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.

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.

Solitary holiday

Park in Royal Tunbridge Wells

I have been on what I have been calling my Solitary Holiday. I have gone away, on my own, to stay in a small rented apartment in Royal Tunbridge Wells, which is in Kent.

Of course I found the apartment on the Internet, and you can never tell what you're going to get in reality, but it is a lovely living space with almost everything one could want, the main exceptions being a cereal bowl and a sieve. They'd even stocked the fridge with milk, bread, biscuits and a bottle of wine ready for my arrival. I put the bread and biscuits out of harm's way, but kept the bottle of wine for emergencies.

I'd selected Internet access as essential with the booking, which is why you have been getting these blog posts, but I'd also brought books to read, a couple of jigsaws, some DVDs, podcasts, books and music on my iPod, and there was the town to explore - another Royal town to compare with Royal Leamington Spa. I'd planned the food to be fairly spartan in the flat so that there was little temptation to indulge (hence the hiding of the bread and biscuits), but planned to eat out at lunchtimes.

The weather at the start of the week was warm and beautiful, perfect for wandering through the town finding out what it's got to offer. I had a few specifics on my shopping list, including buying tops for work, socks and a pair of shorts if I could find one. Luckily, there are charity shops here too! And BHS and M&S, although this season's fashions are really not to my taste. But most importantly, I checked out Kitsu Sushi and Noodle Bar, and fortunately it was as good as the Interwebs had led me to believe. I planned my tourism around being able to go there most lunchtimes.

Monday was a hot day, so after I'd got back and prepared my salad for supper (but before I'd eaten it), I thought it would be a good time for a shower. The information folder told me it was a combi boiler and should provide hot water after a brief delay, but I'd stood in the shower for some time and there was no sign of heat. I phoned the number for the agent/caretaker who told me that the actual owner lived upstairs; I called at the upstairs door and she thought the pressure might have dropped and went to adjust the boiler. A few minutes later she turned up at the door with a bucket, and to cut a long story short I had no hot water that night but the plumber would be coming the next day. This seemed to fit the description of 'emergency', so I cracked open the wine...

The next day I walked into town again, finished all the clothes shopping that I was prepared to undertake in one holiday (hooray for M&S and charity shops), and paid another visit to Kitsu for lunch. The plumber did indeed turn up while I was at home in the afternoon - Keith, a very nice man, who reported serious damage in the boiler department, to the extent that the whole boiler needed to be replaced, but he would do his best to install one this week. This week! There were rats already nesting in my hair and it was only day 2! I haven't had to wash my hair in the sink since, well, I can't even remember. This seemed like another emergency, but I held back on the wine a) because it was only 3 o'clock in the afternoon, and b) because I was due to go out in the evening.

At a rough estimate, Royal Tunbridge Wells is three or four times bigger than Royal Leamington Spa, and I discovered that it gained its Royal status from King Edward VII in 1909 (Leamington got in first: Queen Victoria, in 1838). It has all the right sort of shops, a mix of big high street names and small eclectic boutiques, as many charity shops as I needed, and enough restaurants of many types (although the only one to see my custom is likely to be the above-mentioned Kitsu). There is an indoor mall, outdoor pedestrianised streets, and a quirky old town area with history, called the Pantiles. You can look it up if you want to know more, but I have to say it is very attractive in the sunshine of an unseasonably warm May day.

The Museum and Art Gallery are housed in the same building as the Library. I didn't manage to stop myself going into the library, but came to my senses very soon and headed upstairs. The Art Gallery was closed while an exhibition was being prepared, but I had a good look around the Museum. It wasn't very big (only four rooms), but had the usual excellent collection of random objects associated with the town, including hop cultivation, cricket ball manufacture, a particular type of biscuit that used to be made here, and an interesting display and explanation of Tunbridge Ware, which is a cross between marquetry and wooden mosaic. One of the highlights of this room was a stuffed dog in a decorated cabinet.

Other random objects included two cases of toy dolls, a small room with the usual stuffed animals (I am repeatedly astonished at the tiny size of the weasel every time I see one), some bits of Roman pottery, old glass bottles, a huge doll's house and a massive rocking horse. None of this came close to the majesty of the stuffed dog, who is called Minnie, and who the attendant told me has her own Facebook page. Nothing says 'Having a lovely time, wish you were here' like sending your loved ones a postcard of a dead dog. So I bought a postcard, and sent it to Lola II and Mr M.

Wednesday evening - the TV refused to accept that BBC1 existed, although Radio 4 was still there. Thursday morning, and I was woken by my phone ringing - it was Keith the plumber on his way. Apparently, the lady upstairs has now gone away on holiday, and there had been some discussion about the keys and how to get them, but it would be all right because I would be there to let him in. I had a nice chat with Keith while we were waiting for Dave the engineer, and mentioned my TV problem, and he told me that it might be because of analogue to digital switchover happening this week. He had thought I was a long-term tenant, and became a good deal more sympathetic to my plight when he realised I'm only here for a week, of which I would have been without hot water for about half the time, and now the telly's on the blink.

I left Keith and Dave to do their worst, and headed into town for the advertised Guided Tour run by the town's tourist office. When I got there, the staff apologised and told me that the tour would be running late, because the Earl and Countess of Wessex were visiting, as part of the Queen's 60th Jubilee 'Meet the Subjects' initiative. This meant that instead of sitting on a sunny park bench reading the book I'd brought with me until the tour started, I was able to watch the preparations for the Royal Visit, including the doling out of flags to everyone, the assembling of four sets of excitable schoolchildren, and the activity of some enormous suited security types who occasionally talked into their sleeves. Then I started to wonder if I'd got the right Royals - was it Edward and Sophie, or had I confused my Royals and it would be one of the others?

It was Edward and Sophie all right, although I wouldn't have recognised the Countess if I'd passed her on the street. She reminded me of Eva Peron (in her looks; I don't have any other criteria to judge her). Anyway, they did their job nicely, stopping to talk to the children and anyone who had a baby or a dog or a disability or all three. Rather them than me - it looked very tedious indeed. The Guided Tour eventually started once the furore had died down, but our guide was a little flustered, having just met the eminent personages, and even more flustered when she realised that the route of the tour was going to be disrupted by the personages being in the church she was supposed to be showing us.

The Chalybeate (iron-bearing) Spring that started the whole town's development was 'discovered' in 1606, much earlier than Leamington's which was only in 1784 (although Leamington as a settlement is much older, being mentioned in the Domesday Book. But I digress). We weren't allowed to taste the water due to drought conditions, but the costumed Dipper and the Town Crier were in attendance, although that might just have been because of the Royal Visitation. The tour was interesting and took about an hour, and when it was over I went back to find Dave still hard at work, but he assured me that all would be well by the end of the day, which it was. So on Thursday I had my first shower since Sunday.

On Friday I decided to get out of town for a while, so I drove over to Sissinghurst Castle, which isn't really a castle, it's the former home of Vita Sackville-West and Harold Nicholson, where they lived from 1930 to the end of their lives in the 1960's. It now belongs to the National Trust, and the main attraction is the garden, which is huge, and separated into different areas with characters of their own. There's also a tower that you are allowed to climb to get a great view. The weather was very hot and oppressive, although it didn't actually rain. I took a million photos - well, that's an exaggeration, it was probably no more than half a million.

Saturday, my last day, and I was looking forward to the Farmers' Market, what with Kent being the Garden of England and everything. It was rubbish. We have more stalls in Leamington Spa, which doesn't have an agricultural paradise on its doorstep. There were no more than two stalls selling fruit and veg, one with meat, one with cake, one with chocolate and the rest were jewellery, hats and trinkets. So I had a nice chat to the chocolate man, bought a cake and went home (via my lunchtime sushi spot).

It rained for the first time on Sunday, all the way home. I had planned to return via the falconry centre, but after watching one sodden display where the birds were about as miserable as the audience, I decided to pack it in. And so endeth the Solitary Holiday.

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.

What I've been reading

The Adventures of Tom Sawyer
by Mark Twain

narrated by B. J. Harrison

"This is the story of a boy's adventures growing up in a small town on the banks of the Mississippi river. The cheerful, adventurous hero plays truant to form a pirate band and, together with his best friend, Huckleberry Finn, finds fun, excitement, and buried treasure along the shores of the great river."

I thought that B. J. Harrison would do a better job of a book by an American writer, rather than his previous patchy attempts at British and French pronunciation and place names. And he does. Although I'm sure to have read it on some previous occasion, there wasn't much that I remembered. And an easy read, unlike the one below...

The Audacity of Hope
by Barack Obama

"Barack Obama engages themes raised in his keynote speech at the 2004 Democratic National Convention, shares personal views on faith and values and offers a vision of the future that involves repairing a 'political process that is broken' and restoring a government that has fallen out of touch with the people."

A heavy book (in ideas rather than mass), and I think I would have got more out of it if I had better knowledge of United States politics and personalities. The book was written in 2006, when Obama was a Senator, just two years before being elected President. The US Senate comprises 2 Senators from each State (i.e. 100 Senators), and the most astonishing fact presented in the whole book is that in the US Senate at that time (just six years ago), there were three Latinos, two Asian members (both from Hawaii), and he was the only African American in the chamber. Unbelievable. I find from further research that Barack Obama was "the first male, black Democrat to serve in the Senate." I am in awe of the man.

Three Men In A Boat (To Say Nothing Of The Dog)
by Jerome K Jerome

"Martyrs to hypochondria and general seediness, J and his friends George and Harris decide that a jaunt up the Thames would suit them to a 'T'. But when they set off, they can hardly predict the troubles that lie ahead with tow-ropes, unreliable weather-forecasts and tins of pineapple chunks - not to mention the devastation left in the wake of J's small fox-terrier Montmorency."

I was looking for something bite-size and entertaining - my pile of books to be read contains little in the way of easy fiction. Having recently read the wonderful 'To Say Nothing of the Dog' by Connie Willis, I thought it was a good time to re-read the first half of the title. It's only a little book, and a good companion to the Mark Twain as they write in a very similar style. Most enjoyable.

Falconry

Henry the Harris Hawk and me

Last weekend I had one of the most enjoyable and memorable days of my life.

It was a drizzly, grey sort of day on Saturday, but I set off for the Cotswolds in a spirit of barely suppressed excitement. This was the day I was to redeem my Christmas present from Mr A: a day's falconry experience at the Cotswold Falconry Centre.

When I was in my early 20's, a friend invited me to his wedding in North Lincolnshire somewhere. I don't remember much about the wedding, but what I do remember is that the following day, I went with friends to a local attraction that hosted a falconry centre, and watched the display. I was hooked from the first moment. I made my friends stay so that I could watch a second display later in the day, and then wrote to the falconer with all sorts of questions about what was involved in keeping and flying birds of prey. He kindly wrote me a letter in return, which I still have.

At that time I was at university, having a somewhat disorderly, irresponsible and unsettled life, with all sorts of plans for travelling and without the slightest intention of settling down to the sort of life that would allow me to look after any sort of animal, let alone one as sensitive and time-consuming as a bird. But I never forgot the thrill of that display and the unexpected passion that it aroused.

Move on about 20 years, and Mr A and I visited Ludlow, where we happened upon a sign in Ludlow Castle advertising a falconry display. I insisted that we stay and watch it, and the impact was hardly less than all those years ago - the birds were so beautiful, graceful, powerful and still almost wild. They were certainly not tame or domesticated; there was none of the mutual attraction of a cat or a dog with a human. It was a cold, business-like relationship based on making an easy living on food provided in exchange for flying about a bit. The birds were free to go if they wished, although it was clear that the falconer would have calculated carefully to ensure that they didn't.

Mr A has since said that he hadn't ever seen me in such a state of excitement before. It must have made an impression, because that was at least five years ago, and I was absolutely amazed to receive the envelope on Christmas Day with a voucher for this falconry experience.

So last weekend I headed off into the drizzle, and joined a group of five other people from 9.30 a.m. until 5.30 p.m. We were looked after by four of the staff, and were plunged straight in at the start when each of us was given a bird in turn (Henry the Harris Hawk and Desmond the Great Tufted Owl) and sent off to walk around a field with it. Then, in order to understand the variety of size and weight of falconry birds, we each were given a little American falcon, followed by a Gyr/Saker cross and then... a Golden Eagle. It was amazing - you could hardly feel the tiny falcon on the fist, but the eagle looked me straight in the eye, and was as heavy as a small child. A magnificent creature.

The centre is remarkably big, and has about 150 birds altogether for conservation, breeding, and flying in displays and at prey. They include eagles, vultures, buzzards, caracara from South America, a huge variety of owls, down to the slighter birds: sparrowhawks, kestrels and falcons. At this time of year many are raising chicks. There are several birds tethered in mews (sheltered areas) and weatherings (uncovered) - they are flown every day and brought inside at night, while others are permanently out in large enclosures. The breeding birds are not disturbed, but some of the non-breeding birds in the enclosures are brought out and flown, including a pair of caracaras in one of the displays I watched. But I'm getting ahead of myself.

We were given some information about the 4000-year recorded history of falconry, species and types of birds, how they are cared for, the equipment used (the tether, the creance, hoods, jesses, lures) and some of the terminology that has entered the language. A mews was originally for housing birds, not horses. When annoyed you can reach the end of your tether. It was emphasised clearly that birds don't fly for fun, but for food, and only if they're hungry, and the way to tell whether they are hungry is by weight. A bird needs to be at its flying weight, but if it is too heavy, it is fed up, and will not fly. The last lecture/lesson of the day included tying a one-handed knot - the falconer's knot. Obviously while holding a bird on one fist it is important to be able to manage everything else with the other hand.

We went out into the field with Henry the Harris Hawk and flew him a bit more freely, taking turns to hold out an arm for him to land on and accept the food offered. We were given a glimpse of how manoeuvrable he could be, and we all got thoroughly wet, including Henry. The long grass and the rain soaked into everyone's shoes, and we all spent the rest of the day with wet feet, taking turns in front of the small gas fire when the opportunity presented itself. I think the American lady in the group had the worst time - she had the most inadequate shoes, and being from Texas I think she suffered more than the rest of us from the cold, damp conditions.

The weather was still pretty wet for the first display. Mr A turned up to see this with us, and stayed for lunch. He watched another display and went home, while the group was taken on a tour of the centre by its owner, and given lots of fascinating information. One of the most interesting facts was that the breeding enclosures contained lots of unsteady perches that swayed and required the birds to balance. In order to mate successfully, the male has to sit on top of the female, who is a good deal larger in many raptor species, and not likely to be sitting entirely still. He had received a male bird that came from a different breeding centre with only fixed perches, and realised that the bird had never learned to balance effectively. "Our breeding success improved significantly when we introduced the wobbly perches," he told us.

The weather had improved slightly for the last display of the day - it was no longer raining - but there wasn't a breath of wind and the low, grey cloud hadn't lifted. This meant that the larger birds were reluctant to stay out long because they were getting no help from wind or thermals, and the smaller birds weren't going to climb and 'stoop' to prey because of the poor visibility. I still haven't ever seen a stoop, which is when a hawk (e.g. a peregrine falcon) goes into a vertical dive at up to 100 mph, and takes the prey on the way down.

The displays featured a number of birds in turn, including the caracaras, a bald eagle called Wotan, another eagle called Lulu, and a number of owls. Owls have acquired a reputation for wisdom and intelligence, assisted by books such as Winnie the Pooh and the Harry Potter series, but their real nature came to light in the displays - they are pretty stupid, not very impressive, have no sense of smell, and have never seen their own feet. This is because their eyesight is pretty good, especially in low light, but only at a distance. They are effectively blind to anything close up - the trainer held food up in front of an owl's nose, and it peered dimly past at nothing in particular. But throw the food a little way off and the sound and sight of it prompts the owl to head over there and pick it up. Unlike the other birds, though, having picked it up and eaten it, the owls tended to sit there doing nothing in particular. Their special skill is flying from A to B and then stopping, rather than soaring majestically in wide circles to perch on the lofty branches of tall trees before gliding silently to the falconer's fist, or performing aerial acrobatics to catch food in midair. I was not impressed with the owls.

In contrast, I was deeply impressed with the falcons, hawks and eagles, and also with the quality of the tuition and the knowledge of the team who work at the centre. The vultures weren't bad either. When I came home and told Mr A that I had signed up as a Friend of the centre and was now able to visit free of charge, he said something along the lines of, "I thought you might." I spent the rest of the evening and much of the next two days imagining that I might join a club and go out flying with people who own birds (there is a club that meets every second Sunday at a venue only 5 miles away), and visiting the Cotswolds centre every other week. Realistically, I hope to go there enough times to make it worth my while having paid to be a Friend. Lola II will definitely be forced to accompany me at least once as well.

It was also our ninth wedding anniversary on Saturday. Don't feel bad that you missed it - I was pretty sure that it was in May, but I had to rummage through the filing cabinet to find the wedding certificate with the actual date, which wasn't the date I thought it was. We went out for what turned out to be an over-priced and fairly ordinary dinner at a Thai restaurant - we would have been better off at Wofon for a fifth of the price, even though the surroundings would have been less glamorous. Mr A has provided a few interesting moments during the sixteen years we have been together, but I wouldn't have been without him. Happy Anniversary, Mr A!

Naughty monkey and me

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

Weekends

Crane, Norfolk, July 2011

The May Day Bank Holiday weekend started after work on Friday with a drive to Southampton, checking into an ancient, run-down (but clean) hotel, and almost immediately driving to a gig to see Alabama 3.

Mr A and I arrived at the venue a little late, and when we reached the door into the main room I wondered if we would ever get inside. There was a wall of people, but somehow we squeezed in and found a small space towards the back. The gig had started but I don't think we were very late. We each had just enough room to stand, and of course the tallest man in the room was in front of me - when he started jigging about it was time to beat a retreat in case he reversed into me and caused a nosebleed. Standing at the back was not much better - it was a frequently used through-route and we were constantly having to let people pass. Which was annoying. As were the group of people who seemed to have come for a good chat rather than to listen to the music. So all in all it would have been better had we arrived a little bit earlier.

It was nice to go out in the evening like 'ordinary' people do - it's been a long time since we've treated ourselves to this kind of event. The following day we visited Mr A's parents, and found his mother's dementia has reached the point where she struggles to put a sentence together. They are still managing to live together successfully at home, although I'm not sure how long that can last. Then on to Mr B and his wife and dog and a nice local walk from where we viewed the Isle of Wight and the Needles, and finally to friends J&C for a Chinese takeaway followed by pub (Mr A & J) or chat (me & C).

And back home on Sunday, with all of Monday to enjoy the Bank Holiday. As it counts as a weekend, I was in charge of the Catering Department, and I thought I would forsake Jamie Oliver for once and produce the Ultimate Lamb Biryani (from the Ultimate Recipe Book). The book said it would take 3 hours, but somehow I didn't take this seriously. I did little else that day, and it was a good lamb biryani, but not that good. The Great God Jamie clearly punishes those who forsake Him.

This weekend has been mainly spent in mundane tasks: yesterday contained laundry, a large amount of washing up, food shopping, cooking and then we watched an excellent film that I can wholeheartedly recommend: 'The Guard'. Today I have mostly been trying to renew/upgrade the contracts I have for mobile phone, landline and broadband, which I find fairly difficult and quite tedious. I finally completed the process of negotiation for the mobile contract, and a new touchscreen phone is on its way, my first foray into modern mobile communications. Along with the return to contact lenses, this was supposed to be a luxury that I allow myself as a result of having a job, but in fact the deal is no more expensive than my previous phone contract. The landline/broadband deal is still under negotiation.

Weekends are proving difficult for me. I work much harder in my current job than I have done in any previous jobs, with no down-time during the day other than a 30-minute lunch break. What with badminton on two nights a week, I'm very tempted to do nothing at all at the weekend other than a few easy household chores, food shopping and cooking, which I enjoy. But there are many other jobs that need doing - Mr A mowed the lawn, which was nice, but there is more to do in the garden and all sorts of repair and decoration that would make our house look a good deal better. I need to make a bit more effort during weekends at home.

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.