More tales from the hospital

Harris hawk coming in to land

I have been trying to make friends with the reception staff at my outpatient clinic, partly because they seem to be nice people, but also because they can make the difference between a well-managed clinic and a chaotic nightmare. Last week's clinic gave me some opportunity to chat. The night before the clinic there were eight patients on the list, not a full clinic by any means, but a reasonable number to get through. By the time the clinic started, there were only seven - one had already called to change the appointment. The first patient was early, so I could see her early, and it's always nice a) to get ahead at the start and b) not to make people wait. But the next one didn't turn up, and after the third patient, the list on the computer had shrunk to just four - the others having presumably rung in on the day to cancel. The fourth didn't turn up either. So just two patients in the whole clinic, and although I bring down some stuff to do in case of DNAs, I had nowhere near enough to keep me fully occupied.

So I went out to chat to the staff on reception, not least to ask them whether it was just my clinic, or whether everybody was experiencing the same effect - perhaps it was caused by the first truly sunny, warm day of summer, when people might prefer to go the park rather than a hospital clinic? I asked them their names, and even gave them a box of chocolates that one of my two patients had given me. It was entirely unreasonable to have accepted the gift, because I had taken no part in the treatment plan - this was the first time I had seen the patient and all I needed to do was to discharge him, as he was doing fine. But it proved impossible to refuse.

This was the first time I'd been given anything by a patient, and then I was faced with the dilemma familiar to anyone who is trying to lose weight or maintain weight loss. If I took the chocolates to the office to share, then I would definitely eat some, but I don't want to eat them. So the answer was to give them to the reception staff, which is win-win because then I don't get any and they like me more and may be prepared to help out on the odd occasion when I might need them.

So far I haven't needed to ask any favours, but the other two basic grade Dietitians have both had the problem of patients brought by ambulance not being picked up before the end of the clinic. If this happens, then obviously someone has to stay with them in case they need help and so that the ambulance staff can find them. This should not have to be the Dietitian whose clinic they attended, who is unqualified even to help them to the toilet. Some arrangements have been made to bleep an alternative person to take charge, but this doesn't work reliably, and the Dietitian may be delayed for some time. If it happens to me, I want the reception people on my side trying to think up solutions, rather than walking away telling me it's my problem.

The outpatient clinic is only a brief interlude from working on the wards. One day last week, I was talking to a patient who was telling me that he was taking two supplement drinks a day. All of a sudden his eyes went a bit unfocused and he stopped responding. At that point my mind went into overdrive, fuelled by a burst of adrenaline I could actually feel, along the lines of "Oh my goodness what should I do he's died" but after just another moment I touched him on the arm and he started to respond again. He had a very poor prognosis so I wasn't about to leap on his chest and start compressions, but with hindsight, drawing the curtains round the bed and calling for a nurse would have been the next move. It was one of the more interesting experiences that I've had on the wards so far.

What I've been reading

The Adventures of Tom Sawyer
by Mark Twain

narrated by B. J. Harrison

"This is the story of a boy's adventures growing up in a small town on the banks of the Mississippi river. The cheerful, adventurous hero plays truant to form a pirate band and, together with his best friend, Huckleberry Finn, finds fun, excitement, and buried treasure along the shores of the great river."

I thought that B. J. Harrison would do a better job of a book by an American writer, rather than his previous patchy attempts at British and French pronunciation and place names. And he does. Although I'm sure to have read it on some previous occasion, there wasn't much that I remembered. And an easy read, unlike the one below...

The Audacity of Hope
by Barack Obama

"Barack Obama engages themes raised in his keynote speech at the 2004 Democratic National Convention, shares personal views on faith and values and offers a vision of the future that involves repairing a 'political process that is broken' and restoring a government that has fallen out of touch with the people."

A heavy book (in ideas rather than mass), and I think I would have got more out of it if I had better knowledge of United States politics and personalities. The book was written in 2006, when Obama was a Senator, just two years before being elected President. The US Senate comprises 2 Senators from each State (i.e. 100 Senators), and the most astonishing fact presented in the whole book is that in the US Senate at that time (just six years ago), there were three Latinos, two Asian members (both from Hawaii), and he was the only African American in the chamber. Unbelievable. I find from further research that Barack Obama was "the first male, black Democrat to serve in the Senate." I am in awe of the man.

Three Men In A Boat (To Say Nothing Of The Dog)
by Jerome K Jerome

"Martyrs to hypochondria and general seediness, J and his friends George and Harris decide that a jaunt up the Thames would suit them to a 'T'. But when they set off, they can hardly predict the troubles that lie ahead with tow-ropes, unreliable weather-forecasts and tins of pineapple chunks - not to mention the devastation left in the wake of J's small fox-terrier Montmorency."

I was looking for something bite-size and entertaining - my pile of books to be read contains little in the way of easy fiction. Having recently read the wonderful 'To Say Nothing of the Dog' by Connie Willis, I thought it was a good time to re-read the first half of the title. It's only a little book, and a good companion to the Mark Twain as they write in a very similar style. Most enjoyable.

Falconry

Henry the Harris Hawk and me

Last weekend I had one of the most enjoyable and memorable days of my life.

It was a drizzly, grey sort of day on Saturday, but I set off for the Cotswolds in a spirit of barely suppressed excitement. This was the day I was to redeem my Christmas present from Mr A: a day's falconry experience at the Cotswold Falconry Centre.

When I was in my early 20's, a friend invited me to his wedding in North Lincolnshire somewhere. I don't remember much about the wedding, but what I do remember is that the following day, I went with friends to a local attraction that hosted a falconry centre, and watched the display. I was hooked from the first moment. I made my friends stay so that I could watch a second display later in the day, and then wrote to the falconer with all sorts of questions about what was involved in keeping and flying birds of prey. He kindly wrote me a letter in return, which I still have.

At that time I was at university, having a somewhat disorderly, irresponsible and unsettled life, with all sorts of plans for travelling and without the slightest intention of settling down to the sort of life that would allow me to look after any sort of animal, let alone one as sensitive and time-consuming as a bird. But I never forgot the thrill of that display and the unexpected passion that it aroused.

Move on about 20 years, and Mr A and I visited Ludlow, where we happened upon a sign in Ludlow Castle advertising a falconry display. I insisted that we stay and watch it, and the impact was hardly less than all those years ago - the birds were so beautiful, graceful, powerful and still almost wild. They were certainly not tame or domesticated; there was none of the mutual attraction of a cat or a dog with a human. It was a cold, business-like relationship based on making an easy living on food provided in exchange for flying about a bit. The birds were free to go if they wished, although it was clear that the falconer would have calculated carefully to ensure that they didn't.

Mr A has since said that he hadn't ever seen me in such a state of excitement before. It must have made an impression, because that was at least five years ago, and I was absolutely amazed to receive the envelope on Christmas Day with a voucher for this falconry experience.

So last weekend I headed off into the drizzle, and joined a group of five other people from 9.30 a.m. until 5.30 p.m. We were looked after by four of the staff, and were plunged straight in at the start when each of us was given a bird in turn (Henry the Harris Hawk and Desmond the Great Tufted Owl) and sent off to walk around a field with it. Then, in order to understand the variety of size and weight of falconry birds, we each were given a little American falcon, followed by a Gyr/Saker cross and then... a Golden Eagle. It was amazing - you could hardly feel the tiny falcon on the fist, but the eagle looked me straight in the eye, and was as heavy as a small child. A magnificent creature.

The centre is remarkably big, and has about 150 birds altogether for conservation, breeding, and flying in displays and at prey. They include eagles, vultures, buzzards, caracara from South America, a huge variety of owls, down to the slighter birds: sparrowhawks, kestrels and falcons. At this time of year many are raising chicks. There are several birds tethered in mews (sheltered areas) and weatherings (uncovered) - they are flown every day and brought inside at night, while others are permanently out in large enclosures. The breeding birds are not disturbed, but some of the non-breeding birds in the enclosures are brought out and flown, including a pair of caracaras in one of the displays I watched. But I'm getting ahead of myself.

We were given some information about the 4000-year recorded history of falconry, species and types of birds, how they are cared for, the equipment used (the tether, the creance, hoods, jesses, lures) and some of the terminology that has entered the language. A mews was originally for housing birds, not horses. When annoyed you can reach the end of your tether. It was emphasised clearly that birds don't fly for fun, but for food, and only if they're hungry, and the way to tell whether they are hungry is by weight. A bird needs to be at its flying weight, but if it is too heavy, it is fed up, and will not fly. The last lecture/lesson of the day included tying a one-handed knot - the falconer's knot. Obviously while holding a bird on one fist it is important to be able to manage everything else with the other hand.

We went out into the field with Henry the Harris Hawk and flew him a bit more freely, taking turns to hold out an arm for him to land on and accept the food offered. We were given a glimpse of how manoeuvrable he could be, and we all got thoroughly wet, including Henry. The long grass and the rain soaked into everyone's shoes, and we all spent the rest of the day with wet feet, taking turns in front of the small gas fire when the opportunity presented itself. I think the American lady in the group had the worst time - she had the most inadequate shoes, and being from Texas I think she suffered more than the rest of us from the cold, damp conditions.

The weather was still pretty wet for the first display. Mr A turned up to see this with us, and stayed for lunch. He watched another display and went home, while the group was taken on a tour of the centre by its owner, and given lots of fascinating information. One of the most interesting facts was that the breeding enclosures contained lots of unsteady perches that swayed and required the birds to balance. In order to mate successfully, the male has to sit on top of the female, who is a good deal larger in many raptor species, and not likely to be sitting entirely still. He had received a male bird that came from a different breeding centre with only fixed perches, and realised that the bird had never learned to balance effectively. "Our breeding success improved significantly when we introduced the wobbly perches," he told us.

The weather had improved slightly for the last display of the day - it was no longer raining - but there wasn't a breath of wind and the low, grey cloud hadn't lifted. This meant that the larger birds were reluctant to stay out long because they were getting no help from wind or thermals, and the smaller birds weren't going to climb and 'stoop' to prey because of the poor visibility. I still haven't ever seen a stoop, which is when a hawk (e.g. a peregrine falcon) goes into a vertical dive at up to 100 mph, and takes the prey on the way down.

The displays featured a number of birds in turn, including the caracaras, a bald eagle called Wotan, another eagle called Lulu, and a number of owls. Owls have acquired a reputation for wisdom and intelligence, assisted by books such as Winnie the Pooh and the Harry Potter series, but their real nature came to light in the displays - they are pretty stupid, not very impressive, have no sense of smell, and have never seen their own feet. This is because their eyesight is pretty good, especially in low light, but only at a distance. They are effectively blind to anything close up - the trainer held food up in front of an owl's nose, and it peered dimly past at nothing in particular. But throw the food a little way off and the sound and sight of it prompts the owl to head over there and pick it up. Unlike the other birds, though, having picked it up and eaten it, the owls tended to sit there doing nothing in particular. Their special skill is flying from A to B and then stopping, rather than soaring majestically in wide circles to perch on the lofty branches of tall trees before gliding silently to the falconer's fist, or performing aerial acrobatics to catch food in midair. I was not impressed with the owls.

In contrast, I was deeply impressed with the falcons, hawks and eagles, and also with the quality of the tuition and the knowledge of the team who work at the centre. The vultures weren't bad either. When I came home and told Mr A that I had signed up as a Friend of the centre and was now able to visit free of charge, he said something along the lines of, "I thought you might." I spent the rest of the evening and much of the next two days imagining that I might join a club and go out flying with people who own birds (there is a club that meets every second Sunday at a venue only 5 miles away), and visiting the Cotswolds centre every other week. Realistically, I hope to go there enough times to make it worth my while having paid to be a Friend. Lola II will definitely be forced to accompany me at least once as well.

It was also our ninth wedding anniversary on Saturday. Don't feel bad that you missed it - I was pretty sure that it was in May, but I had to rummage through the filing cabinet to find the wedding certificate with the actual date, which wasn't the date I thought it was. We went out for what turned out to be an over-priced and fairly ordinary dinner at a Thai restaurant - we would have been better off at Wofon for a fifth of the price, even though the surroundings would have been less glamorous. Mr A has provided a few interesting moments during the sixteen years we have been together, but I wouldn't have been without him. Happy Anniversary, Mr A!

Naughty monkey and me

Texture and consistency - in practice

A ski bar, Austria, February 2011

I left you in a quandary: we need to supplement the diet of patients on texture-modified diets, but we don't have texture-modified supplements...

So what do we do? Up to now, working on the stroke ward as a newly qualified Dietitian with zero prior experience, I have done what others have shown me and what I can cobble together from resources lying around. For Texture C and Stage 2 fluids we have a 'pudding' consistency supplement and thick yogurts, as well as the puree menu itself and a powder thickener for drinks. For Stage 1 fluids I have been offering a standard concentrated supplement, which may or may not be acceptable but one of the senior Dietitians uses it in the community so that's good enough for me. We also have milkshakes and soups made up from powder that can simply have less liquid added to make them thicker.

The new Dietitian who joined us last week has some previous experience, and has been asking some very interesting questions, mostly along the lines of "...and why do you do it this way?" My somewhat lame answer has been along the lines of "...because that's how I was shown, and I'm only three and a half months old, and I've had your ward and four other wards to cover so limited time to spend thinking about other ways to do it."

So far she has questioned the way that we start new enteral feeds, the way that blood tests are ordered, and now, the range of supplements that we can offer to patients on texture-modified diets. We did a small experiment, mixing two together to try and achieve an intermediate texture, which I promptly poured down my front in a particularly inept tasting session. But that is beside the point - it looks as though some fresh eyes are going to come up with useful tools for the rest of us to adopt. I've already changed the way I start enteral feeds and order blood tests following her suggestions, so I look forward to a Stage 1 thickened fluid supplement option very soon.

Our newest Dietitian is also going to liaise with the SLT team about other aspects of our collaborative working. Exactly how thick should Stage 1 and Stage 2 fluids be? How much fluid should be added to a soup or shake to make it the right consistency? And I'd like her to talk to the SLTs about the 'Texture E' Fork Mashable menu, which is relatively new, and is currently in a different format compared with the other 'special' menu options. The Texture E food is apparently also more expensive to produce, and there are more appetising choices, which means that the kitchen has restricted this menu to patients who have specifically been put on it by a Speech and Language Therapist.

Introducing a new menu within a hospital is no mean feat, mainly because the hospital is a 24/7 full-time operation, but the staff within it obviously don't work 24 hours a day. So you have to roll out any changes multiple times in order to catch those on different shifts or who are on holiday. Done incompletely, there is nothing but confusion, as some ward staff are aware of the change while some are not. And as time goes by, even those who used to know what was going on become unsure of themselves or forget completely what they were shown.

The Texture E menu is an example of this situation. The SLTs who assess patients' swallow have a special sign that they put up over a patient's bed if texture modification is required, and the sign clearly indicates 'Texture E Fork Mashable' among the options. In the medical notes and when talking to nurses, however, they are less consistent, recording for the same patient that 'soft' or 'soft, moist' food is indicated. The nursing staff and Health Care Assistants, who are used to people needing soft options, often offer the same soft meals for these patients as they would for those without good teeth, from the normal menu.

This is the situation I encountered as a new Dietitian on the ward, and to start with, I didn't realise what was going on - I read the notes more often than I look on the wall above the patients, and didn't notice that these 'soft' recommendations actually meant Texture E. Since it became clear (which happened with the help of the more experienced Dietetic Assistant who worked out what was going on) we have been trying to work out how best to make the ward staff aware of the situation and get them to use the correct menu, without having the resources that were available when the new menu was introduced hospital-wide. Our tactic has mostly consisted of keeping an eye out for people being put on the Texture E menu, and providing multiple copies of the menu to the nurses at that point, while making sure that as many people as possible are told about the Texture E menu option, including the patient. Ideally, I'd like to see the SLTs use the same terminology throughout - in the notes, on their notice and when talking to the nursing staff, but it's not up to me.

The last hurdle is on discharge, if someone is still on puree or Texture E food when they go home, especially if they aren't going to a nursing or residential home. The SLTs have a team providing follow-up in the community, but we don't have any Community Dietitians for this sort of follow-up. We rely on providing written information. a telephone follow-up and/or inviting the patient back for an outpatient appointment. If they aren't able to manage any of these, which is going to be those patients in the most difficult circumstances, then all we can do is let the GP know, and hope for the best.

Texture and consistency - the theory

Norfolk, July 2011

The hospital job that I do involves quite a lot of consideration of texture modification, of both food and drink. This is due to many reasons - poor dentition and dysfunctional swallow being the main ones. Hospital food is obviously not a gourmet delight, and you would be crazy to expect a rare steak (we can't even offer runny egg yolk), but without proper teeth it can be tricky to get through even the softest cut of meat. So there are a lot of soft and wet options on the menu, using minced meat, fish in sauce and stews as well as baked potatoes and sandwiches.

Sometimes the process of swallowing is damaged, either by a stroke or a neurological condition like Parkinsons Disease, Motor Neurone Disease or Multiple Sclerosis, or surgically due to something like head and neck cancer. We learned quite early on in my course that 'Swallowing is the most complex reflex in the body, employs about 25 separate muscles, and once initiated it cannot be stopped.' If any part of the reflex is damaged, whether by a brain injury or surgery to tissue and muscles in the mouth or neck, there is a risk that the swallow will fail, and food will either remain in the mouth, or pass into the lungs (called 'aspiration').

Speech and Language Therapists (SLTs) not only deal with communication in these patients, but are also in charge of the pathway from the mouth to the stomach, which is not reflected in their professional title. Maybe one day they will become Speech, Language and Swallow Therapists. Anyway, they are the ones who investigate and assess the risk of aspiration, using sips of fluid and bites of food, cameras put down the throat (FEES = Fibre-optic Endoscopic Examination of Swallow) and videofluoroscopy using barium drinks, where the internal process of swallowing and route of a liquid can be watched 'live' from various angles.

The treatment they have at their disposal includes both exercise (if the problem is muscular or neurological) and texture modification of food and fluids. Fluid is easier to control in the mouth and to swallow when it is thickened, and presents a lower risk of aspiration. Similarly, removing the lumps from food and reducing it to a puree consistency can reduce the risk of choking. It is not an exact science, and sometimes things 'go down the wrong way.' For many patients, this would provoke a fit of coughing, alerting onlookers that something is wrong. Some do not cough, however, and this 'silent aspiration' manifests itself as a wet voice, 'chestiness', or a drastic drop in blood oxygen saturation as the lungs fill with food or fluid.

Not that long ago, an attempt was made to standardise the classifications of texture modified food and fluids, and the latest reference document is freely available. It contains only the descriptors for food - those for fluids are still under review, although previous standards are still available. The two sets meet in the middle - food is progressively softened and pureed into something approaching a liquid, while drinks are progressively thickened to something approaching a solid.

In the hospital where I work, alongside the normal menu are two 'texture modified' menus, offering Texture C (thick puree) and Texture E (fork mashable) food. Fluids can be thickened to Stage 1 (thin custard) and Stage 2 (thick custard). Each patient is assessed by an SLT, and the most suitable texture is recommended. When any such texture modification of food or fluid is advised, a referral to a Dietitian should ensue (but it doesn't always happen).

The main reason for the Dietitian getting involved is because it is almost impossible for a patient to meet his or her full nutritional requirements on a texture-modified diet or fluids. The thought of thickened fluids - imagine a custard-thick cup of tea or coffee - is enough to put most people off drinking anything, although fruit juice and squash seem much more acceptable in a thickened form. If food is pureed to the right consistency it often has to have water or other liquid added, which dilutes the nutrient content, and many patients who have a compromised swallow will have a small appetite to start with. They simply can't eat enough to provide the protein and energy they need, and again, pureed food on a plate is not the most appetising sight (although I would contend that the taste isn't too bad if you can get past the look of it).

So we ride to the rescue, the Dietitian on the steed of food fortification and nutritional supplements. But hang on - most of the supplements we use are in liquid form, and by virtue of the complex composition which makes them nutritionally complete (i.e. containing all the essential protein, carbs, fat, vitamins and minerals), they are impossible to thicken successfully. There are pre-thickened supplements on the market, but they are not available in the hospital on our contract with the supplier, due to their high price. And the kitchen in this hospital doesn't provide a fortified menu, let alone a fortified puree menu...

To be continued

Weekends

Crane, Norfolk, July 2011

The May Day Bank Holiday weekend started after work on Friday with a drive to Southampton, checking into an ancient, run-down (but clean) hotel, and almost immediately driving to a gig to see Alabama 3.

Mr A and I arrived at the venue a little late, and when we reached the door into the main room I wondered if we would ever get inside. There was a wall of people, but somehow we squeezed in and found a small space towards the back. The gig had started but I don't think we were very late. We each had just enough room to stand, and of course the tallest man in the room was in front of me - when he started jigging about it was time to beat a retreat in case he reversed into me and caused a nosebleed. Standing at the back was not much better - it was a frequently used through-route and we were constantly having to let people pass. Which was annoying. As were the group of people who seemed to have come for a good chat rather than to listen to the music. So all in all it would have been better had we arrived a little bit earlier.

It was nice to go out in the evening like 'ordinary' people do - it's been a long time since we've treated ourselves to this kind of event. The following day we visited Mr A's parents, and found his mother's dementia has reached the point where she struggles to put a sentence together. They are still managing to live together successfully at home, although I'm not sure how long that can last. Then on to Mr B and his wife and dog and a nice local walk from where we viewed the Isle of Wight and the Needles, and finally to friends J&C for a Chinese takeaway followed by pub (Mr A & J) or chat (me & C).

And back home on Sunday, with all of Monday to enjoy the Bank Holiday. As it counts as a weekend, I was in charge of the Catering Department, and I thought I would forsake Jamie Oliver for once and produce the Ultimate Lamb Biryani (from the Ultimate Recipe Book). The book said it would take 3 hours, but somehow I didn't take this seriously. I did little else that day, and it was a good lamb biryani, but not that good. The Great God Jamie clearly punishes those who forsake Him.

This weekend has been mainly spent in mundane tasks: yesterday contained laundry, a large amount of washing up, food shopping, cooking and then we watched an excellent film that I can wholeheartedly recommend: 'The Guard'. Today I have mostly been trying to renew/upgrade the contracts I have for mobile phone, landline and broadband, which I find fairly difficult and quite tedious. I finally completed the process of negotiation for the mobile contract, and a new touchscreen phone is on its way, my first foray into modern mobile communications. Along with the return to contact lenses, this was supposed to be a luxury that I allow myself as a result of having a job, but in fact the deal is no more expensive than my previous phone contract. The landline/broadband deal is still under negotiation.

Weekends are proving difficult for me. I work much harder in my current job than I have done in any previous jobs, with no down-time during the day other than a 30-minute lunch break. What with badminton on two nights a week, I'm very tempted to do nothing at all at the weekend other than a few easy household chores, food shopping and cooking, which I enjoy. But there are many other jobs that need doing - Mr A mowed the lawn, which was nice, but there is more to do in the garden and all sorts of repair and decoration that would make our house look a good deal better. I need to make a bit more effort during weekends at home.

Not keeping up

Mr M and Lola II's garden, April 2012

I am so behind with everything - all the blogs waiting for me in my Reader, audio books unread, and loads of podcasts just sitting there. This is partly because of sharing rides to and from work, so I have to do conversation rather than listening to podcasts or books, and partly because I have decided not to spend so much time sitting at the computer. I'm not sure in what way the rest of my life has benefited, because I don't seem to get a whole lot of other things done, but it seems like the right decision.

Work continues as ever with patients on the wards and in clinic. Last clinic: ten patients were on the list the day before, only nine were left by the morning of clinic and eight remained when one phoned to cancel. Five turned up. This is typical. The reception staff say that Tuesday is the worst day of the week and car parking is so bad that perhaps people arrive, drive around for 15 minutes not being able to park, get fed up and just go away again. The reception staff don't know why Tuesdays are particularly bad. At least I didn't need any interpreters, for once.

On the wards, the Friday before a Bank Holiday weekend seems particularly difficult as ward staff realise that if patients are not seen on Friday then they will not be seen for another three days at least. All my NG-fed patients seemed to be pulling their tubes out, which made me worry that they may not be fed over the weekend. On the other hand, quite a few were transferred out to Intermediate Care, Rehabilitation or other hospitals and one or two were put on palliative care, the End Of Life Care Pathway, or just died.

I have been working with a student for two weeks - not all the time, just three mornings or afternoons a week. It is difficult. I am not a natural teacher, and I am trying hard to find the right level of encouragement compared with correction or instruction. I have only been a qualified Dietitian for three months, and am still finding my own way of doing things, making it difficult to pretend that I know what I'm doing all the time. And as I have said before, it's not so long since I was having a hard time being a student on placement. But we do our best.

You may have noticed the infrequency of my blog posts nowadays. One of the most frustrating things is that I am unable to report much of what goes on, since it involves individual patients or students or colleagues. The golden rule is that I can only write stories that these individuals would not be able to recognise as being about themselves. To do this, I can either change so many details that the point is lost, or write something so generic that there is no recognisable story left. Both of these are clearly unsatisfactory.

A new Dietitian is starting this week, and my wards will change around. My line manager is going on maternity leave and a new Dietitian will replace her later in May. Maybe then I will have some new stories to tell.

I still love Leamington Spa

I really do love Leamington Spa

A quick update on Leamington Spa, where it has been raining a lot recently.

Our garden

Is overflowing with goodness due to the recent rain. Mr A did mow the lawn once, and has been keeping the bird table topped up, but weeds are legion. The tulips always look beautiful as the buds mature, but the rain did what it always does: as soon as the buds open the blowsy flowers are destroyed, petals bend back and fall off and they look a mess. Mr A says they looked nice for quite some time, but I must have missed it. Bluebells are out, though the wisteria is still in bud, unlike in London last time I was there a month ago: there, the wisteria was well into flower. Weeds are flowering well, as always.

Leamington Spa

That previous blog post about the town is still pretty accurate, although there are a few amendments:

4. The skateboard ramp has been removed from the park because it was deemed unsafe. When our local Councillor came round recently to talk about expanding the bowling facility, Mr A took him to task about when skateboarding facilities might be replaced. Sports for the middle class wealthy - what about the yoof?

5. Pubs: I was going to add the Somerville Arms because it was really nice when we went there by chance one time, but the second time we went, last Sunday, it was closed. We went round the corner to the Cask and Bottle instead, which was just as nice, and more importantly, open. Although there was football on a number of screens, the commentary was in Italian (who knows why) so it wasn't too intrusive.

7. Music venues: The Assembly. Great place. Wish we went there more too, but I'm now holding back because Mr A's knees don't hold up to dancing like they used to.

11. The sushi bar came and went, and there's now a noodle restaurant there called Wofon that I have been to so many times that they have given me a 20% off loyalty card that lasts to the end of June. There's also a big banner advertising Wagamama coming soon round the corner, but the hoarding has been there for weeks and no sign of an opening date. If Wofon hadn't opened I'd be gagging for a bit of Wagamama, but I'll still be going to Wofon even when Wagamama opens.

15. The town's restaurants have changed: Wofon as above, Eleven is still the place for a treat, and Casa Valle has been replaced by Kayal which is South Indian rather than Italian but just as good. We haven't been to any of the others for ages due to austerity measures.

Our house

Not much has changed, although a significant event has been the hanging of the mirror and the installation of the light fitting in the shower room. I am somewhat ashamed to admit that I eventually asked Mr A if he would do it for me. While I am certain I could have done it alone had I been a single person, it was a much more enjoyable experience providing Lola-style assistance to Mr A. I hate DIY with a passion, except for really simple straightforward things like painting, and even that didn't go without a hitch last time.

The pub

Just as good as ever, although we don't eat there much any more because of the lack of vegetable accompaniments to the relentlessly meat-and-carbohydrate nature of the food options. I tentatively asked Smurf if he would be interested in some constructive criticism of the menu, but he wasn't really interested, after all, his way is working fine. The beer is as good as ever, though, and the atmosphere always welcoming.

Anthropometry

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.