ED

Monastery in Melk, October 2012

There's not much I can write about on this blog, due to my self-imposed rules of not breaching patient confidentiality and trying not to write anything that isn't positive and constructive. That's why I am so delighted when something happens at work that I can write about.

In the diabetes department we have quite a few lunchtime educational talks, often from reps trying to sell something. Doctors, Diabetes Specialist Nurses, Therapy Assistants and Dietitians all attend on an irregular basis - there is no compulsion, but the lunches are often attractive. This week, a talk was advertised entitled 'ED and lifestyle'.

Eating Disorders afflict people with diabetes in the same way as in the general population, but Type 1 Diabetes brings with it the 'opportunity' for weight loss by under-dosing insulin or omitting injections. Glucose from dietary carbohydrate enters the bloodstream after digestion, but without insulin it cannot leave the bloodstream to be used for energy or stored as fat. The level of blood glucose increases, and when the renal threshold is exceeded, it is excreted by the kidneys into the urine. Incidentally, this is how diabetes used to be diagnosed before insulin treatment was available - the urine tastes sweet because of the glucose in it. So by ensuring that there is little or no insulin about, calories in food are disposed of before they can cause any weight gain.

The drawback of this strategy is ketoacidosis. If glucose is unavailable as a source of energy because of a lack of insulin, then fat is burned instead, resulting in the production of ketones, which are toxic. If ketones accumulate in the blood then the blood becomes acidic, and this is called Diabetic Ketoacidosis (DKA), which is a very nasty condition, and can be life-threatening. It is what diabetics used to die of before insulin therapy was invented. In addition, maintaining the kind of high blood sugars that are necessary to achieve this metabolic state greatly increases the likelihood of complications such as blindness, kidney failure and nerve damage.

The practice of under-dosing insulin and continuously hovering on the brink of ketoacidosis has been termed 'diabulimia', and it has been proposed in some quarters that it should be formally recognised as an eating disorder associated with diabetes. So when RSB and I found out that there was to be a talk on ED and lifestyle, we thought it would be really interesting, and very relevant to our work. Unfortunately, another meeting about student placements that we really had to attend had been scheduled at the same time.

Nobly, RSB volunteered to go to the student placement meeting while I attended the ED talk. The room filled up, and the speaker started with some slides about how inactive the UK population had become, and how this is contributing to the obesity epidemic. Nothing new for me here, but I wondered what the relevance was to Eating Disorders. I also wondered why so many doctors had turned up, because they are busy people and I didn't think that the topic would be a priority for them.

Two minutes later I quietly slipped out of the room, and went on to the student meeting, which had pretty much finished. RSB filled me in on what had happened there, and asked what I had learned in the ED lecture.

"You thought the same as I did, didn't you, that ED stood for Eating Disorders" I said.

"Yes," he replied, "Doesn't it?"

"Ah," I said. "No. It turns out that ED doesn't stand for Eating Disorders where diabetes is concerned."

"Oh." He thought for a moment. "What does it stand for, then?"

"Erectile Dysfunction."

Once he had finished laughing, he amused me further by telling me that he had met the speaker just before the talk, and apologised that he wouldn't be able to stay, but said that we were very interested in ED and lifestyle and I would be there and would feed back to him, and we could take the speaker's contact details if we needed to follow up later. On reflection, I don't think we will.

Low potassium diet

Leamington Spa, May 2012

My thanks to readers who went to the lengths of Googling following my last post, to reveal that SOL in the context of a head scan stands for Space Occupying Lesion (i.e. probable tumour or perhaps a bleed). I somehow don't trust Google to come up with accurate medical abbreviations, but in this case it seems plausible. And nice to know that people other than my immediate family are still reading. My stats last week show 80 unique visitors to this blog, while the previous (now defunct) blog still received 76 unique visitors in the same week. The difference is that the new blog had 55 returning visitors last week, while the old only has 5.

Further feedback from last time asked why I wasn't willing to provide information about a low potassium diet to a patient. This case led to the first proper contact I'd had with the renal Dietitians, who inhabit an adjacent room in the department. The hospital has a large specialist renal unit and is some sort of centre of excellence for kidney disease, so we have quite a few renal Dietitians. Sometimes I bump into them on my wards, if one of their patients develops a condition alongside their renal impairment, and is put in a bed somewhere other than the renal wards.

So here's the scenario: a patient on one of my wards has a raised blood potassium level (which may be harmful if it continues), and one of the doctors asks me to give the patient some advice on following a low potassium diet. They insist it is not a renal patient, otherwise I would have handed it over to a renal Dietitian straight away. But putting someone on a low potassium diet who isn't a renal patient is somewhat unusual to say the least, and one of the threads running through everything we do as Dietitians is to avoid unnecessary dietary restrictions that could put an individual at risk of a dietary deficiency. It might also alarm, confuse or distress them without commensurate benefit to their health.

Add to that uncertainty the fact that giving advice on a low potassium diet is something the renal Dietitians do all the time and I've never needed to do so far, so I needed to read up a bit on what's required and find the most appropriate information sheet from the files. Because we've got a whole load of renal Dietitians sitting in the next room, it made sense to ask them for advice on what I should do.

At this point, to their credit, they didn't just answer my questions, but asked a whole lot more of their own. What is the current potassium level, and what has the trend been in the past? What are the other U+E's like (blood urea and electrolytes), including creatinine (which can give an indication of the level of renal impairment)? What is the main presenting complaint? Is the patient diabetic, and if so, what is their blood sugar control like? What medications are being given, and have any been changed?

Of course I don't know the answers to any of these questions. All I'd been asked to do is provide information on a low potassium diet for someone who isn't a renal patient. So at this point, I started to learn a whole lot of new stuff about potassium metabolism and renal function.

We looked up the trends of blood results on the computer system, and the renal Dietitian pointed out the trends of high creatinine at certain points linked with higher potassium results, suggesting that these indicate times of acute kidney injury, plus the ratio to blood urea showed something else that I can't quite remember. Since the referral, recorded potassium levels had returned to the high end of the 'normal' range. The patient is diabetic, and blood sugar results were higher than one would wish. Insulin also helps to remove potassium from the bloodstream along with glucose, so poorly controlled diabetes will often mean higher levels of blood potassium. The renal Dietitian did a quick calculation that suggested that the patient's estimated kidney function was not impaired to a degree that would require dietary restriction.

I headed up to the ward armed with this information. I was still blindly following orders, and reviewing the medical notes I looked for specific medications that the renal Dietitian suggested might be there. There were also other features in the notes that I can't write about here, all of which suggested that limiting dietary potassium was actually not going to make a whole lot of difference. So I bleeped the doctor to try and discuss the case, but was told in no uncertain terms that I had been asked to provide advice on a low potassium diet, and they would be very grateful if I would do just that.

So I called in the cavalry, and the renal Dietitian came up to the ward, went through all the information we had gathered, and wrote her assessment in the medical notes, concluding that because the high potassium was not caused by dietary intake (and bearing in mind several other documented factors), it did not seem appropriate to offer dietary advice, and the medical steps being taken seemed to be working anyway. It was a masterly summary, which I hoped to copy along with lots of other information so I can document the technicalities of renal Dietetics that I've learned from this case, and add it to my CPD portfolio. But the patient has already been discharged, and I've no idea where the notes go when that happens.

New wards

The Thames from the Woolwich Ferry, May 2012

My (not so) new wards are busy busy busy. Or at least one of them is, referring patients left right and centre via telephone, or face to face when I wander too close. I'm just about keeping up at the moment, mainly because clinic this week was, in contrast to last week, slow. Only three patients showed up. But it was still difficult - they weren't easy to deal with. I don't think I told one patient anything she didn't already know and she is frankly sceptical that it will work, another patient I doubt will take my advice at all, and the third may or may not follow my advice but it probably won't make a lot of difference to the (hereditary) medical condition that she has. But I still enjoy the clinic far more than working on the wards.

Anyway, the (not so) new wards have urology, respiratory and rheumatology patients. There are a whole load more new abbreviations to learn, and new medical conditions to encounter, and I have discovered that a 'productive cough' is a really, really unpleasant thing when you are having a conversation with a patient. There are still quite a few patients needing tube feeding, and often for swallowing difficulties, but I haven't yet worked out how come they feature so heavily on urology or rheumatology wards. Respiratory makes sense: many of the patients have neurological conditions that affect both breathing and swallowing.

• Favourite abbreviations so far: 'TWOC' (Trial Without Catheter) and 'SOB' (Short of Breath). The latter is actually an abbreviation I've known for a long time and is still my all-time favourite. 
• Second and third favourite abbreviations of all time are OTT (On The Throne [toilet]) and TTO (To Take 'Ome [Out]) for medications and supplements that need to be sent home with the patient.
• Abbreviation that I've seen a number of times following CT scans of the head (I think) and still don't know what it stands for: 'SOL'
• Least favourite words that feature heavily in medical notes: 'sputum', and 'productive cough'.
• New word of the week: 'fasciculation', which is involuntary muscle twitching.
• Word that I am most proud of remembering since I first learned it: 'kyphosis', which is curvature of the spine into a hunchback shape.

I have also had a run-in this week with a doctor about providing a patient with information about a low potassium diet. In the end I had to call in a grown-up, in the shape of one of the specialist renal Dietitians, to back me up and write in the medical notes about exactly why it wasn't appropriate to provide this information to that particular patient. Now I need to embed this information so that I understand better all the reasons why blood potassium may be raised, and by which dietary and non-dietary factors.