Gastroparesis (part 2)

Groombridge Place, June 2013

In part 1, I described the symptoms of gastroparesis, what might be causing it in someone with diabetes, and the problems that arise - gastrointestinal symptoms, poor glycaemic control, malnutrition and weight loss, and depression. Now I'm going to write about possible treatments.

Nerve damage, if that's what is causing the problem, is irreversible. We can't (yet) mend nerves: once they're gone, they're gone. There doesn't seem to be an option to fix the faulty pacemaker cells either. But it is always useful to run through a list of things that will definitely not be helping. For example, opiate drugs are known for their constipating effects, and should be replaced with alternative painkillers if pain relief is necessary. Cigarette smoking has been shown to delay the gastric emptying of solids. Unfortunately, high blood sugar has also been shown to significantly delay gastric emptying, which is of no comfort to the person with diabetes who has been trying unsuccessfully to manage wild swings in blood sugar in the face of unyielding opposition from the gastroparesis itself. So I wouldn't bother opening that particular can of worms.

There are three methods used to help improve gastric emptying: pharmacotherapy (i.e. drugs), diet and surgical approaches. Two types of drugs can help with symptoms: prokinetics, which help to speed the intestinal contents on their way, and anti-emetics, which are used to prevent nausea and vomiting. These are routinely used, but changes to diet can be more effective than the medicines.

The Glycaemic Index (GI) is often used to assist with blood glucose control and weight management, and describes the speed at which carbohydrates are digested. High GI foods e.g. foods containing large proportions of monosaccharides and disaccharides (sugars) are digested quickly, and their glucose payload can reach the bloodstream before subcutaneous insulin has had time to get there, causing blood glucose to rise beyond the desired range. Low GI foods (complex starchy carbohydrates) such as oats and pulses are digested more slowly, and therefore deliver glucose to the blood slowly and more controllably, and keep you feeling fuller for longer. Unlike the majority of people with diabetes, high GI foods may help someone with diagnosed gastroparesis. These foods tend to contain simple sugars or processed carbohydrate and little fat and fibre - sweets, white bread, mashed potato.

Another good reason to avoid fibre, apart from its role in slowing gastric emptying, is that as it hangs around in the stomach it can contribute to the formation of unwanted fibrous masses called bezoars. The disadvantage of avoiding fat, however, is that someone with chronic gastroparesis is at risk of malnutrition, and could do with the calories supplied by energy-dense fatty food.

The diabetologist who referred the patient with gastroparesis to me suggested that a low carbohydrate diet might help reduce the volatility in blood glucose levels. The problem with this approach is that taking out the carbs leaves an energy deficit that can either be filled by protein or fat. Protein increases feelings of satiety, which is certainly not what we want, and fat slows gastric emptying. Blood glucose levels may be better managed with a greater proportion of high GI carbohydrate, which might actually be released from the stomach in a more predictable manner.

Research suggests other dietary recommendations, both to relieve symptoms and to maintain nutritional status. Small frequent meals are digested better than three large meals a day, and 'particle size' makes a difference - food should be chewed well, and liquids seem to leave the stomach more easily than solids. A patient might be prescribed three liquid supplements a day, adding a much needed 900 calories. Positioning during a meal, and sitting up and/or walking post-meal can promote gastric emptying; alcohol and carbonated drinks tend to exacerbate symptoms of bloating.

Placing a feeding tube below the stomach and pylorus in the jejunum (upper small intestine) allows nutrition to bypass the problem area, but brings with it the risk of infections and the inconvenience of having to be hooked up to a feed pump for hours at a time - jejunal feeding has to be much slower than feeding into the stomach. If nutritional status continues to decline, intravenous (parenteral) feeding is a possibility, but brings a whole new range of potential complications.

As well as addressing symptoms and nutrition, there are those pesky blood sugars to consider as well. Eating a meal containing carbohydrate requires a matching dose of insulin in order to maintain blood glucose within the desirable range, but we have seen that giving the insulin at the usual time (before, during or immediately after the meal) doesn't work if the glucose hits the bloodstream over a period greater than the lifetime of the insulin. So we could try splitting the insulin dose, perhaps giving 30% of the total dose just after eating, and the remaining 70% after an hour, or two, or whenever we think blood glucose is rising.

If you don't want to end up as a pincushion, this type of insulin regimen can be managed much more comfortably and conveniently with an insulin pump, which can be programmed to deliver insulin at whatever rate you desire. Delivering 6 units of insulin at one-tenth of a unit every five minutes over five hours can't be done with conventional insulin injection devices, but is a piece of cake with a pump.

Unfortunately the NHS doesn't fund Continuous Glucose Monitoring (CGM) systems, which have a subcutaneous sensor that samples interstitial fluid every five minutes linked to a device that translates the reading into an estimated blood glucose level. We lend these systems to patients to wear for just seven days at a time when we can't work out what their blood glucose is doing. Otherwise, users have to buy the kit and consumables themselves, which works out rather expensive. Although not mentioned in the research papers I have read about this condition, I think that CGM in combination with an insulin pump would be a valuable and effective approach to managing blood glucose with gastroparesis.

Finally, there are more technical and innovative options to try.

• Gastric electrical stimulation (GES) was approved in 2000 in the USA. Similar to a heart pacemaker, the GES device is implanted next to the stomach and mimics the role of the gastric pacemaker cells, stimulating and enhancing vagal function and muscle tone. 
• Botox (Clostridium botulinum toxin) is a muscle relaxant used cosmetically to reduce facial wrinkles, but will relax muscles elsewhere to therapeutic effect. Injecting Botox into the pyloric sphincter may cause it to relax sufficiently to allow better gastric emptying, but trials have shown this effect to be short-lived. 
• In future, that universally-cited panacea 'stem cell therapy' may be relevant, providing a way to replace or rejuvenate those faulty pacemaker cells of Cajal.

Diabetes

Garden wall, Royal Tunbridge Wells, May 2012

I've been trying to squeeze in some personal development time alongside the demands of the wards and my clinic, in the specific area of diabetes. So far there have been three opportunities. The first was observing part of a session of 'structured education' aimed at people with Type 1 diabetes, then I sat in on part of a specialist diabetes clinic with a Dietitian, and the last was part of our clinical supervision in the department.

The National Institute for Health and Clinical Excellence (NICE) publishes guidance describing good practice for various health conditions, including diabetes. One of the elements of good practice for diabetes is 'structured education', where people with either Type 1 or Type 2 can attend tailored programmes covering the important aspects of the medical condition, its treatment, and best management by healthcare staff and the patients themselves. The programme for Type 1 diabetes has been developed locally, comprising four full days delivered once a week over four weeks to a group of up to eight people. I attended the start of Day 2.

Since the first session on the previous week, participants were supposed to check their blood sugar at least four times a day (before breakfast, lunch, dinner and bed) and bring the readings along to the second session along with what was eaten that day and any activity within the day. Looking at highs and lows through daily readings over a week can allow better adjustment of insulin: basal (background) dosage of long-acting insulin, bolus 'ratios' of short-acting insulin to match carbohydrate intake, and adjustments for out-of-range high or low readings, activity, stress or illness.

I've seen this type of activity before, so I'm getting more familiar with the 'basal-bolus' regimen of insulin management. The learning points for me at this type of session were more about ways to work with the people involved. The reason they have been invited onto the course, and the reason that they agree to attend, is usually because of 'less than ideal' blood glucose management, so it is fascinating to see the issues they bring to the session. Most straightforward are the ones who just haven't been given the information before, so didn't know how insulin could be matched to carbohydrate intake and activity. They suck up the lessons on carb counting, and off they go. The interesting ones are those who have already been given the tools and knowledge, but aren't carrying it through to daily life. That's what guided most of my questions to the Dietitian later - how do you deal with knowing that your input may make no difference? How do you manage your own frustrations?

The same sort of questions arose in the clinic, where I sat in on three consultations. It is a sobering thought  that diabetes doesn't distinguish between people who are educated and numerate and those who live chaotic lives and can barely carry out the calculations required to keep them healthy. Timings of injections, blood sugar readings, calculating carbohydrate per portion multiplied by the ratio of insulin to carbohydrate or working out how much carbohydrate to eat based on a fixed insulin regime - these are not easy or straightforward decisions. Even knowing which foods have carbohydrate and why it matters is quite challenging for many. Add to the mix the range of lifestyles that exist in all the various strata of society, and the unpleasant and life-threatening consequences of getting it wrong - it seems to me that sometimes the Dietitian just has to work out what the most important single piece of information is, because not much more can be done in some cases.

In clinical supervision the basic grade Dietitians get together each month with a more senior Dietitian, and talk about a topic. We had a short Q&A with one of the diabetes Dietitians and a Clinical Nurse Specialist in Diabetes. This was much more relevant to everyday life on the wards, and related mostly to enteral feeding. If someone on insulin is being fed via a pump at 100 ml/h for 15 hours, when should they be given their insulin, and what type should it be? The answer is generally half of their dosage of short-medium acting insulin at the start and half in the middle of the feed, and the background dosage consistently at the same time each day (it is not critical when this time should be). The dose halfway through the feed may be at a time like 3 a.m. if the pump is running overnight, so it may be worth reconsidering the timing - and the hundreds of other considerations that might affect things - medication, hydration, how likely the nurses are to give the right amount of insulin at the right time, and so on.

People with diabetes in hospital wards have a lot to contend with, especially if they are not allowed to manage their own medications. Hospital food may not turn up when it should, it may not be what was expected, it might be very difficult to judge the carbohydrate content, their appetite may be variable, and blood sugar control is notoriously difficult when the body is stressed, even without additional factors like vomiting. If the nurses are administering insulin, then they should be very aware of whether food has been eaten or not, and what it consisted of, but it is hard to imagine that every nurse would take all these factors into account. There is a 'nurse-friendly' option of 'sliding scale' administration (or VRII, variable rate insulin infusion) whereby blood glucose is measured hourly and short-acting insulin is given based on the reading obtained. While this is likely to prevent severe blood glucose highs or lows, it isn't very patient-friendly, demanding many blood tests a day and preventing any prophylactic control of blood sugars. On VRII, even if you know you've eaten four scoops of mashed potatoes, you can't anticipate the increase in blood glucose, but have to wait until it happens and then treat it.

There has been a campaign on the wards to raise the profile of diabetes and its management in hospital, but whether the principles are always put into practice is doubtful, given the multitude of competing priorities that the nursing staff have to deal with. And the reality of where each patient was coming from. I was asked by one nurse to see a diabetic patient who was 'always eating the wrong things', resulting in higher than desirable blood sugar levels. When I reviewed the patient's notes, it turned out that he was over 80 and had had some previous bad experience with hypos. At that age, the short-term risk of dying from a hypo far outweighs the long term risk of organ damage from high blood sugars, so I told the nurse that I would behave in much the same way as the patient if I were in his shoes and left him alone.

Feeds, food tasting and hand-washing

On the M40, May 2012. No, I have no idea.

Back at work to a three day week after a ten day holiday was challenging last week, and demanded all the prioritisation skills I have. My colleagues dealt with the urgent referrals on my wards while I was away, but there were plenty of non-urgent cases, and other colleagues were away when I was back at work, and I had to reciprocate and cover their urgent referrals. Added to that, I had a food tasting session, a department meeting and compulsory training on hand-washing to squeeze into those three days.

So I prioritised the tube-fed people - those who can manage to eat just had to get along somehow until I could get round to them. And, of course, they were all slightly 'interesting' cases that needed extra time and attention, rather than the quick, straightforward, 'just calculate the total requirement and divide by the number of hours the feed is delivered' cases.

There was one whose feed rate had been reduced to a bare minimum because of unpleasant side effects, so I had to try and consider how to tweak the feed schedule to meet the patient's nutritional requirements. Another was a patient who was frail and elderly, and one of the reasons for admission was because he'd stopped eating - in this case, the purpose of artificial nutrition has to be clarified, because the patient was not suitable for a permanent PEG tube but wouldn't be able to go back to the nursing home with an NG tube. This is one of the worst possible situations - do we allow the patient to remain on the ward indefinitely just so that he can be fed? If not, what is the alternative? Ultimately it's the doctor's decision, but my job to raise the issue to try to ensure that a decision is made.

Another patient had received a trauma injury and had come from Intensive Care where they had placed an oro-gastric tube, which is an alternative when the naso-gastric route is not appropriate - but the tube had come out and nobody on the ward quite knew whether another oro-gastric tube was needed (which would have to be put in place by a doctor) or whether an NG tube would do (which could be placed by a suitably-qualified nurse). Then just as I thought it was all over, there seemed to be another new NG feed schedule needed, except when I got to the ward there was no NG tube in place and some confusion about whether one was needed or not. I didn't hang around to find out - if they'd decided to go ahead there were options they could implement for the weekend and I could re-visit the patient on Monday.

The food-tasting happens about four times a year, and had been scheduled by the hospital Catering department before the Bank Holiday had been moved. This is probably why it had ended up in a three-day week, and that was why only three of us turned up: me, the manager of the Dietetic service, and a member of the lay panel that represents the interests of patients. We were outnumbered by the catering staff hosting the tasting session.

There being no such thing as a free lunch, our job was to rate all the available foodstuffs by appearance, smell, texture, taste, temperature, and anything else we could think of. All the day's standard main course menu items were there, plus a few extras: a 'fork-mashable' option, two from the 'ethnic' menu, one of the 'Lite bites' that are available outside regular mealtimes, plus a couple of puddings. Served at the perfect temperature in this calm, controlled setting, all the meals were pretty good, with a couple of really outstanding options and a couple that were just OK. Served in the normal overworked ward environment, where they may have been heated up for too long or not long enough, and may take a little while to actually reach the patient, I imagine some options may in reality be less attractive.

The compulsory hand-washing training was fairly straightforward, except that I refused to have the UV-fluorescent liquid applied thanks to its paraben content. So the infection control nurse just watched me washing my hands. And he was delighted when it turned out that we had their missing UV light box, which had been loaned to our department and then forgotten about to the extent that they'd given it up as lost.

With my holiday just a dim and distant memory, so the week ended. Some time has passed without me managing to get this blog updated, and much has happened - Sister D celebrated her silver wedding anniversary, Mr A is spending three weeks on 'work experience' in Manchester, and all my wards were swapped for different ones. More to come as soon as I can manage it.

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.

Presentation

Leaves, Wisley, August 2011

My presentation on Re-feeding Syndrome (RFS) went very well, although if I were to do it again I would make a few changes. The audience was small, and all were doctors. Last week was when all the junior doctors changed to a different department on rotation, so there were five brand new doctors in attendance, with their consultant and clinical educator who is one of my favourites. To be honest, any doctor that knows who I am is one of my favourites, but this one has been particularly helpful and welcoming.

The consultant kicked off by giving the new doctors a bit of information about how their placement was going to work, and then I was introduced by the registrar as a Senior Dietitian. I had to explain that despite my appearance I am actually a very Junior Dietitian, only two months old in Dietitian Years.

I embarked on the presentation, which I had been given ready-made by one of the senior Dietitians in the department, saving me no end of time in putting something together. I'd tweaked it a little bit, but not much. It wasn't designed for such a medical audience, so I had to supplement it with some hard facts about treatment, and then we talked a bit about how to manage ward procedures to cope with any patients who actually were at high risk of RFS.

So what exactly is Re-feeding Syndrome? It's "a potentially lethal derangement of blood electrolytes (potassium, phosphate, magnesium and sometimes others) caused by a switch to carbohydrate metabolism from fat and protein metabolism."

What that means in ordinary language is that in normal circumstances we use mainly carbohydrate for energy, adding to or removing from fat reserves if carb intake doesn't match energy expenditure. We don't store a whole lot of carbohydrate - I believe that when marathon runners hit the 'wall' it's when their stored glycogen is used up. For normal people, it would take about two days. After that, our metabolism switches to using mostly fat for energy, which works pretty well as a substitute, as you might expect. When the fat is gone (and to some extent, before the fat is gone) we turn to protein for energy, turning muscles into fuel.

The problem in RFS happens when carbohydrate intake starts up again, and metabolism switches from burning fat/protein to carbs. If the interruption was only a few days, and the individual was not underweight or malnourished to start with, then there's no problem. If it's a particularly thin person who hasn't eaten for more than 5 days (and there are a few other more obscure risk factors) then the risk rises with the rate of feeding. What actually happens is that energy generation using glucose starts up inside cells, which sucks the materials it needs out of the blood to make ATP for energy. The concentration of these electrolytes and vitamins in the blood drops, leading to potentially fatal consequences.

There are not many acute life-threatening conditions that a Dietitian encounters, so there is a good deal of emphasis on RFS in the Dietetics degree. I assess every patient I am asked to see, and if RFS is a possibility I will indicate it in every way I can - in the medical notes, nursing notes, and to the medical and nursing staff on duty.

The main approach for prevention of the Syndrome is to take great care not to feed the patient too much too quickly, and provide them with vitamin supplements. Monitoring the success of the approach is generally by way of monitoring levels of potassium, phosphate and magnesium in the blood, and replacing these if they drop. It is highly unlikely that someone will succumb following ordinary eating and drinking, but much more likely if they have had a period of no oral intake followed by tube feeding, as in the case of a stroke that has disrupted the process of swallowing, for example.

The way we manage tube feeding is that I write down the rate of delivery of the feed and the number of hours it should be given. On each successive day my regimen shows a slightly increased rate of feeding, and in someone at high risk, it is important to check blood results before the rate is increased. The main issue we face is that while I produce the feeding regimen, the nurses actually control the delivery of feed, and the doctors order blood results and review them. At the point when the rate of feeding increases, I definitely won't be there, but the nurse setting up the feed should check that a doctor has reviewed the blood results and approves the increase in feed rate. I wonder if this has ever happened. Mostly, I imagine, we've been lucky and nobody has died.

At the meeting, after I'd done my lecture, I presented this problem and asked for suggestions. The best that we could come up with was the liberal use of a highlighter pen in notes and other records to ensure that the risk is not overlooked, and checkboxes to be ticked to try and ensure that blood results are reviewed appropriately. I have two potential re-feeders at the moment, so we'll see if it makes any difference.

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.

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.

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.

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.