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.

Reducing the workload

Wisley, August 2011

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

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

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

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

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

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

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