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.

The frankfurter octopus

Not my original idea, but something I saw on the Interwebs long ago, and have been itching to try ever since. The frankfurter octopus turned out to be delicious, yet at the same time vaguely disturbing.

Ingredients: frankfurters, spaghetti. Optional: ketchup, mustard. The finished meal included a salad, although you won't see much of that in the subsequent pictures I took. 

What I remembered of the 'recipe' was very straightforward: stick raw spaghetti through frankfurters. What I didn't remember was how much spaghetti, and along which axes? So I constructed a selection of different mutant strains.

The main problem was that the more attractive species, with spaghetti radiating perpendicular to the frankfurter axis, was the more difficult to fit in the pan. Longitudinal was more practical, but appealed less to my aesthetic preference for outlandish sea-creatures.




Both varieties cooked to perfection, and, with a dash of ketchup and mustard, provided Mr A and me with a comforting autumn supper, and leftovers for work next day.

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.

What I've been reading

The Sixth Lamentation
by William Brodrick

narrated by Gordon Griffin

"What should you do if the world has turned against you? When Father Anselm is asked this question by an old man at Larkwood Priory, his response is to have greater resonance than he could ever have imagined. For that evening the old man returns, demanding the protection of the church. His name is Eduard Schwermann and he is wanted by the police as a suspected war criminal."

It's either the book's fault or my fault, and I don't know which. The problem was either that the story's not very engaging and a bit too complicated, or else it's that I left a huge gap between reading the first two thirds and the last third. So I had probably forgotten some of the key points from earlier on, and being an audio book I couldn't skim through the first half to catch up (see below). And some of it was hard to believe factually, and most of the relationships weren't very realistic, and altogether I wish I hadn't bothered. But I rarely leave a book unfinished.

Feet of Clay
by Terry Pratchett

"There's a werewolf with pre-lunar tension in Ankh-Morpork, and a dwarf with attitude and a Golem who's begun to think for itself. But for Commander Vimes, Head of Ankh-Morpork City Watch, that's only the start. He's not only got to find out whodunit, but howdunit too. He's not even sure what they dun."

Slightly different from the other Discworld books, this is a proper mystery, but he makes the usual mistake (as far as I'm concerned) of introducing loads of characters in the first few chapters to the extent that I can't follow the story at all. Combined with a bit of a break in my reading, it meant that I had to go back and read the start again. It was worth it though, unlike the book above.

Blackout
by Connie Willis

"The narrative opens in Oxford, England in 2060, where a trio of time traveling scholars prepares to depart for various corners of the Second World War. Their mission: to observe, from a safe vantage point, the day-to-day nature of life during this critical historical moment. As the action ranges from the evacuation of Dunkirk to the manor houses of rural England to the quotidian horrors of London during the Blitz, the objective nature of their roles gradually changes."

This is actually the first half of a two-part story, the second half being in the next book 'All Clear'. Connie Willis is the author of one of my favourite books, and has constructed a theory of time travel along with a distinctive style of writing that depends quite heavily on cliffhangers. This can be annoying, but the writing is good enough to mitigate this fault, and she actually conveys aspects of the Blitz in London that I hadn't really thought about before, like the very real fear that German forces would invade, and the knock at the door of the air-raid shelter would reveal German troops.

All Clear
by Connie Willis

"The impossibility of altering past events has always been a core belief of time-travel theory - but it may be tragically wrong. When discrepancies in the historical record begin cropping up, it suggests that one or all of the future visitors have somehow changed the past - and, ultimately, the outcome of the war."

More cliffhangers, more flabby narrative, and ultimately an ending that probably ties the loose ends up nicely. I say 'probably' because the two books contain stories set within at least four different time periods and with five main characters, most of whom use different names in each time period. I wasn't paying as much attention as perhaps I should have, so now I'm not even sure that I understood who was doing what at which time, and I ought to go back and read the two books again. But they are much too long for that. She could have done with better editing, and condensed the whole thing into half the size, i.e. one book, in which case there would have been less period detail, but I would have been prepared to read it again. Maybe some other time.

In the respiration chamber

Intro by Nurse A

09.30

A few weeks ago, you may remember that I was measured in the BodPod in advance of taking part in some medical research. Today is the first day I spend in the 'respiration' chamber, a small room containing a flip-up bed, table complete with computer and phone (internal calls only), sink and toilet. I have intercom access to the outside world (well, to Nurse A) and to the next door cell, which happens to be occupied by a Dietitian colleague from the obesity service, who has also contributed to the research by formulating the menu. Before we were imprisoned, she said that she didn't even like the food on the menu that she herself had created.

The research is concerned with inflammation, measured through inflammatory markers in the blood - at least, I am assuming that is why I will have blood taken five or six times a day, via a cannula. I have never had a cannula before, and I don't much like it. But that is not the worst thing so far.

The worst thing so far is that I am very, very hungry. Somewhat ironically, today is the Day of Atonement, the Jewish holiday where one is supposed to fast until dusk, so it is perhaps fitting that I am hungry. My hunger is also a result of yesterday, which was a difficult day, and resulted in a lower dietary intake than usual, but perhaps I'll write about that later on.

Between 8 o'clock and now, I have had the cannula put in and a (large) syringe-full of blood taken, I have been sealed into the chamber and given a small snack of bread and salami, together with a thermos of hot water which I have used to make an Echinacea and Raspberry infusion (no caffeine today). I have caught up with some personal email and blog-reading (Ben Goldacre's new book is published today) and felt slightly guilty at not doing any work.

10.30

I have now done some work, so that's good. There's nobody policing me so I could easily spend the day watching iPlayer, but I've been given 'Study Leave' to help with this trial, which means I haven't had to take any Annual Leave or unpaid time, so I've brought some stuff to do.

So far I have reviewed the cards from yesterday's clinic, which has earned me the first Band 5 Dietetic Medal ever awarded - seven new patients, no breaks, no DNAs. Everyone turned up, some on time, some early, some late. It was terrible. One patient phoned to say that the air ambulance had come in so all the access roads were at a standstill and someone had driven into the side of his car. And he still came to his appointment. I mildly asked one patient if he'd had trouble parking, and let's just say he wasn't happy. By the last patient, who 'only' had to wait an extra half an hour for me, I was in a pretty poor state, and that patient brought a host of complex issues which I was in no condition to address effectively. And to cap it all, a patient needed ambulance transport home, which causes immense administrative problems.

Unlike most weeks, when I could easily have stayed to make sure the ambulance thing happened as it should, yesterday I absolutely had to go because I was giving a presentation in Nottingham in the afternoon, and had arranged to pick up an ex-colleague to do it with me. So the Dietetic Manager had to come and help me out, and in the process saw the state of my cards after that clinic, as I attempted to tidy up and complete all the admin before running away. I reached the room in Nottingham where I was giving the presentation at the exact time that I was due to start. So not exactly late, but it all added to my stress levels, and I reached home again at 6.30 p.m. having had nothing to eat and virtually nothing to drink since breakfast.

The outside window

So that's why I've been so hungry today, and why I have to finish up properly and write all the clinic letters before all the patients get muddled in my head. And I've just negotiated my first urine collection, closing the blinds to the main room and next door cell, successfully catching and decanting it all into the right containers, not even kicking it accidentally all over the floor, then realising I hadn't closed the blind at the outside window...

11.30

The first blood collection since I've been in my cell. I wondered how it would be done, given that I'm inside and they're outside, but the technique is surprisingly low tech. There's a plastic bag attached around one of the air lock ports, with a hole cut in the bottom. I put my arm in through the bottom of the bag and hold the plastic tight around my upper arm forming a seal. They open the air lock and fiddle with the cannula outside, then when they're done I pull my arm back in and they shut the air lock again. I thought I was going to have to do it all myself.

I've also had to fill in a couple of questionnaires about sleep and snoring, because I think there's something about sleep apnoea in the research as well. And every two hours I have to rate how hungry/satisfied/full I am, and how much I think I could eat. I am, obviously, still very hungry, and the next meal isn't until 1 p.m. It's due to be a big one, though.

Still doing research and writing letters associated with yesterday's clinic. I shouldn't have felt guilty about not doing work in here - I think this job on its own will take most of the day, and would have been really hard to fit in around the ward work I would normally have to do. Luckily, my colleagues report that yesterday was quiet on the wards, with very few referrals - let's hope today's the same.

12.30

Still no lunch. I am effing starving. One slice of bread and a bit of salami since 8 p.m. last night. I am drinking Echinacea and Raspberry infusion in the hope it will quiet the rumbling a bit, even though I will eventually have to deal with the consequences. I will definitely close the blinds properly next time, though.

Another setback - cannula not working for pre-lunch blood test, meaning another needle stick in the other arm. The researcher Dr P comments that this often happens before lunch, and he hadn't previously realised the effect of food on ease of blood-letting. So the cannula's still in, and we hope it will work at the 3 o'clock bleed.

13.30

I've had a large lunch, and I'm definitely not hungry any more, but feeling almost light-headed with the amount of fat consumed. We are being fed deliberately high fat meals - hence the salami first thing, and now lasagne and a chocolate eclair (mmm, my favourite). I ate my meal while watching the first episode of a new series of Never Mind the Buzzcocks, on iPlayer.

Now it's back to the clinic cards. It's taking ages, but that's probably got something to do with me breaking off every now and then in order to blog. And Facebook...

14.30

Nothing new to report. Still digesting enormous lunch, feeling sleepy now. No more blood taken yet, but clinic cards finished at last.

15.30

That was close - Dr P nearly couldn't get blood out of me via the cannula, and threatened to remove it and put another one in the other arm. But he managed it, the cannula's still there, and we'll see what happens at 5 p.m.

My afternoon snack arrived - a sliver of a pork pie, hardly worth the effort. I was still full from lunch, anyway. I wonder how they arrived at the quantities and the timing of the food? I saw my allocation written out before I came in, and it showed that I require only 1516 calories for a whole 24 hours of no activity. Obviously if I'm not imprisoned in a hermetically sealed room I can have more, but it's not very much, is it? It's actually exactly equal to one McDonalds Double Sausage and Egg McMuffin with large fries and a large milkshake, according to the McDonalds Nutrition Calculator.

I seem to have done very little in the way of work in the last hour. Where does the time go?

16.30

A thrilling new herbal infusion for the second half of the day - Blueberry and Apple. I'm starting to think I might be able to eat again, which is lucky because my second main meal is coming up at 5 p.m.

Having no mobile signal, and an internal telephone only, I have been maintaining contact with the outside world through Facebook and email - both highly asynchronous and unsatisfying. Then I noticed a Skype icon on the computer desktop - and bingo, I had a nice chat with mum, who was the only person online. With any luck there will be more options tonight.

17.30

The second main meal was a bit pathetic - chicken korma and rice, but a tiny portion compared with the huge 1 o'clock lasagne. These meals seem very unbalanced in terms of size and timing. I'd prefer something more substantial earlier so I didn't spend the whole morning ravenous. And this is the '5 meal-a-day' leg of the study; my second incarceration involves just two meals containing the same overall quantity as in my five meals today, with the first at 1 p.m. I shall definitely make an effort to eat more the night before than I did this time. During this supper I watched the first episode of the new series of The Food Hospital, which took a lot more time than eating the meal did.

The cannula just about performed its job at 5 o'clock, which I am relieved about. We think that on my next imprisonment we'll try the other arm.

18.30

It's actually 7 p.m. and I have no idea what I did in the last hour. Took my cardigan off. Had some more Blueberry and Apple infusion. Remembered to close ALL the blinds. Read a bit about diabetes from some of the uni notes I brought with me. Had a further half a chocolate eclair, the last food I'll see until tomorrow morning.

The cannula finally packed up, so I had to have a needle stuck in the other arm, but that vein wasn't playing along either so Dr P had to go for a third try. It seems my veins are single use only, but at least there's only one more blood test needed. I told Dr P I'd be a terrible heroin addict; he said that he reckons I would manage somehow.

19.30

Stopped reading about diabetes. Sat and stared at the wall, thinking about this and that. Checked Facebook. Checked email. Checked work email. Checked other email. Tried to Skype Mr A twice with no response but he's probably in the kitchen, so I've emailed him asking him to Skype me. More Blueberry and Apple infusion. Lola II, where are you? I'm a little bit bored now, but I've lined up the first episode of the new series of The Thick Of It on iPlayer. I've already watched more TV today than in the last six months.

Mr A Skyped me, but the initial conversation turned out to be very one-sided as he doesn't have a camera and his microphone wasn't working. I spent some time making rude signs at him, just because I could. Change of hard disk later (only a few minutes) and he's back, telling me about his day down in London on his first paying training job for ages. It went well. He torments me by suggesting he'll soon be sitting on the sofa and can help himself to drink and snacks.

21.30

Last lot of blood taken, best ever, using an old-fashioned syringe, took 10 short seconds rather than minutes of jiggling sharp implements in nervy flesh. Watched the episode of The Thick of It, and now I'm starting to feel hungry again. I definitely wouldn't run this meal schedule by choice.

Dr P has shown me the 'sleep machine', which sounds very sinister, but looks as though it will just be measuring my breathing rate and oxygen saturation. That's the end of his working day - I'm left to my own devices, with an emergency call bell to the nearest ward and the on-site Security telephone number. If there's a fire alarm or other emergency, I can just open the door and walk out, although Nurse A said she'd probably want to go into one of the chambers if there really was a fire. It's pretty bombproof in here.

08.00

Trying to sleep with a large box strapped to my chest (the sleep machine controller is about as big and heavy as a packet of four bars of soap), a strap around my waist, a finger-pinching monitor and nasal specs up my nose and around the back of my ears wasn't easy. Add to that the facts that it wasn't quite warm enough and I wasn't particularly tired, having done nothing but eat, read and type all day. I did sleep, and everything stayed in place except the finger monitor lead fell off the controller, but next time I need more blankets.

This morning first thing I followed the supplied instructions to provide a resting BMR measurement - staying awake but unmoving for a measured hour. I listened to a podcast, so that was no hardship. Now I'm waiting for the staff to get back to work and release me from my cell. I hope there's no more needling to do, but they have offered me a shower and I really need breakfast soon. Then it's back to the office and work - today I have a department meeting at lunchtime about student supervision and training, and clinical supervision in the afternoon when I present the difficult case from clinic in case anyone has any good ideas on how to manage treatment.

09.30

They didn't let me out until after 9 o'clock, but there were no more needles, and I saw the trace on the computer of my 24 hours in terms of oxygen, carbon dioxide and movement within the room, which is captured by sensors. They should be able to tell me more about my metabolic rate by the next incarceration event, which is in two weeks' time. Back in the office, the wards have been making up for lost time, and I had rather too many referrals waiting. Luckily, some of them turned out to be duplicates, one had already left hospital and another couple were for renal or oncology colleagues.

So what have I learned from my day in the tank? I enjoy solitude, don't like waiting for my meals when I'm hungry, miss my decaff tea, have veins that are not suited to repeated withdrawal of blood, need only around 1500 calories on an inactive day, and have a reliable bladder capacity of almost exactly 500 ml.

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.

Catching up

Leamington Food & Drink Festival, Sept 2012

It really has been a very long time since I last sat down to do some serious blog writing. It's due to a combination of circumstances: weekends filled with duties to perform, weekdays filled with patients and students that I can't write about, and evenings recovering from both of these, plus extras like badminton.

Since last time, then, in brief.

• Work: a meal out with some of my lovely colleagues, which was very slightly gate-crashed by Lola II and Mr M who turned up early for a family event. 
• Family Event - thank you very much to all those who travelled many miles, some of whom returned home with a gift of tiny pathogens from Lola II and have been ill ever since (get well soon, mum and dad). 
• Another trip to the Cotswold Falconry Centre accompanied by a subset of the attendees of the Family Event. 
• The Leamington Food & Drink Festival, which far exceeded expectations, mainly due to the weather, which was glorious for both days. Most memorable was the Chilli Jam Man, whose samples ranged from very hot to almost unbearably hot. Having engaged in conversation with him, I was foolhardy enough to try the offered fresh strawberry filled with his most fiery jam, which actually made my sunglasses steam up on the inside. It really did.
• After coming back from the Food & Drink Festival on Sunday, Mr A and I attacked the garden. We took four full car loads of unwanted vegetation to the tip, much of it viciously thorny. About three quarters of the garden is now in an acceptable state, with only one corner left to deal with.
• Work again: we had another food tasting session, department meetings, wards and clinics as usual. Both our students passed their placements and have left us, and since then I have been inundated with referrals. It would have been a considerable challenge to manage the workload if this many referrals had come in while I was supervising 'my' student. The only real trouble I had was running my clinic together with the student, which didn't go all that well. A patient who arrived late was missed, ended up waiting an hour and then had to leave before being seen. I feel bad about that.

I decided to go to another Diabetes UK local group meeting, the first since I started my current job. The advertised topic for the meeting wasn't all that attractive: a personal account from a blind kidney and pancreas transplant patient, but these things come in handy when you're trying to construct an attractive CV. In the event, the speaker cancelled at short notice, and the alternative activity dreamed up by the group Secretary was to have us chat in small groups about various subjects, and then report back to the meeting on the most interesting or useful bits. This is the sort of thing that makes my heart sink in professional seminars or workshops, but in this case it turned out to be very interesting. At the other meetings of this group I have struggled to make any connections with the other people there, and barely spoken to anyone. This time, I could actually find out a bit about their experiences of diabetes, which is one of the reasons for going to these meetings.

Another work-related thing this week was that my body composition was measured in the Metabolic Unit's newest toy - the Bodpod.

"Air displacement plethysmography is a technique for measuring body composition. Subjects enter a sealed chamber that measures their body volume through the displacement of air in the chamber. Body volume is combined with body weight (mass) in order to determine body density. The technique then estimates the percentage of body fat and lean body mass through known equations (for the density of fat and fat free mass)." (from Wikipedia)

This came about because I have volunteered to be a subject in an academic research study which aims to measure inflammation in subjects given two different types of diet: either two large meals or five small meals in a day. I have been booked for two periods of 24 hours in which I must remain in a sealed chamber large enough for a bed and a table and a toilet, with all sorts of vitals being collected and measured. In preparation for this, I had to sit in the Bodpod for a minute or two dressed in a swimsuit, and the machine calculated that I comprise a whisker above 30% fat, which puts me right at the fattest end of the healthy range for a woman of my age. So that's good, I suppose. My colleagues think I'm a bit crazy for looking forward to being confined in a small room for 24 hours. I remind them that I went on holiday for a week on my own.

I can make no predictions about how soon the next blog post will appear. I have plans for a couple of posts which may turn up quite speedily, and then there will probably be another big gap. All I can say is that I probably miss my blog as much as you do, and I'm doing my best to keep it going.

Work and play

Norfolk, July 2011

I seriously cannot wait until I retire, when I will have time and energy by the bucketload and everything will be delightful and sunny and the house will be in perfect condition because we will have sorted it out beautifully. This will obviously not happen, because life is not like that. But I would like to have more time, and I would like to attend to the shortcomings of our 'home-making', and the two are clearly connected, along with our disinclination to spend our limited leisure hours on structural improvements.

In the work arena, the grown-ups in our office (senior Dietitians) were both away on Friday, which meant that when the call came to see a patient in the private hospital, one of the kids had to stand in. So off I went to the fancy shmancy 'ward', which comprised carpeted corridors and bedrooms rather than hard floors and beds separated by curtains. Obviously I will say nothing whatsoever about the patient and the treatment, but I feel slightly embarrassed that for such a large amount of money, the patient received dietetic treatment from a Dietitian with nearly seven whole months' experience.

This has been my first brush with the interesting relationship between private healthcare and the NHS. You certainly get better accommodation by paying for it, but is that all? I suspect that nursing care is also more attentive, but clearly therapy is absolutely no better than NHS, and you get the same doctors with the same time pressures and no better treatments to offer for the money. Investigations may be done without waiting quite so long for your turn on the CT scanner, and you might get your treatment more quickly. But it will be the same treatment, and if there's an emergency you'll be shipped into the NHS Emergency Department quicker than you can say "Find me a trolley and call me a porter".

Outside work, Lola II and Mr M have been visiting, and we had a very successful day on Saturday. Lola II has been converted to the One True Way of the Charity Shop, and found another skirt and pair of trousers, this time in an even smaller size than before. I now have a car charger for my phone, so no more telephone boxes for me on long journeys. Lola II has lost so much weight that even her feet have shrunk, so we ended up buying her shoes from the childrens' department of Clarks, where she had her feet measured in the old-fashioned way where you can choose shoes according to both length and width. The advantage is that shoes are not quite as expensive as in the adult department; the disadvantage is children's shoes tend to be flat rather than with heels.

Then we all went off to the Red Lion in Hunningham to watch a film on the huge inflatable screen followed by camping in the adjacent field, which was all lovely, despite the usual early wake-up call from a nearby small child who doesn't understand that it isn't necessary to shout at 6 a.m. in a campsite. I discovered several things about breakfast in Leamington - the cafe I'd been told about is definitely there, but closed for two weeks in August, and Sainsbury's doesn't have a cafe, just a Starbucks. But we have a 'Frankie and Benny' outlet, and it turns out that they do breakfasts, so that's where we went.

Mr A was away at a wedding (I don't do weddings) so after Lola II and Mr M had departed I had some wonderful free time, which I used in cooking for next weekend's family gathering, going to the cinema, reading books, listening to podcasts, and working in the garden. Each time I tidy up about a quarter of the area, but the other three quarters seem to gain on me quicker than I can deal with them. Sadly no badminton tonight because of the bank holiday, and it's back to normal and to work tomorrow.

Camping holiday in the Southwest

Brixham marina

Mr A and I have been on holiday. My main recollections from this holiday included a great deal of long distance driving, interspersed with reading for delightfully long periods, with talking to interesting people coming third and a significant amount of mist and rain in fourth place. At one point, I discovered I had reached one of my personal goals without knowing it - I had forgotten it was lunchtime until Mr A pointed out that I was being unaccountably ratty and it might be a good idea to have something to eat. This signifies that I have, albeit briefly, begun to think like a thin person. I am hoping that it continues - not the 'missing meals' or 'being unaccountably ratty' part, but the 'thinking like a thin person', because it should make it easier to remain the size I currently am.

I digress. Long distance driving - this also included reading for long periods, except I didn't like my main audio book but needed to carry on with it in case it got better. Luckily I had a few podcasts too, and the first series of 'Fags, Bags and Mags', a delightfully surreal sitcom about a Scottish shop which is both amazing and great. Reading was also indicated for long periods in the tent, while waiting for the mist/rain to pass, and enjoying the peace and quiet of the evening until it got dark.

The talking to interesting people included the friends I've previously given the blog handle 'The Bikers' (or 'Biker Couple') who have now produced an attractive child and no longer have any bikes. We stopped with them on Friday night, and made our way onwards to the campsite on Saturday. We dismantled Mr A's two-man tent which had been there since Thursday and pitched the enormous family tent, then did very little except sit and read for much of the rest of the day, with small excursions to see the nearby beach and to a local town to eat fish and chips. The road to the beach was narrow and we kept having to stand in the hedge to let cars past, the beach had quite good surf but was otherwise unattractive (and it kept getting misty and raining), but the fish and chips were both amazing and great.

On Sunday we'd arranged to see a lady who used to teach English to Mr A at secondary school, and we did very little except drive all the way to her house in Cornwall, have a nice lunch including an authentic and delicious Cornish pasty, and then drive all the way back again. Then there was more sitting and reading. On Monday we did some proper tourism, spending most of the day in Brixham, which is famous for its seafood. So we had some oysters and a crab sandwich each, and it was very sunny and didn't rain for a change, and we walked about a bit and would have gone to the museum except that it was closed.

After that we drove a long way to Mr A's cousin and her husband (who has now given up the beef farming). They have bought a motor home and spend two months in France every year, from where she continues to work full time with the assistance of a satellite Internet connection. Finding them was an achievement - I was hoping to rely on the excellent directions I had been getting from my phone via its built in navigation system, except it ran out of battery and I don't have a car charger. So I found a red telephone box (haven't been in one of them for ages) but it only took BT Charge Cards and not coins, so I went back to the previous town and found a different phone box that accepted coins. I discovered, along with the directions and the fact that it costs 60p to phone from a telephone box nowadays, that the first phone box I had been in was less than a mile away from the farm - but I would never have found it by guessing.

Back home now, and I have an extra day's holiday which arose because I lost the first day of my holiday because of having an interview on Friday, which also explains why Mr A started his holiday on Thursday. The interview went as well as could be expected, but also had the anticipated negative result, given that I only have six months' dietetic experience. They were very nice about the rest of my interview though, including the presentation. I really must buckle down to the admin that's still waiting. A pity to spend a day's holiday on income tax and pension arrangements, but if I don't do it now I'm not sure I ever will.

William of Orange landed 'near this spot' in Brixham

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.