Tenth week

It's happened at last, I suppose it was inevitable. One of 'my' patients has died. She seemed reasonably well when I saw her, even though she was receiving a blood transfusion at the time, and just said that she really had no appetite at all. It seems her time had come.

I've been spending a good deal of time unsupervised, even though Consolidation starts next week. This means I'm doing well - my fellow student J is taking a little longer to get there, but then I'm 25 years ahead of her in terms of life experience and communication skills. Out on the wards it is taking me about an hour to 'do' a patient. This includes:

• Finding the medical notes and trying to make sense of the code as well as the handwriting. This week I learned what ATSP stands for. In previous weeks I have learned LRTI, PE, and the most enjoyable abbreviation, OTT (in the 'urine output' column of a fluid balance chart). [Answers at the end of the post.]


• Finding the nursing notes, where they write about how the patient is eating and drinking, sometimes give a Nutritional Screening Tool score, note treatment of pressure sores, pain relief, mouth care, mobility and other general and nursing matters


• Fluid balance charts (should document all fluids in and out, and bowel movements)


• Food record charts (if required, these should list everything a patient has been given to eat, and how much of it they actually ate)


• Drug charts (should show how often the prescribed supplements have been dispensed and how many were refused by the patient as well as all the other medication dispensed)


• Finding a record of the patient's weight (which can be in the nursing notes, or maybe on a separate sheet, or not done at all)


• Deciding whether the intake by mouth or tube meets requirements, possibly doing a calculation of requirements based on weight, stress, activity and need to gain or lose weight, and possibly asking the patient what they're eating and drinking


• Talking to the patient, if alert and not demented or otherwise unable to communicate, about how they feel, their food and drink preferences, any symptoms, and anything else of relevance to diet


• Deciding what action to take - changing the feed or supplements, asking for the patient to be weighed or for food record charts to be kept, highlighting some other problem that might need medical input (e.g. vitamins to be prescribed and electrolytes monitored in cases of potential refeeding syndrome), advising the patient on what to eat and usually encouraging them to eat more, or setting up a feed regimen for a tube feed


• Writing it all up on the dietetic record card and in the medical notes, a feat of memory that I am only now beginning to achieve in part


• Handing over any changes or requests to the nursing staff responsible for the patient


• Following up any other actions, like writing the supplement prescription on the drug card and finding someone to sign it, or contacting the kitchen about some aspect of the patient's food, or asking the nurses whether they keep a particular feed or supplement on the ward, or advising them that the standard supplements aren't suitable for people with swallowing difficulties unless they are thickened.
  

The location of all these documents can be in a hanging file in a trolley, in a ring binder in a rack, in a filing cabinet, in a folder or clipboard at the end of the bed, with the pharmacist or nurse on a drug round, or with the doctors on a ward round. Or elsewhere in the hospital if the patient is out of the ward having a procedure done.

Talking of procedures, J and I arranged to see the insertion of a Percutaneous Endoscopic Gastrostomy tube: a feeding tube directly into the stomach. After the endoscope is inserted through the mouth and down the oesophagus into the stomach, air is pumped in to inflate the stomach and give a good view. The doctor actually took the endoscope beyond the stomach, and showed us a couple of duodenal ulcers that he found. He took pictures and samples of the gut wall for biopsy, to see if there were signs of the bacterium Helicobactor pylori, which causes ulcers and can be treated with antibiotics.

Back in the stomach, the endoscope then shines a light from its end that can be seen externally, so the hole can be made in the right place from the outside into the upper part of the stomach. This is surprisingly high - just below the level of the ribcage for most people. A string is fed in through this hole, one end of which is drawn out of the mouth with the endoscope while the other end protrudes through the hole, then the PEG device is attached to the 'mouth' end and pulled into the stomach down the oesophagus. The external part of the PEG tube then comes through the hole, while the stomach part remains inside. It bled surprisingly little, and normally the tube can be used for feeding after just 4 hours.

When we told people in the office we were going to see the PEG insertion, two of the dietitians said they had fainted when they were watching a similar procedure. Luckily, neither of us felt in the least bit faint. We could have stayed to watch a sigmoidoscopy (this goes in at the other end), but we thought we'd better get back to the office.

* Asked To See Patient, Lower Respiratory Tract Infection, Pulmonary Embolism and 'On The Throne'.

Progress at work and at home

I have a case study to finish, but you dedicated blog readers know how far I will go to please you. My stats tell me that there are a declining number of visitors, and oh! you are a silent lot. No comments for ages. Never mind, it won't stop me writing.

I am weary of the placement now, just as I am becoming competent. Not proficient, mind you, just competent, and that is quite a struggle. People ask me whether I am enjoying the placement - well, no, enjoyment is not the predominant sentiment. I don't wake in the morning full of beans, looking forward to driving 50 miles, traipsing around hospital wards, being supervised minutely, getting involved in conversations with patients and staff that almost always end in the prescription of nutritional supplements, trying to write down everything that everyone has said in the last hour, then driving another 50 miles home. It isn't fun.

This may change with next week's 'Consolidation'. This word is to placement students what the word 'Christmas' must be to two year old children - an utterly unknown concept that everyone keeps talking about as if it must be the most wonderful thing in the entire known world. Consolidation is a time when we are allowed out on the wards on our own, virtually unsupervised, to do our worst with the poor innocent patients. I am hoping that it will be enjoyable, but if not, I am resigned to serving just under three more weeks before I am released back into Student World.

We have made a little progress with our bathroom, as you can see: Alf has tiled the floor and completed the tongue and groove panelling as well as a couple of other little jobs here and there. This means that quite a lot of sawdust and other detritus found its way into the house, and much as I would have liked to work on my case study, I really didn't want to work on my case study, so I did cleaning instead. Even when the cleaning was done, I didn't want to work on my case study, but now I'm glad it did. It's very nearly finished.

So in the two days that I am becoming reacquainted with in the guise of the 'weekend', I spent one day cleaning and one day working on my case study. Not the most enjoyable weekend I've ever had, and Mr A wasn't even here to share my pain, he was away staying with friends and take in an air show (which unfortunately was mostly lost in the fog).

And now, in 'Other News':

no, just joking, there is no other news.

Week nine

My university tutor visited this week, bringing with her some uniform tunics one size smaller than the ones I've been wearing. They're a snug fit, but better than being swamped by my current ones. Aside from the uniform issue, she confirmed that I'm doing fine. This is a relief, since it means that, barring any accident, I should be able to finish the placement as planned, without a need for additional days.

I'm becoming much more confident on the placement, and the whole thing is much less stressful now that I'm not completely incompetent. I've had a great deal of ward practice now, which makes me feel much more comfortable about the ward environment. The change came very suddenly - one day I was having terrible trouble dealing with all the different types of information, the next day I was writing dietetic and medical records with hardly any bother. This last eight weeks has been the steepest learning curve I think I will ever experience.

I've been seeing both inpatients and outpatients myself, albeit supervised, and occasionally the supervision has been at a distance. This is Very Good Progress Indeed. I have written letters to referring GPs and other physicians, followed up my case study patient at home after discharge, and seen every patient in a general adult outpatient afternoon clinic, where almost any type of dietetic intervention might crop up. Although eight patients were booked in, three cancelled and one didn't attend, which made it just possible for me to keep up with the record keeping as we went along. I can't imagine how I would have coped if all eight had turned up.

The only things that are obviously missing from this placement are type 2 diabetes and weight management, which is a great shame because these are pretty much the predominant complaints within our society. There are many more types of rarer disease conditions that I haven't met, but I would have liked to see more diabetes, and I need to know more about how weight management is done by the professionals.

The worst symptoms have happened this week, though - I've been waking up in the middle of dreams where I've been calculating patients' nutritional requirements. And today I've spent the whole time writing up my case study, but at least this means I might not have to spend any time on it next weekend.

Two weekend trips

The weekend started on Friday, after I'd finished writing a two-page Reflection. Reflecting is an activity that healthcare professionals are supposed to engage in frequently, where you review an aspect of practice, and mull it over some more, and you think about how it could have been done differently or better, and what you will take from this into future practice. It can be done in three sections: "What?", "So What?", and "Now What?" I've been writing a reflection every week, usually less than one page, but this was a doozy, because I'm actually doing more myself rather than observing, and because it's so easy to find things I could do better.

Anyway, Friday evening found me stuffing vine leaves to take up to Manchester where I met mum and Lola II and visited our lovely cousin H and his lovely wife B. Mum brought a kilo of hummus, some okra and pita bread, and Lola II unloaded some more of her plum compote - she has a plum tree in her garden, and plums seem to be featuring heavily in all our diets at the moment. (The plum jam that Mr M made was so good that I had to have a second slice of bread so I could have some more.)

Imposing all three of us all at once on our poor relatives resembles cruel and unusual punishment, but they stood up to us well, although H was powerless to resist the pressure to join Facebook (for the photos, you know). He put up a bit of fight, protesting weakly about 'privacy' and 'spam', but Lola II just showed him the photos of his nephew and great-nephew, and capitulation swiftly ensued.

Sunday night was a real treat. I had been made aware that Smurf the ex-landlord of the Pub Next Door was now associating with a different pub, the Red Lion in Hunningham. So we thought we'd pay a visit, especially as we'd heard the food was rather good.

We had a most wonderful time - Smurf was there to welcome us, introduced us to the owner, recommended the beer and was almost his usual self. 'Almost', because as he confided later, he has to be a little less 'exuberant' given the more upmarket clientele that this pub attracts. I interpreted that as: 'less swearing, and no nicking chips off customers' plates'. The setting is delightful, next to the river with not only tables but deckchairs for customers. Best of all, during the August Bank Holiday there's a beer festival plus a film screening outside each evening, with camping.

I think that our Bank Holiday activity is now sorted, for Saturday night at least. The rest of the weekend may find me writing up my case study, which is due to be handed in on the Tuesday after the Bank Holiday. Unless, of course, I get it all done in advance.

Eighth week and punting

I'm sure I've said it before, and I'm sure I'll say it again, this "working all day" thing is definitely not as good as lounging around as a full time student. I seem to be tired all the time, although going away last weekend probably contributed to the fatigue. Not that I did anything exhausting, but going away meant that I didn't have weekend recovery time at home.

I've lost track of which Dietetic Week we're in, other than this was my eighth week out of twelve, and I don't think there was any theme. The great news is that my Healthy Eating presentation is done and delivered to a charming group of older people, mostly ladies, in the lounge of a sheltered housing complex. I haven't had my written feedback yet, but the supervising dietitian seemed pleased on the whole, albeit with some valid criticisms of the content I'd chosen.

I've felt more competent overall, although there are occasional glitches when I feel very incompetent indeed. There was one minor indiscretion where I queried something in a patient's medical notes to my supervising dietitian and the person who had written it was standing next to us, but I think I got away with it. I have had to go to my placement mentor to let off some steam about one of the other dietitians, but we came up with a plan together to cope with it. It's all going quite well, really.

Last weekend was splendid, in the company of friends who have been friends for such a long time it feels nostalgic to think back to when we got to know one another at university in the mid-1980's. More than 25 years ago. Family JJL&J invited the group of friends that tend to spend New Year together every so often, and many of us assembled on Saturday to set up our campsite in their back garden. Mr A couldn't come - he was on a pre-arranged motorcycle trip in southern Scotland, getting devoured by midges and sleeping in some hammock arrangement.

I brought Mr A's enormous 1980's A-frame tent, Lola II and Mr M brought Lola's little dome pop-up tent, and our other camping neighbours M&N brought a tent that they'd bought three years ago when camping was trendy (they are a trend-setting couple after all) and never used. This palatial nylon residence not only had a hallway and two rooms, but came with a lighting system. Now that they have actually slept in it, I doubt that it will emerge from its compact storage bag again - I don't think they are that keen on camping, really.

Once all the tents were up and we had eaten lunch, we all went punting. Unfortunately the weather was changeable, and there were a succession of small bursts of rain, but nothing to dampen our spirits. We needed two punts to cater for the full party, but of course Lola II had brought walky-talkies, although the main use for these was to hurl distant abuse and sing songs to each other. We briefly moored to eat cake, but the weather wasn't great for leisurely dallying. Other punting parties provided the most amusement, especially the hen party who had an inflatable 'member' in their punt, which distracted our navigators to the extent that we hit the bank.

The rest of the weekend passed in an enjoyable manner, including games, food, more games, more food, walking and more food. It was lovely to see everyone, and look forward to our next get-together at New Year.

What I've been reading

The Island
by Victoria Hislop

narrated by Sandra Duncan

"Alexis Fielding longs to find out about her mother's past, but Sofia has never spoken of it. When Alexis decides to visit Crete, however, Sofia gives her daughter a letter to take to an old friend and promises that, through her, she will learn more. Arriving in Plaka, Alexis learns that it lies a stone's throw from the deserted island of Spinalonga - Greece's former leper colony. She finds her mother's friend, and hears the tale of her great-grandmother, and her daughters, and a family rent by tragedy, war and passion."

I was lucky with this choice - I didn't have a recommendation and have never read any of her books before. It made me look up the history of leprosy treatment, and didn't get too involved in the business of book-writing, by which I mean that it didn't use suspense as a tool. If the reader needed to know what happened next, it was told next, rather than interspersing two lines of narrative and making you wait. I liked it.



The Poison Paradox
by John Timbrell

"From fears of food colouring and pesticides, to industrial accidents and terrorist attack, we are assailed with scare stories about the chemical dangers lurking in our food, our homes, and the environment. The Poison Paradox explores the dark side of chemistry, and provides a lively and rewarding introduction to the science of toxicology."

This is a book that I acquired in return for work done as a member of the Oxford University Press Biosciences Panel. I've had to choose my favourite book cover design, review a couple of books, fill in some surveys about what I find useful in a bioscience textbook, and in return I get credit that I can use to buy OUP books. Given its reputation, I would have expected this OUP book to be better than it was - the writing was very 'clunky', a bit more like lecture notes or a textbook rather than popular science. An interesting subject, despite the less than engaging writing style.



Piccadilly Jim
by P. G. Wodehouse

narrated by Jonathan Cecil

"The life of Jimmy Crocker has been little more than one drunken brawl after another. His formidable Aunt Nesta has had enough of his antics and decrees that the young Crocker must be reformed. However, Jimmy has fallen in love and decided to reform himself. Unfortunately, to win the heart of his intended, Jimmy must pretend to be someone else and take part in the kidnapping of Aunt Nesta's loathsome offspring Ogden."

The usual tortuous plot involving a man pretending to be someone else pretending to be him, but I just love the vocabulary. I'd forgive him a pretty weak plot just for using the word 'shrubbery' in the context of a man's facial hair.

Obesity week

Not much in the way of obesity this week, but I've been working hard on a presentation about 'Healthy Eating for Older Adults', and trying to make a start on my Case Study.

I'm finding the presentation challenging because I know too much, and I need to simplify it down or else it won't fit into the hour I've been allocated. Actually, my contact at the venue suggested it might need to be less than an hour, because the audience might find that a bit too long, so I'm guessing they are adults who are pretty old, or infirm, or both. Apparently they still cook and shop independently, so I'm going to do a section on food labels, as well as focusing particularly on fluid and fibre for the constipated among them.

My supervisor had a look at my draft presentation and said she liked it. She made a few suggestions for interaction, e.g. a quiz. I wasn't keen on a quiz, but I've now changed the presentation quite drastically, and the main section is now about comparing a lunch of beans on toast, soup and bread, sardines on toast or cheese on toast. It still needs cutting down, though - I might have to lose the section on the Eatwell Plate.

I can't remember whether I've mentioned that I've found someone who's agreed to be my Case Study, but I'm being very cautious about writing about real patients on this blog. The Case Study is a piece of work where I document the patient's medical and social history and treatment, and discuss the justification and reasoning behind the dietetic input. I have to present this formally in a meeting of the department, which is assessed.

I'm starting to work a little more actively with patients, given that I'm a little more familiar with what's expected and how to do things. I've now carried out quite a number of independent consultations, mostly in outpatient settings, where I've done the whole thing including follow up letters to the referrers. We use checklists that are misleadingly known as 'Assessment Tools', whereby the supervising dietitian observes our work, and indicates whether we have met professional standards or need to make improvements. Three of these outpatient consultations and the one consultation with my inpatient Case Study have been formally assessed using the Assessment Tools.

I'm not doing too badly - the communication side of things was always likely to be good, given my previous jobs and my mature age, but it's not entirely trivial to remember all the 'rules' and avoid the pitfalls. It is too easy to make assumptions, e.g. that people know that salt should be restricted to control blood pressure, or assuming that everyone eats or drinks something in the morning. Writing in the dietetic record and the medical notes is the hardest thing, requiring entries to contain all the relevant information, in the right order, without crossing anything out, but in just a few lines. I am incredibly slow at this at the moment - avoiding repetition and deviation simply induces hesitation.

In terms of obesity, I did have a chat to the Program Manager about their adult weight loss programme that has been developed for local delivery, called 'The 10% Challenge'. It's a 12-week course available free on the NHS to people whose BMI is 25 or more, which seems an absurdly low threshold. I didn't quite understand how they aren't overwhelmed by demand, but I found out that unlike smoking cessation and cholesterol treatment, GPs have no weight loss or BMI targets, so are not funded specifically for weight management. This would certainly make the programme less competitive in terms of GP funding for participants.

I also spent some time with someone in charge of the weight loss programs for families including a child who needs to lose weight. The obesity team have also loaned me a pedometer and given me a free T-shirt, and thus won me over. I'm not hard to please, although I'll have to sneak the T-shirt past the clothes police, aka Lola II.

Other news: I have had another birthday, and made myself a wheat-free and gluten-free banana cake with cream filling and chocolate ganache topping. I used Doves Farm flour and it worked so well that I actually forgot that it was 'special' as I took the beautifully raised cake out of the oven. My wheat-intolerant badminton-playing friend was delighted, as she usually has to miss out on any treats going round.

Mr A has also had a birthday, and we treated ourselves to a trip to the local sushi restaurant. It was not a great experience - the food was fine but service a bit flaky, and the cost too high to overlook this. On the way home Mr A expressed a desire for more food, so we diverted via a local Chinese restaurant. It was so salty that he told me today he thought he would have palpitations, and although I only had some prawn crackers and a spring roll I drank half a litre of water during the night without needing to get up and get rid of any of it.

Cancer week

Oncology was interesting, but the main issue during the week was the overworked state of the dietitians. They obviously cannot control the number of people who are referred to the department, and must see new referrals within 2 days, but they must also review existing patients according to a system of priorities. Last week, with holidays and lieu time off, there weren't enough people to cover, especially when slowed down by two students tagging along and getting in the way.

The different dietitians manage this state of stress in different ways, but let's just say I didn't have a great week. There were some highlights, though, and I completed three supervised consultations, which is quite an achievement. One patient also agreed to be my case study. I am now half way through this placement, and surviving. I will be very glad when it is over.

The most interesting aspect of the week in cancer was finding out how radiotherapy in the Head and Neck department is managed. A multidisciplinary team (MDT) reviews the scans and history with a surgeon, chemotherapist, radiotherapist, radiographer, clinical specialist nurse and others, and devise a plan of action: radical or palliative surgery, chemo or radiotherapy. I have observed two of these meetings, and the quality of the online scans (projected onto a screen) and the interpretation of them is a wonder to behold.

The team then sees the patients and explains the clinical situation and their proposed treatment, and the patient is asked to consent. If radiotherapy is to take place, the next step is to construct a mask to go over the head and chest to immobilise the patient while treatment is delivered, to ensure exact targeting to the tumour. The mask starts off flat with small holes, is put in a warm bath for three minutes which softens it to the texture of soft chewing gum. When it is then placed over the patient, the plastic stretches and the holes expand to a wide mesh as it is moulded to the exact shape of the face, neck and chest, as it hardens.

The whole process of making the mask took about an hour, then the completed mask and patient move to a different room where the mask is marked up very accurately and a CT scan done so that the treatment can be planned very precisely in relation to the reference points on the mask.

The role of the dietitian in oncology of Head and Neck is vital, because most people will have trouble eating at some point - either because the site of the tumour encroaches vital spaces (e.g. the mouth or oesophagus), or because of the effects of the treatment. Both chemotherapy and radiotherapy produce unpleasant gastro-intestinal symptoms: nausea, vomiting, loss of appetite, and often inflammation in mouth and oesophagus (mucositis). It is important to try to maintain the nutritional status of the patient, not only because it will help recovery if enough nutrients are available to the body, but also so the mask fits. If someone loses a lot of weight, the mask may become loose and have to be re-done, because accuracy of positioning within the treatment field is crucial.

The routine of mainly one specialty area per week is about to be broken as the obesity dietitian is away for my obesity week - but that will give me time to work on the presentation and the case study that I need to prepare.