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'.