Outpatients and inpatients: clinics and wards

Groombridge Place, June 2013

The consultant-led clinics have been a bit like a roller coaster for a week or two. One of our regular consultants has been ill, and sometimes another doctor has provided cover, and sometimes the admin staff have had to try and contact everyone to cancel at short notice, and sometimes patients have turned up and been seen or not seen depending on who's available and what's needed.

For one particularly busy pump clinic (where patients with Type 1 Diabetes who are using insulin pumps usually spend much more time with the Diabetes Specialist Nurse than in most clinics), we only had one DSN, and the consultant delegated the clinic to two subordinates, neither of whom was familiar with how to manage a patient using a pump. This meant that the poor DSN had to support the doctors as well as trying to do her own job. The whole thing provided a pretty unsatisfactory experience for the patients - none of whom complained, despite having to wait ages.

The whole scenario was relayed back to the consultant, who overcompensated the following week by bringing three doctors with him. Unfortunately we don't have enough rooms in the building to house all these doctors as well as ourselves, and consequently neither the DSNs nor I were able to see patients and we had to squeeze into rooms occupied by researchers and secretaries. There were also far fewer patients booked into this clinic than the previous week, which meant all these doctors had long gaps between patients. At one point, a patient with a baby and a toddler was dealing with a nappy change in the room I was in, and the only place left for me to sit was in the waiting room.

This is unusual - most of the time the clinics run pretty efficiently and on time, and most times I get to see the people I think I should be seeing. I have taken to advertising the very low carbohydrate lifestyle with a few posters on the wall, and flyers given to the patients that I think might benefit. This has rustled up a few candidates, and I am starting to build towards a group that can meet regularly to share experiences and recipes and generally keep each other motivated. There are plenty of others who don't need or want to follow that diet, and I am still seeing new people all the time. It is always very interesting, even if I sometimes end a consultation thinking that I could have done better. There are plenty where I feel I did well.

And in between all this interesting and rewarding outpatient contact, for the last five weeks I have had to spend a day a week on the wards. I've disliked this type of dietetic work from the start, and now I've come to hate it. I would rather spend hours with a recalcitrant diabetic who has no intention of taking any advice from me or anyone else while ignoring spiralling blood glucose, than 15 minutes trying to get a confused malnourished inpatient to drink a sickly sweet milky supplement because that's all we have to offer. I would rather be resigned to the inevitability of diabetic-related complications than despair at the likelihood of hospital-acquired pneumonia.

I have enormous respect for the nurses and healthcare assistants on the wards, who are frequently doing three or four things at the same time, often unpleasant and involving bodily fluids or orifices or both, and who listen to me with patience and good humour even while I'm telling them what they already know. But despite my regard for ward staff and their dedication to doing the best they can, the institutional setting thwarts most of their best efforts. I heard today about a patient with Type 1 Diabetes - elderly, frail - who kept having hypos while in hospital, so the doctor stopped their insulin. Just stopped it. Two days later, the patient had to be transferred to the main hospital for life-saving treatment in intensive care.

Our health service is amazing - the care that is offered without additional payment in NHS establishments is incredible. But I would do almost anything to avoid having to spend even one night in a hospital ward.

Diabetes services

Greek sunset, June 2014

I've got a half-written blog post that I've been trying to finish, but it's taking ages because it needs a bit of thinking time and I'm just not getting round to it. So I'll do some writing off the top of my head, just to keep things ticking over.

I'm still working five days a week, being paid for about five hours on that fifth day doing general dietetics on the wards, which means mostly nutrition support. The hospital is a small one with only six wards, and holds patients who are not acutely ill and/or who live in the area. They are generally old and not actually needing further treatment but cannot go home until some sort of provision is arranged to make sure they can cope (a 'Package of Care'). Nearly all those who need dietetic input are not eating or drinking well, usually because they have dementia. I absolutely hate it. I have two weeks to go before the Dietitian who has been off sick is due to return, and I shall do everything in my power after that to be completely unavailable for this type of work in future, although there will be a lot of moral pressure to 'help out' if a similar situation happens again.

My real job is still very interesting. I have managed to start two people on the very low carb plan, but unfortunately one did not return for the follow up appointment and wasn't answering the phone when I rang. My first Structured Education course for people with Type 1 Diabetes finished this week. This is designed to give people a lot of information and practical experience of how to best manage their diabetes, and we run it one day a week for four weeks. We had eight attendees, and all of them seemed to get a lot out of it. I found it a little stressful to have so much responsibility for delivering material that is so critical to the course.

At least half of the course is about carbohydrate counting. This is a skill that is fundamental to good control of Type 1 Diabetes for those who want to have the flexibility of eating what they like when they want to. Teaching carb counting is a core skill for a Diabetes Specialist Dietitian, and I would say I have reached an intermediate skill level - not too bad, but I've only been doing it in earnest for a few years. Nearly all of the people on the course have had diabetes for much longer than that.

Despite my nervousness, it went quite well, although I think I can improve with practice. We cover all sorts of ways of estimating the carbohydrate content of food - using food labels, weighing food and using reference tables, using apps, websites and pictures, and plain and simple educated guesswork. The part that makes me a little bit uncomfortable is that while my estimates are based on my experience with a number of different people as a day job, I don't actually act on the data and inject insulin, so I don't get any personal feedback about the accuracy of my estimates. When I get it wrong, it's someone else that suffers. I take this responsibility very seriously, so I often lose sleep worrying about whether someone I've seen in the day is going to end up with very high or very low blood glucose as a result of something I've said.

As well as the course and the individual consultations, there has been some discussion in the Trust and the Clinical Commissioning Group about funding to expand the very low carb programme that we offer. This has caused some controversy, because we haven't any solid evidence for its value in our service. We have lots of anecdotal evidence of patients who have found it life-changing (in a positive way), and we have a spreadsheet with lots of data, but the data hasn't been analysed and there's been no data collection from those who haven't found it helpful, nor have we sought views from anyone who may have experienced negative effects.

There are a number of healthcare professionals in our Diabetes service who are positively messianic about the plan, and they are all in favour of the expansion in funding because they have seen so many people find it beneficial. Having joined the service so recently I am more sceptical, and feel that we must carry out some analysis of our data to provide evidence of benefit and investigate any negative aspects properly. Our Team Leader has very sensibly defused the situation with an eminently rational proposal, including the view that we should be offering people choices rather than putting all our energies into selling the low carb idea.

Whenever I have met up with other Diabetes Dietitians, I have asked them their views on very low carb diets. So far I haven't met any that are offering anything like our plan, but they have all been very interested in hearing about what we do. I would like our next stage to be a proper audit of what we have, if not a research project culminating in a peer-reviewed publication, but I'm not volunteering for the job.

Shopping and running

Just a nice picture from 2004

Good news

The gastroparesis article is finished, the editor seems to like it, and has sent a pro-forma invoice for me to submit. They are going to pay me! Given the amount of time it took, the hourly rate probably works out at less than the minimum wage, and I ought to declare it for tax, but on the whole I think this qualifies as good news. Finishing the writing has freed up my Tuesdays for more interesting things.

I have been on a shopping spree. Nearly all online, of course, but still, it felt like going into the street and throwing money at things that I've wanted to get for a very long time but it was just too much effort to go into shops. Quite ordinary things mostly: a dish drainer tray, oven gloves, electronic kitchen scales, a new kitchen bin. The bin is not ordinary because it is a luxury touch-top item from Brabantia and cost more than all the other purchases put together, but it is a thing of beauty while being utterly functional.

I also bought a new mobile phone, or more accurately, a phone contract that comes with a new mobile phone. It had taken me two years to bump up against the limitations of my first smartphone, but eventually I realised that I should be able to download more than two apps and use the camera without it seizing up. It took a few long sessions on the Internet and a fairly extended discussion in a shop, but my new mobile has changed my views on smartphones, and has excelled in an entirely unexpected field - my running.

I downloaded an app that used the GPS signal to track my location and speed. This was hopeless on the old mobile, but the new one coped very well. I turned the app on at the start of the run and then examined it at the end and it told me all about my route and speed and it was great. Then it emailed me a link to create a Spotify playlist, so I thought that would be fun. I no longer need or want the plinky-plonky music that came with the Couch to 5k podcast, but it's much less boring to run when listening to music.

The revelation came when I managed to put all these things together for my second Parkrun. The phone was robust enough to access and play the music, and I started up the running app alongside it and they both worked together, and I plugged in the earphones and I could listen as I ran. It wasn't even raining. All of a sudden, a few minutes into the run, the music was interrupted for a second and the running app gave me an update on how I was doing - how far and how fast I had run. I'm no newcomer to the power of the Interwebnets, but this was a combination of utility and ease of use that I found astounding.

So my running career has culminated in a time of 35-and-a-bit minutes for 5 km, which I am very pleased with. A friend was also there on Saturday, and speaking to him afterwards I was sure that I wasn't going to do any more runs, because all the way through I'd been thinking how tedious it all was, and how much more fun it is playing badminton. Subsequently, however, I looked back on the event with some pleasure, and now I'm not so sure that I won't do it again. I think our holiday will get in the way, but we'll see.

Lastly in the good news category, I spent the best part of a whole day cleaning the oven. Not good news in itself, but it doesn't half look nice when it's clean. That should last about a week.

Bad news

I mentioned that my ipod died and was revived - well, it has died again. Rather than ending my life, Mr A has generously lent me his, which is so far performing as it should, unlike my laptop. The poor laptop has been groaning and shuddering for a while, taking about 20 minutes to boot up and generally being more sluggish than a snail without a home. Mr A bought me a new hard disk and operating system, and once the gastroparesis article was finished I started installing it. Unfortunately, the new and powerful hard disk seems to overtax the geriatric laptop (born in 2009) so that after about 10 minutes of usage the fan fires up noisily and within a minute or two it shuts down without further ado. That's as far as we've got with the laptop. Mr A is experimenting with my ipod to see if he can keep it alive for a bit longer.

Meanwhile at work, there is bad news masquerading as good news. The Dietetic Manager is juggling her many fecund female staff who seem to come back from maternity leave for all of three minutes before admitting to being pregnant again, and that's not counting the ones whose family members require their immediate attention or are themselves needing some time away from the office. Not to make light of a distressing situation, one of the two hospital Dietitians where I work is unavoidably absent, and the Manager is taking none of my excuses or suggestions, and requires me to spend some time On The Wards.

I have tried to keep this to the minimum that is ethically possible, but I notice that I seem to think patients need a lot less attention than the Dietetic Manager does. I am going to have to see people in hospital beds who need nutrition support, and it is not the area of dietetic practice that interests or attracts me, which strongly suggests I am not going to be very good at it. Let's hope my attitude and out-of-date skill set doesn't land me in trouble. I really don't like ward work.

As a carrot dangling before my eyes, however, the same Dietetic Manager has suggested that more paid work may be available in Diabetes. This has been mentioned before, and timescales are vague, as are the actual content and location of the extra work required. I'm not holding my breath. I've started to enjoy my Tuesdays and I'm not quite so keen as I used to be to rejoin the world of full time work.

Also in the bad news category is the garden. I have done absolutely no work in the garden this year, which has left us with an attractive meadow instead of a lawn, an enormous amount of foliage covering every inch of soil, most of the walls, and causing the 'paved' area to resemble, well, more garden. We are about to go away for a week, and it keeps raining, so the plants may well have staged their bid to take over the house as well by the time we get back. If you look closely, the picture shows the dominance of the ten-foot thistle over the puny efforts of the human race. Although its two colleagues were broken by wind/rain, it has latched itself on to the rose bush and shows no signs of halting its assault on humanity. Luckily, its legs have not yet formed so we may yet be able to conquer it when the time comes.

Lastly in the bad news category, you may have noticed a lack of book reviews (good news for some, I believe). I have picked on the book 'Middlemarch' for leisure reading, and it is proving to be hard going. I've found a few good audio books though, and shall take some less heavy duty reading on holiday next week. I wonder how many I should pack?

Oh yes, our doorbell has stopped working too.

Procrastination

Brixham, August 2012

Each time I post a blog, I think "That was fun, but I wish I had more time to write. Why don't I start the next one straight away?" And then I don't.

This year, and last year, I was the nominated family member to produce the family calendar. This means collecting photos and uploading them and inserting them into the online calendar template and then ordering the resulting calendar for four households. It's quite a lot of work. This year, I thought "I have some pictures left over - why don't I start next year's calendar straight away?" Of course, I haven't.

The car is a filthy mess, and with the occasional early morning horizontal sunshine, I need to clean the windscreen properly on the inside. A job that will take, maximum, 15 minutes. I can't even remember how long I've been meaning to do this. And the interior needs hoovering, but that hardly features on the list.

I stupidly volunteered to be the Secretary of the Monday badminton club, where the only real duty is to get the members of the club registered with Badminton England in October. I finally managed to get it done last week, only to have them come back with an additional job because I'd registered the two under-18's that we have under the wrong code (they are junior club members, not members of a junior club. Doh). I'm not going to predict when that correction will be done.

Thankfully, things that have immovable deadlines tend to get done, like job applications and cleaning when we have visitors. It helps that we have very few visitors. But even things that you might imagine having immovable deadlines don't get done, like Christmas greetings. I would like to wish all who know me a very Merry Christmas and a Happy New Year, because you probably won't be getting cards this year. Postage is extortionate nowadays, anyway.

Things I do spend my time on include watching films with Mr A on the sofa. Last weekend we watched two: The Band Wagon (with Fred Astaire) and Marathon Man (with Dustin Hoffman and Laurence Oliver). Also: reading books, as you will know, and reading the magazines that come from my various subscriptions to professional, charitable and academic institutions. Oh yes, I spend quite a bit of time reading a variety of blogs, and dealing with email. But we all do that, don't we?

At work, we are gearing up for Christmas, with the cardiac wards well ahead of any others in getting their decorations out of storage. There is now tinsel a-plenty in the Dietetic office, shedding shiny strands all over carpets and clothing. We have the office party on Saturday with dinner and dancing, and then a special lunch the following week in honour of two of us who are leaving: one to have a baby, and me.

I have been juggling all these employment options for what seems like months, although looking back it has only been about six weeks. The interview for the nearest job was this morning, and if I had been successful, I might not have had to leave my current job, because there was a possibility of doing both old and new jobs part time. But they were admirably quick in feeding back that I wasn't successful. With near-perfect timing, the HR department from the first job contacted me yesterday to say that all the pre-employment checks had been done and do I still want the job? So I will be contacting them again tomorrow to let them know that I do. So the lunch in honour of two of us who are leaving can actually celebrate two of us leaving, rather than just one.

There has been talk of a buffet lunch in the office as well, and a 'Secret Santa' event where gifts for no more than £5 are bought and randomly allocated among us. There has been some confusion over these ideas, partly because we are running out of dates to hold events. I have, unusually, managed to purchase a Secret Santa gift, but now am slightly concerned that it will not be distributed as planned. The only other time I agreed to take part in a Secret Santa event was when I was working in Birmingham, and I spent a very unhappy lunchtime in shops in the city centre, being jostled by other shoppers, wholly unable to find anything suitable, and getting crosser by the minute.

Work on the wards continues as usual, with the added lottery of odd wards being closed due to norovirus. So far none of my wards have succumbed, but I expect it will happen before the end of the winter. I am quite looking forward to seeing how Christmas is celebrated in a large hospital, especially as I am led to believe that as many patients as possible are turfed out and admissions tend to be few, so there may not be all that much to do. Of course people will continue to have accidents and emergencies, but if we're lucky, not too many will involve malnutrition.

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.

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.

Electronic referrals

Sissinghurst, June 2012

We have a new computerised referral system. The old referral system involved the telephone and pieces of paper with words written on them. Nurses on the wards would phone our office, and the admin team would write some scanty and usually misleading details about the referral, on paper forms kept in a file. When each of us had seen a referral intended for us, we would tick the form to show we were dealing with it, and go off and deal with it. This involved the admin team in answering the phone quite a lot, but on the plus side, they would do some basic triage and reject inappropriate referrals or bleep us if they thought we needed to know about a referral straight away.

The new referral system has been added to one of the many hospital systems that exist. The most surprising things about the introduction of this system were a) that we were told on the Friday that it would start on the following Tuesday, and b) we were given no information about how it would work or what we should do to pick up referrals or manage them once we had them. You can imagine that it has been a pretty steep learning curve, both for us and for the nurses on the wards. The main people to benefit have been the admin staff, who no longer have to write anything on the referral forms, but do still have to tell the nurses who continue to call the office that we don't accept telephone referrals any longer.

It has been an interesting experience, working with a new computer system that has not been designed or adapted for our use. I am still ignorant of the purpose of the change - why ditch a paper system that worked perfectly well for a computerised system that seems to work no better? It is possible that some numbers can be extracted more easily from the computer than from reams of paper forms, but which numbers are they, and what do they mean? If numbers were at the bottom of the change, then surely we would be given some instruction on how the system should be used, so that the numbers extracted would mean what they were intended to mean.

As an example, the nurses on a ward complete one section of the online referral form, and we then open the entry and can see what they have written. The referral has three options for status: when it is created it is 'Open', then it can be 'Under Review', where it sits on a viewable list, or 'Closed' when it still exists and can be viewed and edited, but is no longer on the special list, which only shows referrals that are Open or Under Review.

So we can assume that 'Open' means the referral is a new one. The next thing that used to happen was that we would tick the referral form and do a bit of background research before seeing the patient. We might see the patient several times, before they either died, left the hospital, or didn't need our input any more. At which point should we change the status to Under Review, or Closed?

The system has been in use for nearly two weeks, and the consensus about this has shifted several times. The latest informal discussion concluded that ticking the form in the book corresponds to changing the status to Under Review and typing our initials as the first entry. Actually seeing the patient prompts a change to a status of 'Closed', even though we may continue to see the patient many more times. And now, each time we see a patient, we are supposed to write something on the electronic record as well as writing on the record card.

I imagine that someone will gather the numbers about how many of these referrals are made, and perhaps the time between the various changes of status. That 'someone' will have little information about what these numbers or times mean, otherwise they might have specified what they wanted and told us how to operate the system in advance of going live.

The overall effect of this new system, after nearly two weeks of operation, is that the admin staff have considerably less to do now that phone referrals have almost stopped, but there has been an equivalent increase in workload for nurses and doctors who are now making the referrals online, and we Dietitians having to make additional notes where we didn't before. And our head of service is getting some data that she didn't have before.

There is a positive side to this, however. In time, we will be able to see whether a patient has had previous contact with a Dietitian on a ward, which is very useful information that we don't have at present. We might also be able to see details of what was done on that previous occasion without having to track down a physical card that might be archived in a warehouse somewhere. The electronic referrals also have scope for the nurses to provide a good deal more relevant detail about a patient than they used to on the phone.

The negative aspects, apart from those outlined above, also include the fact that access to computers on the wards is very limited - the doctors are usually using them to look up blood results, scans and x-rays and results of investigations. This has made it quite difficult for nurses to actually do the referrals online.

If you have read this far, you either know me personally and imagine that this blog entry will get more interesting by the end, or sufficiently obsessive not to be able to stop reading until you have finished. Or, in the case of Lola II, you will have skipped the majority of the boring bits and reached here to finish off, which is not a criticism of Lola II, but in this case a very sensible way to deal with a fairly tedious text. Well done for getting here! Next time, perhaps there will be something more interesting. Unfortunately, the most interesting bits are about patients, and what makes them interesting is precisely what makes them impossible to write about.

Henry vs. Schofield

Sissinghurst, June 2012

You will be pleased to learn that this week has been sooooo much better than last week. Two colleagues have returned and only one has gone on holiday, my wards are unusually quiet, and the other dietitians seem to be picking up the extra work at the moment. I don't know if it's deliberate so that I can have a bit of a break, or just that they don't realise I don't have that many referrals at the moment. Instead of seeing loads of patients, I have been constructing presentations.

Some months ago I volunteered to do a presentation about a new set of equations that are supposed to be slightly more accurate for estimating daily energy requirements. We use this type of estimation all the time for patients on the wards, where we calculate how many kilocalories (kcal) and grammes of protein they are likely to need in order to meet their nutritional needs and promote recovery. If they need a tube feed, then we estimate energy and protein requirements in order to judge how much feed to give; if they are eating and drinking then we estimate from their own descriptions and from written records how much energy and protein they've taken in of their own accord, and suggest options to make up the difference.

In an ideal world we would then weigh the patients regularly to find out whether they are gaining or losing weight, and try to adjust our recommendations accordingly. The reality is that either they get better and are discharged, or turn their noses up at our supplements and continue to lose weight, or hang around for ages without being weighed so we don't really know whether our estimations are close to real requirements or not. Up to now we've always used equations for calculating Basal Metabolic Rate (BMR) that were published in 1985 by a chap called Schofield.

Basal Metabolic Rate is not the minimum amount of energy that the body needs to operate, but it is the rate of energy consumption of an unstressed body at rest, lying down but fully awake, at least 10 hours after food and in a thermo-neutral environment (22-27 Celsius). It can be measured directly by monitoring the heat emitted by the body in a sealed environment (calorimetry), which is obviously impractical on the wards, so we have to use equations which differ according to sex, age and body weight.

To estimate the total energy required by a person, we start with BMR and then add on the energy needed due to the stress caused by illness, an estimate of activity, and 'diet-induced thermogenesis' (DIT), which is simply the energy we use to digest our food. In a person who is not metabolically stressed we can also adjust our estimate of energy required by either adding some extra kcal if the individual is underweight, or subtracting some if they are overweight. Beyond a BMI of 30 kg/m² (i.e. if the person is obese) there are a number of other ways of adjusting our estimates.

Back to Schofield - he looked at all the available data from about 1914 to 1980, and came up with his set of (linear) equations in the form '(A x Weight) + B'. It has been recognised for some time that the Schofield equations are flawed, and not only because they don't work for obese people, as metabolic requirements don't increase linearly - fat tissue is less metabolically active than muscle and organs, so BMR tends to plateau as weight increases. The dataset he used included a disproportionate number of fit Italian males, many from the military, whose BMR results were very high relative to the 'ordinary' population, skewing the results. There were also very few subjects from tropical regions.

New research was commissioned to come up with better equations, which were published by a chap called Henry in 2005. It's taken a while for them to permeate through to the coalface, but I volunteered to investigate how the Henry equations compare with Schofield's, with the underlying aim of changing our practice in estimating BMR. Henry did his analysis with more data, excluded all the Italian subjects, and included more from tropical regions, to make the equations 'more relevant to the global population'. His equations are also in the form '(A x Weight) + B', with different coefficients A and B, and are similarly inappropriate for people who are obese. The Henry equations generally come up with a lower BMR than Schofield, except for subjects over about 100 kg (about 15 stone 10 lb, or 220 lb).

Of course, having volunteered ages ago, I did nothing whatsoever about the presentation for as long as possible, especially as the last two weeks have been a bit busy. Not knowing that this week would be a little easier, I actually spent Sunday afternoon on it, and then Monday afternoon as well. On Sunday afternoon my biggest challenge was trying to think of a way to compare the two methods graphically. On Monday I just tried to make sure the content wouldn't be too boring. In the end the presentation was short, but seemed to be well-received, and we collectively made the decision that we would start using Henry instead of Schofield on the wards.

The results were not entirely cut and dried, though. Subsequent to the publication of the equations, a comparison was done between Schofield, Henry and actual BMRs measured by calorimetry. This research found that Schofield was within 10% of the measured BMR in 69% of subjects, and Henry scored 79%. Not a particularly accurate estimate, then.

Henry produced equations that included height as well as sex, age and weight, and I was hoping that this would successfully deal with the issue of high BMIs. Henry himself concluded, however, that there was little benefit in using height as well, and including height makes the calculation quite difficult (although not impossible) with a non-scientific calculator, which is what we generally take onto the wards.

I did manage to produce some graphical comparisons between Schofield and Henry, one for each of four adult age ranges. Three of these made sense, but the one for the oldest age group (>70) showed that up to a weight of about 70 kg (11 stone/154 lb) Henry's estimated BMR was lower than Schofield's, but above this weight Henry's estimated BMR increased dramatically and unrealistically. On reflection, however, it is highly unlikely that we would encounter anyone on the wards who is both over 70 and heavier than 70 kg.

Our Dietetic Manager is also in favour of a completely different calculation which deals much more successfully with obese subjects, and which she has set up in an Excel spreadsheet for our benefit. We had a short discussion about this after the presentation, and decided to stick with Henry, for two reasons: firstly, we very rarely deal with obese patients on the wards, and secondly, we don't have access to Excel on the wards, and her preferred equation absolutely requires a scientific calculator. In clinics, where we can use Excel, we very rarely calculate energy requirements, because we work on the basis of eating more if you are underweight and less if you are overweight, in comparison with your current intake. It isn't usually helpful to estimate what the absolute calorific value of that intake is.

The other presentation is for my interview tomorrow. I have had to lose almost two days of my holiday and almost every evening this week for these presentations. I hope it's worth it.

Doubts

Sissinghurst, June 2012

Last week was a difficult week at work, for a number of reasons. Firstly, both of my peers were on holiday, leaving me and the two seniors covering their wards as well as our own. Luckily, things were quiet, otherwise I'd have had a worse week than I did. I had to give up my outpatient clinic, though, and I missed it.

As well as the greater workload, I had some challenging patients. Not that they were challenging people, but their situations were complex, difficult and depressing. And a patient that I'd spent a lot of time with, and really tried to help in many different ways, died. I'm not usually affected by this, but on this occasion I spent a minute in silent contemplation when I found out.

I'm also annoyed at having so little time for thinking, and when I did stop to think this week, I was assailed with doubts. Was that the right treatment? Should I have considered other alternatives? Did I really do my best for that individual, or am I just going through the motions? Am I doing a good job?

I have to admit that this job has not improved with time, and my original thought when I started the whole process of retraining for this new career still holds true: the hospital setting is not where I want to end up. I look forward to my outpatient clinic with eager anticipation that I don't feel for another day on the wards. I am frustrated by my role in nutrition support, which doesn't seem to utilise much of the enormous body of knowledge that I acquired during the degree, and gives me little opportunity to promote behaviour change, which it turns out is what I am really interested in. Working on the wards does not inspire me.

I was discussing this preference with a colleague, who described a similar level of frustration with outpatient work. She finds it frustrating that outpatients come to the Dietitian for advice, but then often don't follow that advice and either don't return, or come back without improvement. She is much happier to work in the ward environment, where we might have a little more influence over whether our advice is put into practice or not.

I feel the opposite: an outpatient has the choice whether or not to follow my advice, and my job is to help them find the right path, tailoring and tweaking my advice to take account of their lifestyle and supporting them in reaching goals that I may have helped them to choose. I find the ward environment frustrating because there are so many institutional variables that prevent patients from achieving nutritional objectives, which are mostly imposed upon them. I acknowledge that I have no control over how a free-living individual chooses to eat and drink, but we ought to be able to do better on the wards, and often we don't.

I have applied for another job in a different NHS Trust, and have told the Dietetic Manager (because I had to list her name as a referee). The good news is that I have been offered an interview; the bad news is that it is scheduled in the middle of our planned holiday in the South West. We are adjusting our plans so it shouldn't disrupt the holiday too much.

I think that it is appreciated that when one has a temporary post covering maternity leave (or in my case, two days permanent and three days temporary per week), one has to take up opportunities when they present themselves. But I don't think that the Dietetic Manager is aware of the main reason for me applying for the job: it is in Primary Care rather than the hospital setting. Finding myself in the position of anticipating an interview, only seven months after the end of the last round of interviews, makes me rather apprehensive and a little sad. Interviews really are painful, and not just because of the Lady-shoes. And this time I have to do a presentation.

It is also for a job that is a higher grade than the one I have at present, and this seems very precocious given than I have only completed six months in a Dietetics role. The same Trust is recruiting for posts at my current level as well, but because the students in the year below mine have now graduated and are looking for their first jobs, the vacancies at that grade closed almost immediately, well before I could put together my application. If I am given the role I have applied for, it is possible that I will be senior to Dietitians who have more dietetic experience than I do. That is a sobering thought.

Looking on the bright side, there are many positives to offset the negatives in my current job. My colleagues really are the nicest people I have ever worked with, without exception - if I get the new job, I shall be truly sorry to leave them behind. And aside from work, when we happened to mention to Smurf that it was my birthday on Monday, he offered us a free meal in the pub, which we had on Tuesday. I've played badminton twice this week, watched two films, we had dinner in Wofon, and while writing this I'm sitting on the sofa with Mr A opposite, in my pyjamas, with a nice cup of tea and some birthday chocolate. Things could be a lot worse.

Another week in hospital

Norfolk, October 2011

The wards allocated to me at the moment are tricky, and the patients are time-consuming. I don't know why they should be any more difficult, but somehow they are. The wards also seem less organised, and I trust the nurses less to do the things I need them to do, like ensuring that the supplements and feeds that I prescribe are available to give to the patients when they need them. The patients, as always, are rather poorly. There is, however, a much larger proportion that are able to speak, and a significant number that actually recover enough to come off tube feeds and supplements.

The clinics remain my favourite part of the week, and I can now add Russian and Polish to the list of languages spoken by patients that have needed interpreters in my clinic. None of us has yet earned the certificate and medal for a full clinic with no DNAs. In one clinic (not mine), there were just two patients, although at least they both turned up.

We have had some input from the Dietitians working in the morbid obesity service, describing what they do and the thresholds and criteria for referral and for surgery. The thresholds are pretty high to be eligible for surgery, and the waiting list is long. They expect to carry out between 100 and 150 bariatric operations during the year. We asked whether patients in their clinics are successful in losing weight, and the answer without hesitation was, depressingly, "no." I am not sure whether they meant patients who have surgery or those who don't.

There has also been an employee 'Wellbeing' event, where various stands were set up to publicise various health-related services to staff in the hospital. I volunteered to cover the dietetic stand for the Community Dietitian, for just a couple of hours while she was at a meeting. Among the stands describing counselling, orienteering, catering and much more, our little stand was in a cluster next to two gorgeous squaddies advertising British Military Fitness courses on one side (outdoor fitness training military-style) and Health At Every Size on the other side.

The HAES program originated in the US but has been taken up by a local Dietitian whose research contradicts established wisdom (aka evidence-based opinion) on weight reduction. She suggests that dieting has been proven not to work - the vast majority of those who lose weight gain it again shortly afterwards - and yo-yo dieting often leads to gradual increase in weight over time. So the HAES approach is to address the person, their self-worth, happiness and general health, and let the weight sort itself out once people start to appreciate the barriers to change that they face in their particular and individual circumstances.

I can certainly see some value in this approach, and can imagine pointing some people in their direction - people who are simply unable to lose weight by conventional means (eating differently) and are not likely to be helped by three-monthly appointments of 15 minutes with a well-meaning but ineffectual Dietitian. The other attraction to the HAES stand was their scales, which were covered in pink fluffy fabric and had descriptions rather than numbers for your weight: 'Hot', 'Ravishing', 'Beautiful'.

What else this week? Badminton, watching DVDs from the sofa, Lola II visiting last weekend and The Boy this weekend. I have had a cold developing since Saturday. We went to the Falconry Centre yesterday, the first genuinely warm and sunny day since May, and I am now rather pink, mostly on one side.

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.

CAE and CPD

Henry the Harris Hawk, May 2012

Well, we have swapped wards, on the first day following the three-day week. During that previous week I worked all three full days, colleague #1 worked two days, and colleague #2 worked one and a half which included an outpatient clinic (and therefore she was not available for ward work for half a day). I handed over my patients all up to date and tidy, and received wards in return that contained all sorts of loose ends (and the wards in question have not stopped referring patients since Monday).

Then two specific things happened. Firstly, a Clinical Adverse Event (CAE) was recorded about a patient on one of my (new) wards who had not been seen despite having been referred and then chased. Secondly, it became clear that the referrals continued to come in at a rate of two new patients for every one I was able to actually see. Add the fact that my outpatient clinic on Tuesday was the biggest ever (full clinic, no gaps, ten patients! Only one DNA!) so there was much letter-writing to be done, and I had a day's professional development course all day Thursday when I wouldn't be able to see any patients at all.

At this point, I had to ask for help from our new clinical manager, who is covering for maternity leave and has been in post for less than a month. I have to say that she took the load of referrals away from me in a matter of minutes, and I was able to go for my CPD with a clear conscience. I did make the small mistake of looking in the referrals book before I went off on the course, and the relentless stream of new patients didn't seem to be diminishing at all. Of course the nature of referrals is that they do not necessarily come in at an ideal rate, sometimes too many and sometimes too few, but I know which I prefer.

By the way, I am not in the least concerned about the CAE. When I did go to see the patient, he was not in a particularly bad state, and I wouldn't have prioritised him over many of the other patients needing nutrition support. He had been looked after as I would have wished, offered snacks and supplements, and his intake (mostly) recorded along with his weight and other details that form the evidence base for my intervention. As this is a ward that is wholly unfamiliar to me, I can make no judgement about why the CAE was raised and by whom, but I hold no grudges - presumably someone thought that the poor nutritional state of a patient was important enough to complain about, and that is generally a good thing. I can't take it personally, given that nobody on the ward knows who I am yet.

The course I went on for a day was part of something called 'Preceptorship', which is supposed to provide a framework for supported ongoing learning within the first year post-qualification. The organised forums are mostly aimed at nurses, with a couple of session suitable for other healthcare professionals. This one was mostly about patient safety and brief behavioural interventions, and was much more relevant than I was expecting it to be, especially the session about Motivational Interviewing. This is an evidence-based technique for promoting behaviour change, which turns out to be the part of the job of a Dietitian that I like the best, although I'd never have guessed it before I started. I actually like weight management! Up until very recently indeed, I was claiming that this was an area of Dietetics that really didn't interest me.

I have also spent a short time with a Specialist Diabetes Dietitian, planning how I might gain an insight into what they do. This is for the enhancement of my CV, my professional development portfolio (which at the moment is rather in the nature of a virtual portfolio until I get round to actually writing things down and filing them) and for brandishing at a future job interview to show how interested in diabetes I am. Among the wealth of practice-related matters that I gleaned from this session, I also took away the abiding impression that all the Dietitians currently in the Diabetes service are young, committed, and unlikely to move away to leave any room for me in the near future. There are also many impediments to expanding the service, so it may be some time before any vacancies appear. The last Dietitian recruited into the Diabetes team had remained at my current level for seven years before the opportunity arose for her to move upwards. But you never know.

[I have also looked into volunteering at Diabetes UK weekend events, and the only thing currently putting me off applying is the need to express enthusiasm about working with and/or supporting children. Being a truthful person, I have yet to contrive a convincing response for this area of the form.]

The good news was that thanks to my manager I was able to leave at the end of Friday with most of the new referrals seen, although there are still a few that are having to wait until Monday. As for the type of interventions I'm seeing on the new wards, that will have to wait for a future blog post.

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.

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

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.

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.