No time to blog properly

I have had a busy week, and in half an hour I must take myself away to a badminton match. There has been little time for blogging, so here is just a flavour of the last few days.

I have been getting better slowly from my terrible illness. Sunday was my worst day, but I valiantly tackled more slash and burn in The Garden and took another load of bags to the dump on Monday. As predicted, it doesn't really look any better, and still needs attacking some more, cutting back the big trees in particular.

Alf has been to repair and renovate various bits of exterior wood, brick and paint. Our usual lackadaisical attitude meant that we had to choose a colour for the whole house to be painted while I was at uni and Mr A was delivering a training course, so we did most of our colour choosing in the dark or under artificial light or when one of us wasn't there. When I turned the corner coming home this evening, thankfully it looks as though it will be fine. Pictures will follow, along with more detail (perhaps).

The new term has started and I have only three modules: my research project (worth half of the total marks this semester), Advanced Dietetics and Professional Issues (worth one third) and Nutrition in the Community 2 (worth the remaining one sixth). Key events so far: 1) I was late to the first lecture and then my phone rang and I couldn't turn it off; 2) I have sold my lab coat and safety glasses to a first year; 3) we are all swapping notes on our clinical placements over the summer because we will be choosing the location of our C placements imminently.

Must get going now. Tomorrow the forecast says there will be torrential rain over most of the country, which is why I will be heading south with Lola II to do some camping. I would love to do more blogging, but electricity supply and internet access are in short supply in most fields. I am sure there will be much to report on our return, though.

Feeling ill

I am Not Very Well. Following the family reunion last weekend, three of those present are now suffering. It would not take a brilliant detective to determine the source of our infection.

Despite illness, I was very brave and tackled The Garden. This did not involve careful nurturing and tending delicate seedlings, but attacking plants which seem to have the constitution of a wrought-iron railing, but a railing that doubles in size every year. I have used secateurs and a small hand-saw, and taken many bags of 'clippings' to the dump. If I feel better this afternoon I will do the same again, and The Garden will still look as overgrown and threatening as it did when I started.

Other than The Garden, I have been whimpering gently as I make my snotty way around the house to make cups of tea, and sitting at my desk thinking about doing some things that really need sorting out even though I'm not feeling well. Car insurance, credit card statements, filing receipts - perhaps I'll see if Lola II will come and help. [Only she will appreciate the true comedy value of that statement.]

My brave persistence with everyday life despite my weakened condition has also manifested itself in making supper. Mr A has been doing a lot of the cooking in recent times, especially while I was out working all day, and his recipe research method was usually Internet-based, and resulted in something by Jamie Oliver. So I bought him a JO cookbook for his birthday, and it has been quite a success. One thing I hadn't appreciated about Jamie was his use of fresh chillies, to the extent that we regularly have some in the fridge, waiting for the next Jamie recipe.

I concocted one of Jamie's recipes, with the result that as I was sitting on the sofa afterwards, tissue in hand, I happened to rub one of my eyes. I spent the next half hour with both my nose and one eye streaming.

School starts tomorrow. I think it is fair to say that I am not particularly looking forward to it.

Type 2 diabetes

The days are whizzing by, and I'm starting to feel threatened by the looming start of term, and the need to buckle down for another semester of university life.

Each year has been marked by a significant increase in the difficulty and intensity of the work, and a raising of the expected standard. I've been told that this year should be easier than last year, although I'm not sure why that should be true, other than half of this semester will be taken up by my 'research'. I suppose that should be less stressful than lectures and exams because I will be in control of progress, and also because I already have an interest in the research task and its outcomes.

In my last remaining days of freedom I have been engaged in a university-related task. One of my lecturers is doing a PhD about the value of communications skills in the dietetic consultation. As part of this work she is video recording qualified dietitians carrying out a consultation with a simulated patient before and after they go on a communications skills training course. The different styles of communication that I found within the group of dietitians I was shadowing over the summer was one of the most interesting parts of the placement for me, so when she asked me to act as one of the simulated patients, I was very happy to agree.

There were two qualified dietitians to video, and this was the session before their course. I was pretending to be a patient newly diagnosed with type 2 diabetes, and I was given a scenario containing all the details of my history and condition that I needed for consistency.

Both of the consultations were all right, I suppose. The assessment was not about the accuracy of the information or advice given, but about the manner in which the meeting was conducted, and the effectiveness of the communication. Which was a good thing, because unqualified though I am, I'm sure that both of them actually gave me incorrect information about healthy eating for type 2 diabetes. To be fair, one was a paediatric dietitian and the other a renal dietitian, so they don't routinely give advice specifically about type 2 diabetes.

It was very illuminating to be on the receiving end of a consultation, rather than observing or leading. I learned a few powerful lessons from this experience that I hope to implement in my future dietetic practice.

The first is to concentrate on the key messages, and try not to introduce extraneous material. Treatment of diabetes is about helping the body deal with the blood sugar that comes from sugary food and starchy carbohydrate. The main methods are by drug treatment, by diet and by exercise. Stick to these, and explain them well, and that's enough.

The second, and more important message, is to talk about what is now happening rather than what might be. The drug prescribed for type 2 diabetes in my scenario helps the endogenous insulin remove glucose from the blood rather than stimulating pancreatic insulin production, and so cannot cause hypoglycaemia. So don't mention hypoglycaemia, it's not relevant, and will just introduce another bit of information and potential concern for the already overloaded patient.

That last phrase is also the key to an effective consultation from my vantage point as the patient. There's a lot of information and advice that can be given in a consultation, but any more than three things is too many. In both the consultations, I felt the dietitian did more talking than listening. It would have been much more useful to have a clearer description of just a few things than the large amount of confusing stuff that I was given.

So the things I think might feature in a consultation with a type 2 diabetes patient might be:

1. A very simple and basic description of the condition:
   Some of the food we eat is turned into sugar, transported around the body in the blood and used for energy when required. Insulin is the substance that enables sugar to be taken from the blood and used for energy. A diagnosis of type 2 diabetes means that there is too much sugar in the blood, either because there is not enough insulin being produced, or because our insulin is not acting as well as it should.


2. How any prescribed medication works:
   Either it helps the body to produce more insulin, or makes the insulin there is work better.


3. Why it is helpful to work towards a healthy weight (if the patient is overweight):
   If blood sugar is to be used effectively for energy, it must get out of the blood through a 'door' into cells. Insulin is the key, but the body provides the lock. Excessive weight can distort the shape of the lock, so that the insulin key doesn't work as well as it could. Losing weight removes some of the distortion, so insulin works better. Losing weight may allow medication to be reduced.
   


4. The role of physical activity and diet in weight management and control of blood sugar:
   Physical activity also removes some of the distortion in the 'lock' so that blood sugar can get out of the blood and produce energy. It also helps with weight loss. A healthy diet can also help you lose weight, and the types of foods eaten will affect the control of blood sugar as well.
   


5. Specific aspects of diet, tailored to the individual patient:
   This is where a diet history is useful, to see what the patient's normal diet looks like so that appropriate suggestions can be made. Examples would be:
   - avoid sugary food and drinks, or replace them with sugar-free alternatives if possible
   - eat plenty of salad and vegetables, and some fruit
   - eat starchy carbohydrate foods in moderation, but include some in every meal.
   There should be no more than three specific recommendations for action as a result of the consultation. It is best if they are proposed by the patient, rather than by the dietitian.
   

On my last placement I had no opportunities at all to observe dietitians or work with patients with type 2 diabetes. The nearest thing was my session on gestational diabetes. I am hoping to be able to get this experience on my final placement, when I shall look back at this list to see how right or wrong I was.

In London again

Thanks to Lola II, you haven't been deprived of top quality blog fodder while I've been taking it easy after 12 whole weeks of working. If only all jobs could last just 12 weeks, then give you two weeks off before starting again. [On reflection, if you get 6 weeks holiday a year, then they could.]

After the frenzy that was the Food and Drink Festival, I had three days of more sedate activity, including some home cooking and some paperwork and a bit of tidying up before launching myself down to London. At one point I had about six lists on the go, covering future plans, daily plans, longterm plans, a shopping list, and a plan to use up all the leftovers in the fridge that accumulated while Mr A was in charge of the kitchen.

Now I'm sitting at Lola II's kitchen table, contemplating the list of jobs she's given me to do while she's out, and considering my options for entertainment in London for the next two days. I feel another list coming on...

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Thursday and Friday

So, out on the streets of London I have met a couple of friends to catch up, and helped Mr M to nearly win the pub quiz (actually they lost on the tie break and I didn't really help at all). My list is nearly untouched, having done no jobs for Lola II, but all my shopping for Japanese goods.

I spent the afternoon in Lola II's office, doing homework for school: reading and commenting on a chapter about DNA replication. I learned some more things, but by the end of the chapter I was struggling to understand what was going on. It reminded me of how much knowledge we have about the molecules that constitute our bodies, and how much there is still to learn. The sum of human knowledge is truly remarkable.

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Weekend

This morning the sun is shining, I'm still in bed, providing valuable moral support at a distance for Lola II who is cleaning her shower. She is cleaning it so thoroughly that it has taken all morning. We did necessary admin work all afternoon and most of the evening, taking a break for just an hour or so to eat Japanese food.

Then there was a family party to celebrate the departure of 2nd nephew to university, which included food and piano playing and hairdressing and digging in the garden, followed by a tortuous journey taking mum and dad home by car. 22 miles, 2 hours, average speed 11 mph. I won't volunteer to do that again, we'll go by public transport like everyone else.

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Monday

Jobs for the parents: cleaning the scum out of the heating header tank, downloading a security update, and advising on ways to edit and classify images before creating Powerpoint presentations. I now need to document all the programs and what they do, so that dad can get started on creating his lectures electronically rather than using the old-fashioned (but reliable) method of a slide projector.

Food & Drink Festival

Hello, Lola II here.

Lola I, blog-owner extraordinaire, made a little harmless comment recently that there have been no contributions to her blog from anyone else for a while. Since I am the only official guest contributor (I don't mean you lovely commenters), I assumed that what she was actually saying was:

"I've had to go to work for weeks now and it's exhausting and it would be really helpful if you could do a little writing. Firstly because it'll be a nice break for me, but mostly because I love your writing style, you are eloquent, your grammar are second to a none and your speelling is exemplorrie".

My own motivation for writing is that Lola's brain is the size of a planet, near full capacity, and unless I give her a break and do a little writing myself, it is likely to explode. Not such a problem except that she is due to come and stay with me from today until Sunday, and I hate cleaning.

Last weekend Mr M & I visited Lola I and Mr A, and dropped in on the Leamington Food and Drink Festival.

The Taste Trail comprised of nine restaurants offering free food in return for a rating from the tasting public. The restaurant's hope is that, by the end, they will be classed as GOLD! Our part of the arrangement was free food, and entry in raffle to win a dinner for two. Mr M said he'd donate the meal we were sure to win to Lola and Mr A. Mr M is a much nicer person than me. I generously conceded that I would visit them before our meal.

Meanwhile, in a park nearby, there were oodles of stalls selling and demonstrating and tasting a variety of food, from Caribbean to Greek to French to Thai to Sausage Heaven and Olive Oil-tastic. All accompanied by soft background music, punctuated by the singer saying "oh sorry, that was the wrong verse".

My objection on the sampling food front is to the man who got the last piece of a pork pie and fed it to his greyhound. I stood back to watch the stallholder's reaction, ready to dive in and support local industry in light of this grossly unjust and disrespectful behaviour! In the blink of an eye I considered whether I was prepared to wade into a fist fight. Possibly. One with a dog involved? Oh yes, I love dogs.

What does the stallholder say? He says "is that an ex-racer?" SampleStealingMan says yes and the stallholder gave him the thumbs up!!!! Unbelievable. It's a sorry state of affairs when a proper sampling law-abiding person such as myself is trumped at the pork pie stand by a doggie. Hrrmph.

Top notch moments were the free bites to eat in Sabai Sabai (Thai) and Kayal (South Indian),the best chocolate florentine I've EVER had - crystallised ginger was inspired. Having a little dance with Mr M, his first cobnut, and seeing Mr A run like greased lightening down the stairs and out of the house with Lola realising almost immediately that it was because there was some kind of fancy airplane zooming past outside. Turns out it was a Spitfire, so Mr A's attempt to break the four second mile was justified.

We had a Rocky Road disaster, Portuguese nata cake-thing that wasn't up to scratch and the worst nutella crepes I have EVER experienced in all my life. Worst of all was when I popped off to the public loo and I saw a 14 year old girl walking towards the men's. In my super-helpful citizen mode I shouted out "no, that's the men's!" The child turned to me and said, "yes, I know". That little boy should jolly well get his hair cut.

B Placement - finished

At last it's over, 12 weeks completed and assessed and all boxes ticked. That's three months like no other I've ever experienced, in terms of the journey travelled and amount of learning acquired.

In my final week I was pretty much left to my own devices on the wards, reporting back daily and asking advice where necessary. I was looking after oncology patients, most of whom needed feeds and/or supplements. Nobody died, but nobody got better either. I saw one particular patient every day, until he went home the day before I finished. He seemed to appreciate my efforts.

In that last week I was also scheduled for an outpatient clinic. I read through the patient records in advance, and there was no way that I was prepared to see them on my own - most had complex dietary problems or mental health issues, and one had both. The only straightforward one came halfway through when I was completely overwhelmed with all the others, so the senior dietitian supervising me did that consultation as well.

One patient in particular provided much food for thought (no pun intended). She went to her GP with 'poor appetite' and her GP had given her some supplement drinks. When she came back for more he referred her to a dietitian before prescribing them, which was the correct course of action (although still a rare occurrence).

I was expecting the patient to be emaciated, or at least on the thin side. She actually appeared well-nourished, and I started the consultation by trying to find out what exactly the problem was. She had various issues, but in terms of quality and quantity of her diet, I thought there was nothing much to worry about.

At this point, I felt I didn't have the experience to draw conclusions and make any suggestions, so I handed over to my supervisor. She was confident and experienced enough to ask the patient a) whether she was concerned about the situation, and b) whether she actually wanted to change anything. If the patient had said no, then that would have been it, and we would have sent her on her way and wished her well. In fact she did want to make some changes, so a plan was agreed and a follow-up appointment made.

As I took her over to the receptionist to make the appointment, I noticed the patient was smiling, and I asked how she was feeling.

"When the GP referred me to the dietitian," she replied, "I thought I would just get what I wanted, rather than what I need." She almost sounded resentful.

"But you're smiling," I said.

"Yes," she said.

I'm still not sure if she was actually pleased with what happened, or if she was smiling because she had challenged us and 'lost' - she hadn't got the repeat prescription for supplements that she had wanted.

So the last week passed by for J and me, with our case study presentations, a trip to a local pub after work to celebrate, many patient consultations, and I spent an hour watching a nutrition nurse show a patient's wife how to look after a PEG feeding tube and administer a feed and flush the tube with water. On my last day I saw the senior dietitian for my final interview before heading off to the wards for what I thought would be a brief review of a few sets of notes, but turned into two new referrals. That was a more challenging final day than I was expecting.

I am glad that it's over, although I am still mulling over a few of the consultations in quiet moments. Lola II and Mr M have been here for the Leamington Food and Drink Festival this weekend, which has taken my mind off my hospital placement a little. I have commissioned them to blog about our weekend adventures. When they have gone and things are quiet again, I think I may think a bit more about what I did over the summer. I'm pretty sure we will discuss it as a group when I am back at uni for the final year.

While it was a valuable experience, there were a few things missing: most notably the department lacks a dietitian who specialises in weight management, so we didn't see any of that. There was also very little in the way of community experience, that is, dietetic work outside of the acute hospital ward. I have asked for this to be noted so that it can be addressed in my next placement, due to start in February after the next academic semester.

First week of consolidation

I have been deemed fit for purpose and given three wards to look after on my own, which amounts to between six and ten patients. If I come across anything complicated on the wards, I bleep a grown-up dietitian. I also have to run a radiology clinic, a general dietetic outpatient clinic, give an assessed presentation about healthy eating with Gestational Diabetes to a room full of pregnant women (which I've done, and it went very well), and do an assessed presentation about my case study.

It's not bad. I have been asked a few times if I'm enjoying it, and still the answer is no. I think that to enjoy myself, I must be able to relax, and there's not a moment when I can do that. On the wards I inspect the notes minutely so as not to miss anything, and usually ponder for some time before deciding what to do. This is in a ward where people are buzzing around with bulging files and stethoscopes and bedpans and mops and wheelchairs and drip stands and walking frames, and the myriad sets of notes and documentation could be anywhere and might be taken away the moment I find them. It's not a calm and peaceful environment where I can peruse the case carefully and consider my decision at length.

One patient last week took me 90 minutes from start to finish, which included reviewing the medical and nursing notes and all the charts, calculating nutritional requirements, formulating a feeding regimen that ramped up over several days and included fluids, prescribing the right feed in the right format on the drug chart, planning the whole intervention and documenting it unambiguously in the medical and dietetic notes. Add to that the challenge of finding all the supporting information, and it's clear why patient contact can take so long for a beginner.

Two patients referred to me for dietetic advice last week were discharged back home, one of them before I'd actually seen her. A decision had to be made about whether to take any follow up action, like writing to the GP or inviting the patient to an outpatient clinic for subsequent dietetic advice. These two cases provoked some interesting discussion in the office about the practice of prescribing supplements for people leaving hospital.

One was an elderly lady, frail as a cobweb, who'd been admitted with an infection and confusion. The other was a previously malnourished man whose oesophageal stent had shifted, preventing food from reaching his stomach. Both were discharged 'well', i.e. without infection and with the stent replaced where it should be.

The criteria for prescription of oral supplements are that the person must have one of several specific conditions, mostly gastro-intestinal diseases that impair absorption of food within the gut.* There is one generic condition given in the British National Formulary (the rules for prescribing medication): disease-related malnutrition. Neither of these patients met the criteria: the old lady because she had no disease, and the man because he was no longer malnourished. But she was clearly not eating well, while he loved his supplements and had talked the ward into giving him a big bagful to take home.

I talked to the man about his food intake, and how he is using the supplements he had previously been prescribed at a level of two bottles a day. His wife cooks him a proper meal in the evening, but for the rest of the day he relies on these bottles of supplements. Up to six of them in a day, and up to two supplement soups that perhaps he had persuaded his GP to prescribe without our input.

"If I wake up hungry in the night," he said, "I might have one then."

"But they are medicine," I told him. "You don't take medicine for a condition you don't have, just because you like it, do you? If you wake up in the night, you could have a cup of cocoa instead."

"I don't like cocoa," he replied.

"Well, have some tea, or toast, or a sandwich," I said. "These supplements are not simply for your convenience."

"I have them because they make me feel better. They give me the strength to eat my dinner."

We would have liked to prescribe supplements for the little old lady, who would surely not manage to eat well on her own. We could imagine the man persuading his GP to continue prescribing more supplements than are strictly required. My supervising dietitian has written a very carefully worded letter to his GP to say that there is no justification for this. It's our taxes that pay for it, after all.

I wake up thinking about individual patients that I've been seeing. I find myself mulling over calculations and assumptions that I've made. Consolidation continues this week. I'm still not enjoying it, but it's better than the ten weeks that went before.

* Short bowel syndrome, intractable malabsorption, pre-operative preparation of patients who are undernourished, proven inflammatory bowel, following total gastrectomy, dysphagia, bowel fistulas, continuous ambulatory peritoneal dialysis, haemodialysis.

Making mistakes

I finished and handed in my case study last week, and did a bit of work on the presentation about it that I have to give next week. A bonus was that I discovered an element of best practice that wasn't being observed in this hospital, so I can put that in as a recommendation, concerning water-soluble vitamins (B and C) being given to patients on haemodialysis.

I was intercepted by an Infection Prevention nurse on one of the wards last week, and invited to do a handwashing test. She smeared some gunk containing 'germs' that could be seen under UV light, and then I had to wash it all off and check with UV afterwards. I did quite well, but missed a patch on my wrist. It was an interesting exercise.

I've already mentioned that the mistakes that I make are picked up and recorded and I am given feedback at the time, and at my next review, and no doubt for eternity. While I have been with the qualified dietitians, they have made similar mistakes, and it is mildly annoying that I have to keep quiet.

For example, in the High Dependency Unit (one step down from Intensive Care) I was shadowing another dietitian when we discovered that the wrong feed was being used. In this particular case this was quite a serious error because the patient was at risk of refeeding syndrome and her blood electrolytes were a bit out, but the dietitian made a bit of a fuss in front of the patient who then looked worried, so I said something reassuring. If that had been me, it would have been put on my record and I would never hear the end of it.

The same dietitian also mentioned in the office, when talking to someone else, a howler she had made when looking through medical notes on the ward. She noticed that someone had written that a patient should be given 'soft fluids' (this may be a confusion of 'soft diet' and 'thickened fluids'), and had said something like "What does that mean?" Turns out, the person who wrote it was standing within earshot. This is exactly the mistake that I made earlier in my placement.

On the other hand, I am still making mistakes too, even if they aren't observed. While I was out on a ward on my own I was talking to a tube-fed patient who had undergone quite a major head and neck reconstruction following excision of a tumour. He wasn't able to speak, but wrote on his notepad that he was looking forward to a cuppa. I mentioned that his medical notes stated he might be able to start trying to swallow again soon, but he hadn't been told this by the medical team.

When the tea trolley came round, luckily I was still hanging around the ward and he came over to ask whether he could have a drink. I had to say no, and that I probably shouldn't have mentioned it because it's the doctors who make that sort of decision. It would have been positively dangerous if he'd tried to have a drink, given that he'd just had surgery to his tongue and oesophagus - it might have gone into his lungs, which is potentially fatal. I have learned just as much from this error while I was on my own as I would if someone had been watching me.

Visit the Red Lion!

Hooray! The Red Lion cinema trailer I mentioned in my last post is now available here. Enjoy!

Bank Holiday weekend

I'm looking forward to the end of my placement so much that I'm planning the contents of almost every day of freedom that will take place for the two weeks between the placement and the start of lectures in my final year. And thinking about the next phase of home maintenance - it will consist of a few odd jobs around the house, and then possibly exterior renovation: woodwork, brickwork and paintwork. And the car needs a major service, and I will need a haircut and a new bag for school, and I want to see ex-colleagues in Birmingham and Lola II and the rest of the family and some friends in London.

But before all that, we have had a three-day weekend, in which we were particularly looking forward to the Red Lion beer and film festival, including camping. Of course I let some people know that it sounded like a good prospect for socialising, and most unusually, three friends actually turned up! Unfortunately, one arrived earlier than us and left before we got there, but we did see two lovely people! And tried some different beers, although I think I still like the Slaughterhouse Brewery's Saddleback beer best, and that is served next door all the time.

[Note: Best beer of all time is still Timothy Taylor's Landlord, but only when it is served in tiptop condition, which is rare. It used to happen in The Metropolitan pub, round the corner from where I used to live in Manchester, and we once found it completely at random in a pub off the M1 somewhere, but even Smurf couldn't quite get it right at the Cricketers.]

Then there was the film, which was Léon, shown on the most enormous inflatable outdoor screen you could imagine, and projected from the back of a Landrover. But before the film, they played a brilliant introduction featuring the pub itself, which mimicked those old scratchy advertisements with still photos and a voiceover, for a women's clothing shop or Indian restaurant 'just 100 metres from this cinema'. I have looked for it on YouTube and on the pub's website without finding it, so you'll just have to believe me when I say it was utterly brilliant.

The wind dropped so the screen didn't move around much, and the sound was great, but it was quite cold. Then off to our tent, even though we hadn't really had much to drink, and Mr A could probably have driven home legally. Never mind, it gave us the chance to try out his second newest tent (don't ask), which is relatively easy to put up even when you've already had some beer, although smaller than the palatial tent we have previously enjoyed. We slept well, and came home next morning for breakfast and a shower.

We enjoyed the screening so much that we headed over again for Sunday night's film, which was Point Break. We wore more clothes that time, so were generally more comfortable, but we drove home again afterwards rather than camping. On Monday we attempted a hat-trick of films, but King Lear starring Ian Holm rather defeated us, so we have half of that still to watch.