Cruising

View from our cabin, Budapest, October 2012

This will have to be short. Life is busy at the moment, and I'm only writing this because badminton has been cancelled tonight - there are two matches on, which means no spare courts for ordinary club. It doesn't happen often, but actually it's quite handy tonight because of all the stuff I should be doing. Except I'm not doing it, I'm writing this.

I have been away. You would hardly notice nowadays, given how rarely I get round to blogging, but for a week, the entire Lola clan (ten of us altogether) spent quality time together closeted on a boat on the River Danube sailing from Budapest to Linz and back again. We stopped at Esztergom (Hungary), Bratislava (Slovakia), Dürnstein, Melk, and Vienna (all Austria) and from Linz we took a coach trip to Salzburg. It was all organised by Riviera Travel, and I have to say there was little to complain about other than an excess of luxury.

Some of the party (me, Lola II, mum) were trying very hard to maintain our sylph-like figures, and practised some level of self-denial in the food intake department. Others (Mr M, Mr A) seemed to regard the multiple-course gourmet menus as a challenge. Given that scurvy is an ever-present threat when it comes to the male of the Lola species, I thought we were in trouble when Mr M's stance on the 5-a-day matter was backed up by an interesting letter from the ship's captain, placed under the door of our cabin. It reads as follows:

"THIS IS YOUR CAPTAIN.

MARMALADE DOES COUNT AS A PORTION OF FRUIT.

YOUR CAPTAIN

PS I DOES NOT NEED TO PROVE I IS YOUR CAPTAIN."  

Mr A thinks it might be a forgery, but we never did get to the bottom of the matter.

Another highlight was the ship's pianist playing Beethoven's Moonlight Sonata, which we had asked him to do because it's dad's favourite piece of music, but he said he would unfortunately need the music. Unfortunate is right, because, anticipating such an eventuality, we'd brought the music. All I can say is that it was recognisably the right piece, but as Eric Morecambe might say, some of the notes were not necessarily in the right order.

Some of us tried out the open-air jacuzzi on the sun deck. Others had a go in the sauna and steam room. We lounged in the lounge, sunned ourselves on the sun deck, played card games and word games, read books, and variously walked and wheeled ourselves around the various sights of continental Europe that were presented to us. It only rained on the very last day.

There was a mountain of work awaiting me in the hospital on my return, and the interview is tomorrow. What I should be doing at the moment is looking at potential interview questions, devising cunning strategies to present my weaknesses as strengths, and coming up with the perfect answer to the question of why I applied for this job. I will have to remember to take make-up to work with me, and I also have to construct a suitable outfit. This includes working out what combination of outerwear, footwear and hosiery will allow me to a) drive, b) walk and c) appear tall, confident and presentable rather than a just scruffy person wearing clean clothes and Lady Shoes with heels that are a bit too high.

Dietetics and more

Sissinghurst, June 2012

Events move apace in the Dietetic department, while I blog about inconsequential matters like my reading habits and creatures made from meat and pasta. There has been laughter! tears! patients! clinics! and a few interesting developments.

Wards

We have swapped wards again. If you have been following the saga since the beginning, I started with the stroke and elderly wards, followed on with respiratory and urology wards, and now have cardiac rehabilitation and neurology. Next rotation, I may get the orthopaedic and labour wards. Admissions at the start were for reasons of 'general deterioration', then it became 'shortness of breath', and now 'chest pain' or 'headache'. Or I get patients transferred over from Critical Care or the stroke ward. But in the end, patients are just patients and the dietetic treatments they receive are pretty similar, whichever ward they're in. A combination of artificial feeding, nutritional support and frustration.

Neurology and neurosurgery are slightly more gruesome than any of my previous wards. Head injuries and intracranial bleeds are not pretty, and often affect personality as well as physiology. There are loads of new and very obscure abbreviations both in neurology and cardiology, and sometimes even the nurses are a bit vague about what they stand for (I don't tend to bother the doctors with my questions). Strangely enough, I have found the doctors' handwriting is an order of magnitude worse in neuro notes. But the cardiac wards win the prize for the most badly kept folders, to the extent that sometimes it isn't possible to find what the doctors have written over the past days or weeks, or you have to look in three different places to get the full story.

Complaint

I have been involved in a complaint about treatment received by a patient a few months ago, and had to revisit the notes I took at the time and at the decisions I made and documented. It wasn't too bad, although there's always something to learn. In future, I intend to pay a bit more attention to making sure everything is done as it should be when a patient is discharged home.

Staffing

You may (or may not) remember that there are three of us 'junior' Dietitians, all on partly or wholly temporary contracts. We are occupying posts that belong to three other Dietitians who have been filling posts left unoccupied by three further Dietitians who are on maternity leave (it's actually not quite as simple as this). Until those latter three decide what they would like to do, and until a plan is agreed by The Authorities, none of us knows what the future holds. There's a further 'senior' Dietitian who is on a temporary contract, filling in for yet another Dietitian on maternity leave, who is my team leader. This temporary stand-in has now found another job and will be moving on in just three weeks' time, leaving a very short term vacancy at quite a senior level.

It is all very complicated, and I may not have explained it very well in the above paragraph, but the immediate upshot is that we will be short of bodies at the coalface very soon, and the Dietetic Manager is taking steps to try and make sure that we will all be able to cope. For a dreadful minute or two, I thought this meant that I would lose my clinic, but a swift reorganisation has restored it to me, albeit on a different day, and I am very relieved. There will still be extra work to do, but I think we will cope.

Job application

I have applied for yet another job, and heard today that I have been offered an interview. Just for a change it is not in the middle of a holiday, although it could have been - Mr A and I and all the family are going away for a week very soon. In the past, this might have disrupted the flow of this blog, but nowadays it will hardly be noticed. The interview is for a job that I would very much like to have, but it is quite a long way away and would involve a significant amount of commuting.

Other news

I have been to London to meet up with children I went to school with (who are now adults with children of their own) and our former clarinet teacher and her husband, who do not seem to have aged in the slightest. Then onwards to Lola II's and Mr M's house where we always intend to do things like go for a walk but end up just mucking around. I can't even remember what we did in the end, but I'm sure it was lovely. Oh yes, we went out for Japanese food, for the first time in ages.

What do points mean?

Yes, I have won another prize from a blog, through the medium of my favourite joke. To see it, you will have to visit this page and look in the comments. I received a bag of Jordans Superfruity Granola, and three Jordans Absolute Nut bars, which arrived last week. I have tried one of the bars (delicious! but 260 calories per bar), but we haven't opened the Granola yet. I'm sure it will be jolly tasty.

The frankfurter octopus

Not my original idea, but something I saw on the Interwebs long ago, and have been itching to try ever since. The frankfurter octopus turned out to be delicious, yet at the same time vaguely disturbing.

Ingredients: frankfurters, spaghetti. Optional: ketchup, mustard. The finished meal included a salad, although you won't see much of that in the subsequent pictures I took. 

What I remembered of the 'recipe' was very straightforward: stick raw spaghetti through frankfurters. What I didn't remember was how much spaghetti, and along which axes? So I constructed a selection of different mutant strains.

The main problem was that the more attractive species, with spaghetti radiating perpendicular to the frankfurter axis, was the more difficult to fit in the pan. Longitudinal was more practical, but appealed less to my aesthetic preference for outlandish sea-creatures.




Both varieties cooked to perfection, and, with a dash of ketchup and mustard, provided Mr A and me with a comforting autumn supper, and leftovers for work next day.

Nutrition Team

Brixham, August 2012

One of the roles of the senior Dietitian is to take part in the Nutrition Team ward rounds. The Nutrition Team is a multi-disciplinary group that takes referrals for more complex nutritional issues, such as parenteral nutrition (PN) - feeding a person intravenously. They are also called in when there are difficult judgements to be made about other types of feeding - an example might be when someone with a number of serious conditions is no longer able to manage normal or textured food. It might be neurological, such as Motor Neurone Disease, or due to a stroke or dementia, or an obstruction or non-functioning bowel, or some other restriction to intake. It might be a patient who is simply not eating, because of nausea, vomiting, diarrhoea or other effects of a disease, or possibly because of a psychological disturbance - we find these cases very difficult to deal with, because the patient can eat, but doesn't. Is it appropriate to intervene? If so, how invasive should we be? If not, how do we justify our inaction?

The core members of the Nutrition Team are a Gastroenterology Consultant, a Nutrition Nurse, a Dietitian and a Pharmacist. The round that I joined also had a number of others in attendance: a Specialist Registrar, a Senior House Officer, two medical students, and me. It was a pity that I'd chosen that particular day to join the round, because the group was really too big and unwieldy, and the Consultant had to attend a meeting so was missing for most of the round, which led to a bit of a leadership vacuum.

All of the cases on this round were for PN. A couple of the patients were in Intensive Care, and I'd never been there before in this hospital. It seemed less spacious than the equivalent wards I'd seen on placements (although this might have been because of the size of the group), but otherwise equally well equipped with a myriad of machines that go 'ping' keeping people alive in various states of incapacity. The rest of the patients we saw were on other wards where PN can be supported, which are more familiar environments, but still difficult to manage with a group of nine people.

In terms of what was dealt with, these were far more complex cases than I've been expected to deal with so far as a lowly graduate with little experience. The patients had mostly had gastrointestinal (GI) surgery or an inflammatory bowel disorder like Crohn's Disease or other complication of the GI tract. One or two were in hospital because their intravenous lines had become infected, which raises the risk of serious illness given that pathogens might be introduced directly into the bloodstream. The parenteral feed has to be treated much more carefully than standard intravenous fluids (which is why not every ward can support PN) and nursing staff must be properly trained to administer it aseptically. The Pharmacist was part of the group because of the need to tailor the composition of the feed in terms of nutrients and electrolytes, which is their job. We can either buy standard bags of parenteral feed, or have them made up specially in the Pharmacy department.

So I mostly hung around at the back of the group, watching and listening and trying to understand the reasoning behind some of the discussion about rates and timing and composition of feed and bowels and surgical procedures and how blood test results related to everything, drawing on my knowledge of the forms and functions of the different parts of the GI tract. The senior Dietitian and the Nutrition Nurse tried to help me out by explaining some of what was going on, but that just added to the noise and chaos of the huge group milling about the nursing station on the ward.

The main thing I learned was: given that the small intestine is mostly used for nutrient absorption and the colon for water absorption, there is a difference in nutritional impact if different sections of the gut are removed or non-functioning. If an opening (ileostomy) is made at the far end of the small bowel, nutrient absorption may be unaffected but the patient may lose a lot of fluid and electrolytes. Higher up, and PN may be needed because there isn't enough absorptive capacity to meet the nutritional requirement. Nutritional supplements may actually make things worse by drawing water into the bowel to counteract their high concentration (osmolarity).

I found the experience a little too chaotic for comfort, but I should be able to observe again another time when the group is smaller.