause distress and confusion and be pulled out, or do we offer food and drink orally that may be aspirated and cause chest infections, or will we allow them to starve? Unfortunately there are no easy answers.

The rep and the norovirus

Courtyard, Pompeii, 2006

There really is no connection between the rep and the norovirus, they just happened on the same day. The rep came at lunchtime with some sandwiches and snacks, told us about changes to the feeding products from her company that are prescribed in the hospital, gave us some pens and sticky pads, and announced that her maternity leave starts next week. The NHS is no longer allowed to buy pens, and what with writing all day every day and having to write everything at least twice, we get through them like nobody's business. If you're thinking of treating some NHS employees, get them pens. And don't expect to see the same rep twice in a row.

The norovirus hit one area of one of my wards towards the end of last week, and spread to another two areas of the same ward the next day. What with being a very modern hospital, isolation measures aren't too difficult to implement, but when I came to see my patients on that ward I had to take off my outer clothing and put on scrubs. Unfortunately it was towards the end of the day and supplies were running low - I found some trousers that I could hitch up above my waist to the extent that my feet emerged from the lower end, but I was not so lucky with finding a top that did not reach down to my knees. People actually laughed when I emerged into the ward.

The week was pretty good on the whole, and I managed to get my workload slightly more under control. But I learned the hard way about discharging a patient who needs to be enterally fed at home (through a tube into the stomach), by neglecting to make most of the arrangements until after the patient had left the hospital, and then finding out what I should have done beforehand. I was at a further disadvantage because all the people who normally help out with these arrangements were away. It then proved impossible to negotiate the website where I should have ordered feed supplies, so I had to do it the old-fashioned way via a fax, then the supplying firm phoned to say that the feed didn't come in bags of the size that I had ordered... and on it went. The important bits were done, but some was left over for Monday when the essential staff returned and I had to ask for help. I need to make a list for future reference.

In fact, I need to make many lists, and get myself properly organised. I have a desk, two drawers and a shelf to call my own, and the drawers and the shelf are empty while everything that I have been given in the first three weeks is in a single pile on the desk. It is driving me mad. It should be possible to spend a bit of time sorting it all out so I can find things when I want them, but any time I'm in the office I'm worrying about how many patients I haven't seen this week on the wards. It's fewer this week, so that's a good sign.

Birthday walk

Cubbington, Feb 2012

Lola II came to visit for her birthday, with Mr M. Lola II loves surprises, Mr M loves Lola II, so surprises are called for. Of course, I love Lola II as well, but I am too lazy/busy/preoccupied with my own troubles (delete as you think fit) to bother with surprises very much, in addition to the fact that I can't keep a secret to save my life, and Mr A isn't much better.

Surprises planned by Mr M:

• Getting Skype installed on a computer at mum and dad's house in advance so they could Skype Lola II on her birthday
• Creating masks with the face of Lola II for mum and dad to wear for the Skype call
• Producing more Lola II masks to be utilised at any appropriate time
• Arranging for our American/Israeli cousin to Skype Lola II
• Producing calorie-free green peas, which consisted of the letter P cut out of green cardboard
• Getting the music and playing the piano part of an Adele song so Lola II could sing along
• A tiny birthday cake
• About six or seven birthday presents.

Surprises planned by me:

• A walk in the countryside and a pub lunch with seven other people
• A packet of Durian crisps.

I think this indicates clearly the amount of effort each of us is prepared to put into the task of creating surprises for someone with a birthday. I did manage to assist with the green P's, scheduling the Skype call from our cousin, and practising the song.

Things started to fall apart when Mr M couldn't get Skype installed successfully for mum and dad, but sister D and family were going to be visiting on Sunday and might be able to complete the installation. Then the Skype call from our cousin didn't turn up on schedule at 6 p.m. our time, but my mobile rang at midnight (Lola II had sensibly turned hers off), waking me up enough to answer but not enough to hold any sort of meaningful conversation. Our cousin had thought we would be awake and celebrating - he obviously knows us less well than we thought. And as we drove off to the start of the walk, Mr A let the cat out of the bag by asking "Have your parents Skyped you yet?"

Millennium Way walk, Feb 2012

The walk and pub lunch were wonderful, the weather was perfect, and Landrover Man navigated with distinction. I learned a new Bee Fact: you can transport bees in their hives inside a car, but it's a good idea to wear protective gear while you're driving just in case they get out.

Prioritisation

Jephson Gardens, Feb 2012

My main weakness over the first weeks of my first dietetic job has been the tendency to accept referrals and agree to review patients that a more experienced Dietitian would discharge from their care. Without the experience to be certain that my practice is safe and correct, I have tended to want to review patients to make sure that all is well, and to find out whether my recommendations worked. This is commonly found with new Dietitians, and a sign of increasing confidence is to reject a referral or discharge a patient from dietetic care.

What this has meant is that my caseload is rather too big, and I wasn't able to review all my patients last week. This is fine, because if there had been any cause for concern, the ward staff would have bleeped me or called the office, which they actually did once or twice. New referrals kept coming in, and those patients have to come first.

When you are interviewed for a job as a Dietitian, invariably there is a question about prioritisation, which goes like this:

"It is Friday afternoon and four referrals have been received in the dietetic office. What do you do?"

Then they describe the four different patients, who usually are as follows: one overweight patient on a ward wanting healthy eating advice, one person with newly-diagnosed diabetes about to be discharged home, one malnourished in-patient with poor appetite, and someone who has just had a nasogastric (NG) tube placed and needs a regimen for feeding through the tube. What you do is offer the overweight patient an outpatient appointment, go and see the person with diabetes before they go, tell the ward staff to give the malnourished patient food, snacks and supplements and re-refer if things don't improve, and tell them to use the emergency regimen for NG tube feeding that has been drawn up for just such contingencies, until you can see the patient on Monday.

Up until last Friday I had thought it was a useful exercise to ensure that candidates can make the right choices when demand for dietetic input exceeds the number of hours in the working week. Last Friday I discovered that it is actually a very accurate description of real life. I had new referrals for a patient with type 1 diabetes, another who was obese, a third with Crohn's disease, another with a reported BMI of 15 kg/m² (which is seriously underweight), and I was on a ward reviewing a patient receiving an NG feed. And it was 2 o'clock on Friday afternoon.

It all went to pieces through an unprecedented chain of events that meant I had to spend a long time on the ward sorting out a potentially harmful situation, and then reporting a 'Clinical Adverse Event'. It's interesting to find that as the end of the working week approaches, priorities sort themselves out - three of the referrals ended up being somehow much less important than I had originally imagined, and, for the first time, I rejected a referral. It felt good.