Sunday, 27 June 2010

Hospital food

White flowers entwined around a black railing
The first week of my B placement has ended, and I have a weekend in which to play. I deliberately kept it clear of commitments in case of exhaustion or mental stress, but I have experienced neither, and have spent the day cleaning and cooking. Also, we have taken our plumbing situation a step forward by two trips to the DIY store (OK, it should have been one trip but we're a bit rubbish), and we successfully exchanged the towel radiator that was leaking. Mr A has installed it, so far without incident. Now we have to wait a little while to see if it leaks, but if not, we can progress with the bathroom floor, followed by the rest of the bathroom. Meanwhile, the rest of the house continues to rot. Very slowly.

The placement has started slowly, as might be expected with any new job. I have started to find my way around the hospital site, learned to use the bleep system, filled in a record card, and been given a swipe card for the locked doors in the department, a Student Dietitian badge, a photo id for the hospital, a parking permit for my car, and a free biro. I have successfully used the photocopier, and I know where to find the kitchen.

We have also been introduced to the catering department, a critical therapeutic function of a hospital that is often overlooked. A lot of work goes into the design of menus, and there are always several competing demands: gluten-free, dairy/lactose-free, fortified (which is called the 'recovery' menu in this hospital), and soft or pureed for those who cannot chew or who have an impaired swallow. There are meat, fish and vegetarian options, hot and cold options, starters, mains and desserts.

When I was in Rotherham they made everything from scratch on the day, which meant that patients had to fill in their orders a long time in advance, and new admissions received whatever the previous occupant of the bed had ordered. This hospital operates a 'cook-freeze-chill-regenerate' system, so that food is cooked in bulk in advance and frozen, then brought to chilled temperature and plated as needed, loaded into ward trolleys then heated in big docking stations in ward kitchens. The trays are divided in two and half remains chilled, so an order of both hot and cold food in the same meal can be accommodated. Orders for the following day are collected in the evening, and new admissions can usually make a lunch choice at breakfast time the same day. It seems very efficient, but I expect that it needed a good deal of capital investment in the necessary equipment.

We met the 'Diet Chef', who is responsible for the pureed meals, gluten and dairy-free menus, and anything out of the ordinary (like vegan). He uses real food and thickener for pureed meals, which also contain extra energy and protein on the assumption that those who need soft food are probably in need of building up as well. The different components (e.g. sausages, mashed potato and vegetables) are frozen separately into molds, so that when plated up they resemble the original food, rather than unattractive mounds on the plate. He assembled four pureed meals for us to taste, and I really wouldn't have minded finishing any of them. One of the other chefs also gave us a plate of the standard chicken curry to taste, and it was delicious.

In Rotherham I spent a morning on the lunch conveyor belt, loading gravy onto plates that were going straight out to wards. The belt here plates up chilled food, so the workers were all dressed in fleeces, hats and gloves during the hottest week of the year so far. We went out to a ward to shadow a 'hostess', responsible for dishing out the food and helping people to eat it. I helped feed a lady with pureed food - she ate no more than two tablespoons of chicken, a teaspoon of mash, and two teaspoons of chocolate sponge. The (pureed) sponge had the consistency of a chocolate terrine and looked delicious; I tasted some afterwards, and unfortunately it was unpleasantly gluey.

There are several other ways that patients can get meals - the wards are able to collect food from the standard restaurant and there are 24-hour snack boxes. Unfortunately, both of these incur an extra cost to the ward, and may not be offered to patients.

The main food focus for most patients is to ensure that they get the meals that are available and are suitable for their situation. The ones who can't manage to eat enough in the normal way might be prescribed supplements, usually in the form of 200 ml bottles of flavoured drink: sweet, yogurt-style or juice-style, or there are soups for people who prefer savoury, and thickened desserts for those with an impaired swallow. There are versions with and without fibre, and low potassium for renal patients. These supplements contain all the necessary vitamins and minerals as well as protein and energy, so can actually replace the whole diet if necessary, and there are a couple of options that pack it all into 125 ml doses instead of 200 ml if patients have a really small appetite and can't manage any more.

Meal times on wards are pretty hectic. It's difficult to provide timely assistance to those who need it, to help them eat their food while it's hot. Other patients may be doing all kinds of things in the next bed, then you're feeling ill, and there's the hot weather, and you may not like the food much. It's not entirely surprising that most people lose weight in hospital. This might sound like it doesn't matter too much for all of us overweight people, but you need the full range of nutrients for the immune system and for wound healing, so hospital residency becomes longer if people aren't fed well, and that costs money.

Wednesday, 23 June 2010

Start of second clinical placement

View of front door and lawn through arch of leaves, Leamington Spa
Pictures are again courtesy of my walk around Leamington during a particularly boring stretch of revision last month.

It's now the end of my third day on clinical placement, and the first opportunity I've had to write anything sensible. Lola II came to visit last Friday, we walked around town and went to the Leamington Peace Festival on Saturday, and when she left on Sunday morning I went straight out into the garden and spent the whole day hacking things down, sawing and chopping them up, and filling refuse sacks. I took two carloads to the dump, and then collapsed, exhausted.

My exam results arrived as well, and it's all very good. So that meant that on Monday morning, bright and early, the other new student and I used the stairs or lift to get to the first floor, walked along the corridor as instructed, and pressed the buzzer marked 'Nutrition and Dietetics'. No response. Eventually, someone passing by noticed us waiting outside the door and let us in. It turned out that the incredibly detailed letter omitted to mention that we would be starting at 10 a.m. on the first day.

Garden in front of grand house, Leamington SpaIt's been hard work for a number of reasons. Admittedly it's been quite hot since Sunday, but the temperature in the brand new office is much too high: 25 degrees at 9 a.m. and over 30 degrees by lunchtime. On Monday I dutifully turned up in my new uniform, but without any change of clothes, and it felt as though I was wearing a coat all day. Since then I have followed the example of others, and worn much lighter clothes in the office, saving the uniform for patient contact in the hospital itself.

This new building is separated from the main hospital by a large car park, and we are a short walk away from the town centre. As a 'treat', we walked into town with our mentor and had lunch in town on the first day. There were a couple of problems with this: 1) I was very self conscious and very hot in my uniform, 2) I was wearing shoes that I knew would be OK for moderate walking, but this was a much longer trek than I had anticipated. So not a treat at all, really, and my feet have not yet recovered.

Add to this my aching muscles from a whole day of gardening, plus badminton on Monday night, and the tropical office environment and it's not surprising that I've been completely shattered. My lovely family are also keen to know how things have gone, so I've spent some time talking to Mr A, Lola II and mum and dad, and blogging has had to take a back seat. Tonight is the first time I've felt human enough to do anything but shower and vegetate in the evening.

It's been quite a different experience compared with the Rotherham placement two years ago. Everyone has been helpful and friendly and they all take every opportunity to reassure us that they want us to have a successful placement. I'm not imprisoned in bleak accommodation out of range of all modern communication, nor forced to wear ridiculous clothing. So far, neither my communication methods nor my cooking skills have been criticised. The other student on placement is lovely, and although she is less than half my age and we have few interests in common, I'm finding her very easy to work with.

A grand double-fronted two-storey Regency house in Leamington Spa

Thursday, 17 June 2010

Food and visual impairment

Regency balcony with wrought iron and hanging foliage balls
This business of 'being on holiday' is really quite good - not having lectures, coursework, revision, exams, clinical placement or employment means there is time to do things I want to do.

There are still things that must be done, and some deadlines are starting to loom again, not least the start of my clinical placement on Monday. My uniform has arrived - it is a long white tunic labelled 'Student Dietitian' that is slightly too big, and black trousers that need hemming. I've also received detailed instructions on how to get into the department that must have been developed in the light of some very stupid students. For example, the letter contains the following statements: "...we are on the first floor so you need to use the stairs or the lift. We are at the opposite end from the lift so you need to make your way along the corridor..."

I have also sacrificed some of my free time to help out at an event held by my previous employer - the same type of event where I volunteered last September, but this time taking place in Birmingham. Again, it was a chance to catch up with old friends and colleagues, but with a few added extras:
1) I wore clothes and shoes similar to those I will need to wear on placement, to see if I can survive for a day. I can, but only just.
2) I was put in charge of looking after one of the VIP attendees for a few hours. He is an interesting man with unconventional ethics and a knack for causing immense amounts of trouble for his colleagues by making provocative public statements.
3) I talked to some people about my research project about food choices for people who have vision impairments.

The scope of the research project that we have agreed on is very tiny indeed. Just 6 to 8 interviews lasting for an hour at most, asking people a bit about how they choose what food they buy and cook and eat out, which I then analyse for 'themes' and write up my findings. It's clear that such a small number of subjects will not be representative of the thousands of blind and partially sighted people in the UK, let alone the world, but we have to be realistic for a university project.

There doesn't seem to be any other research going on in this area, and I have so many ideas. Without wishing to anticipate outcomes, it is clear that people with poor sight will not easily be able to read ingredients lists or nutrient contents on food packets. It is likely that the food they buy will be 'easy' to prepare and eat without sight, and I am curious to know whether these choices turn out to be nutritionally unbalanced in any way - ready meals that are high in fat and salt, for example. The 'healthy eating' messages that are put out by government and others may not be fully accessible to this group of people either, but then neither is the advertising from food retailers and manufacturers.

There will obviously be a wide range of cooking skills, knowledge and abilities out there, and nutritional knowledge will vary widely as well. The length of time that someone has been losing their sight will affect cooking ability, as well as age and gender. Are people who are blind from an early age given better instruction in cooking than those who lose their sight later in life? Do they bother to cook at all? What is the difference between food choices of people with different levels of useful vision, and different methods for reading print? Do people who can use the internet and do their food shopping online read the additional nutritional information that is available? Is it accessible, and meaningful?

Black Griffin with open mouth on a pillar in Leamington SpaThere is also a medical angle: diabetes is known to cause visual impairment (retinopathy), and macular degeneration is associated with obesity (without looking it up I'm not sure if it's causative or not). Perhaps certain food choices associated with obesity predispose an individual to macular degeneration, or the excess adipose tissue produces higher levels of hormones affecting the macula, or an obesogenic lifestyle contains factors that also affect the macula? It is known that the increasing prevalence of childhood obesity is associated with sedentary behaviours, and independent exercise is not easy when you can't see - I know one extremely fit gentleman who is blind, and he regularly goes hill-walking and cycling (tandem), but I think he is the exception.

Then there are the visual aspects of food and its effect in weight management. We make food look good for a reason, and if you can't see how appetising a dish looks, do you eat a different amount? I have been using a smaller plate to try and reduce the amount I eat, but that tactic would be wholly ineffective if I couldn't see the food on the plate. How do hunger, satiety and vision relate to one another? Does a blind person choose how much to eat using the same mechanisms as someone who can see, and which techniques for weight management are most effective for this group?

And finally, there is the sensitive and tricky area of physical appearance. In general we find thin people more attractive to look at than fat people. Some people are therefore motivated to remain thin or to lose weight by their appearance in the mirror (although by no means all: discomfort, health concerns and shopping phobia are obvious alternative motivations). If you can't see what you look like, and what others look like, do you pay more or less attention to your body size?

RNIB is already working on accessibility in the NHS, trying hard to make sure that appointment letters and information leaflets are produced in alternative formats, and signage and guidance around hospitals and health centres is accessible. There's still an awfully long way to go, and I don't think my input would make much difference in this area.

My day of volunteering ended in a nearby hotel with some particularly old ex-colleagues that I hadn't much time to talk to during the event. I caught up with some of the workplace politics, and laughed at more stories from when we were young and foolish. The friend and ex-colleague I met a couple of weeks ago was mentioned, and the story of the time he had burned off all his chest hair while showing his 2 year-old grandchild how a cigarette lighter works. Wrong on so many levels, but if you knew him, you'd have to laugh.

I spent another day in Birmingham on my quest for flat work shoes and sturdy sandals, and managed to find some at last, despite the absence of Lola II in person. The city is hosting an International Food Fair, so I spent a bit of time browsing the various stalls, before meeting up with more lovely ex-colleagues, and more gossip. The next opportunity for this kind of decadence will be after my placement, in September.

Row of Regency porticos, Leamington Spa

Saturday, 12 June 2010

Bruges #3

Mr A and a tureen of bouillabaisse
On Friday it was a grey day but no rain was forecast, so like day trippers to the seaside, we went to Ostend. It's only 15 minutes by train, after the 15 minute wait for a bus, the 15 minute bus trip to the station from our rented house, and the 15 minute wait for the train. So an hour, then.

It was a good day, though windy and not warm, and included a great deal of walking. They are doing some sort of work on the beach, but the part that was accessible had very high quality sand. We examined one of the last Icelandic trawlers in a rather good exhibition. We had lunch in a fairly posh restaurant facing a town square that was essentially a car park, where Mr A's bouillabaisse was outstanding, in size as much as quality (my salad was not worthy of a photograph). The park was nice and had a bandstand, fancy little bridges and statues as well as flowers and trees, and compared very favourably to Jephson Gardens. We had a cup of coffee when I became too cold to think straight, then looked inside the 'English church' which had some modern stained glass, including a portrait of a modern Belgian leader wearing glasses. You don't often see specs in stained glass. We missed seeing the contents of the historical museum by four days, since it doesn't open until 15 June.

Lola in front of a shop called LolaAfter six hours in the open air plus travel time, it is nice to come back to a house rather than a hotel room. We have rented a very small house, with an open plan downstairs sitting room and kitchen and vertiginous stairs with no banister to the first floor. We have a bathroom, toilet and bedroom, and there is even a further storey accessed via more near-vertical stairs, with two more beds that we obviously haven't needed. Outside, we have a paved area with a picnic table and seats, but it hasn't been quite warm enough to sit outside, and on most days it has rained quite hard at some point. There is also a garage that we haven't needed. It is very quiet except for when the churches all decide to mark the hour with melodious chiming, and that's actually quite pleasant.

On our last full day we went to the main square on the other side of town, where there is a Saturday market. Many of the food vendors from the Wednesday market were there (mmm, cheese) as well as clothes and stuff. We went on to the 'Beguinage' which is a bit like a nunnery but not quite, and was very peaceful, and then we tried and failed to find the Minnewater park. I'm pretty sure my map-reading was to blame.

The sun finally came out properly, and it was quite as warm as the day we arrived. Mr A just tried to sit outside at our picnic table, but has now come in because it is too hot. It has been a lovely break, but we are ready to come home.

Duck on a canal sluice gate

Thursday, 10 June 2010

Bruges #2

Canalside houses viewed from a bridge
Our self-indulgent holiday continued with a visit to the Wednesday produce market, although so early in the day we were reluctant to buy anything to carry around for hours. The cheese looked wonderful, though. Then on to the Half Moon Brewery, which is the only brewery left still operating within the city limits. The guide, a lady, had a very dry sense of humour, but it didn't much look like the brewery was running more than a very basic level of operation, just so it could use the promotional line.

The fish marketWe stayed for a fine lunch with our free beer (served by another scowling waitress), then treated ourselves to a canal trip with a guide who looked like Willie Rushton. While generally walking about in town we were accosted by a very assertive man in period dress with a magnificent moustache, who kissed my hand and wanted to know where we were from. He claimed to have heard of Leamington Spa, and told us correctly that it is in Warwickshire. He also said we had warm smiles, but when he tried to encourage us to visit his shop, we admitted that while our smiles were indeed warm, we had absolutely no money.

Icon built into the corner of a 17th century houseWe wandered at random into a seriously chocolate-focussed street, where virtually every shop claims to sell authentic hand-made artisanal Belgian chocolate. I was vaguely looking for a chocolate medal to award to Lola II because I owe her one, but one shop drew our attention by displaying in its window not only the 'hilarious' chocolate breasts that you sometimes see in novelty shops, but various male and female reproductive parts, some even festooned with trails of white chocolate. Yuck.

Having web access from our accommodation is an unaccustomed luxury. We can check the weather forecast and keep up to date with email as well as feeding my blogging habit. We happened to see a flock of tourists riding Segways - I've always wanted to have a go, so I checked the website. Much too expensive.

The weather on Wednesday was grey but warm, with occasional spots of rain that never really turned into anything. The forecast for today was heavy rain, although it was fine in the morning. We decided not to plan anything except stocking up on groceries, and then found we needed more cash so went for a walk out of town to find an ATM. That was when it started raining, and the rain continued through a delightful cafe lunch and on into the evening.

Whichever angle you look at it, Bruges is one of the most picturesque places I've ever been.

View of rooftops taken from the Brewery roof

Tuesday, 8 June 2010

Bruges #1

Mr A and I are installed in our new Bruges-based residence for the week, sitting at the small dining table opposite one another, each tapping away on our laptop PCs. We really have fun on our holidays.

The journey over was uneventful. I enjoyed it, but Mr A prefers to be in control, and thinks we could have driven in the same sort of time. I liked the train terminal far more than any airport or ferry, the ability to read the paper undisturbed, looking out of the train window, comparing Belgian wildlife with the UK (more horses in Belgium but vegetation not discernably different) and commenting on the potential for making my fortune selling trampolines to the Belgians, because they didn't seem to have any in their back gardens. Then I saw three, including a green one - I previously believed the species only came in blue.

Mr A relaxing with a bookThe lady who's renting us the house came to pick us up from the station, which was very welcome. After the business of rental was complete we went round the corner to have omelettes and salad and a small beer, sitting outside in the occasional sunshine, at a little bar/cafe a stone's throw from a huge windmill and the canal that circles the town. Then we walked some way through the quaint, cobbled streets to buy some groceries.

The combination of sun, beer, and a very early start meant that I slept for two hours in the afternoon, and woke up feeling very much like a prune.

Canalside house with roses around the windowsDay 2 was orientation. We didn't get up very early, and then walked into the town just to get the feel of the place. I was slathered in waterproof sun protection, but the waterproofing was tested a little further than the sun protection by the huge thunderstorm. We sought refuge in a cafe and were served some lunch by a scowling waitress. The next rainstorm sent us into a very nice church. In between the rain we saw a lot of central Bruges, which is incredibly picturesque. Every time you turn a corner, there is another wonderful building, or canal view, or a gothic church. No two houses are the same, and the variety of front doors is incredible.

The main tourist squares and shopping streets are busy. Not busy like London, but busy like Leamington Spa. Away from these areas, and not far away, maybe just one street away, there isn't a soul. The roads are deserted except for a solitary cyclist every now and then. The house we are renting is close to the encircling canal and ring road, a short walk from the centre, and it is incredibly quiet. It suits us very well, especially with the conservatory and outside area to sit when it is sunny. When I started this update, Mr A was reading in the same spot as yesterday, but now he is asleep.

View of canal, houses and the Belfort

Sunday, 6 June 2010


The family in Lola II's garden
It's been a bit hectic, considering these were supposed to be lazy leisurely post-exam days. Lola II woke me up with good news and bad news. The good news: the flight that our cousin M, her son A and friend J were arriving on was early. The bad news: the flight was early! Our preparations, bedmaking, cleaning and tidying had to be squeezed into a shorter time, and I had to go and buy euros, given that I'd failed to do so for weeks and only had one working day left before we were due to travel to Bruges.

Meeting the party at the airport, we held up our sign, which had A's name in large letters and M and J in very small letters underneath. An elderly man was moving along the line of people holding their signs, obviously trying to find someone waiting for him. He paused at ours, and looked at us hopefully. We laughed and we told him we were waiting for a 5-year old boy and his mother and friend. "If they don't show up?" he said. "No problem," we said.

Lola II painting A's toenailsThe journeys to and from Heathrow were inordinately long - all the trains seemed to be running slowly and we kept having to wait, and it was awfully hot. But we all reached Lola II's house in the end. M and J made the mistake of leaving Lola II and me unattended for an hour or two in charge of 5 year-old A, while they had a jet-lagged sleep. We painted A's toes with nail polish: a different colour for each toe. He chose the colours, and then he chose the colour for my toenails. We just can't be trusted with any childcare responsibility.

Since then, there has been much conversation, a huge family Chinese meal, serious Lego action, sitting in Lola II's garden admiring Mr M's garden management skills, and luxuriating in the unusual heat at 10 p.m. Now Mr A and I are bracing ourselves for a very early start to our European holiday tomorrow.

Friday, 4 June 2010

Messing about after the exams

Wisteria, trees, table and chairs
In order of unpleasantness, there is revision, housework, blogging and messing about. While revising, housework is definitely allowed, blogging within reason but no messing about. When revision is over, messing about takes up a lot of time, blogging is neglected and housework doesn't stand a chance.

The last exam took place in a large echoing sports hall packed to the rafters with students on the main campus of the university. It demanded more than the usual amount of focus and concentration from me because of all the other people there, the unfamiliar environment and noises and distractions. But I think I did OK, then drove home, we went out to dinner, and I couldn't stop smiling with the relief of not having to revise any more. Since then I've been messing about all over the place: getting my hair cut, cooking, and most importantly, packing for a few days in London and then a week in Bruges.

I came down to London yesterday and met up with an old friend and ex-work colleague. It was lovely to see him, and there's always a good story to hear: this time about how a tree he was cutting down ended up falling on top of him. There was some current news and updates on people I used to work with, and a little reminiscing, like the time we had a team Christmas meal out, when life was good and our jobs were fulfilling and satisfying. That was the best team ever, but people change and move on and we can't expect such good times to last forever. So then we talked about drugs for cholesterol and the Big Bang and global warming and bowel movements, the sort of thing any friends might talk about. I love meeting up, and I even found out that he reads this blog. I'm sorry I forgot to take a photo, but I was having too much fun.

It didn't take much thinking for me to decide on eating at my regular Japanese outlet before moving on to the pub quiz where Mr M is a regular. My contribution (Utah, Stephen King, Nicholas Witchell, ELO and Rock Aria) was enough to take us to first place and the prize of a round of drinks, but by that time I was ready to go back to Lola II's house and sleep. I remember the same thing happened when we did a regular quiz at home - the only time we ever won was when a 'ringer' joined the team who hadn't played before (and never joined us again).

So now on to today, which started with a list of jobs for me to do while Lola II went to work, involving planning transport options to meet our American cousin and her son and her friend at Heathrow, and trying to work out what Oyster card rules apply to a 5-year-old. Then I met Lola II and Mr M at Westfield Shopping Centre (more like a town to a rural bumpkin like me), where we had lunch and then Lola II and I shopped for hours.

As usual, I failed to find any of the things I really wanted - a mac or raincoat and sandals - and bought socks and underwear instead. It was really hot, and Lola II flaked out while I had one last shot at looking for sandals, and then we came home by bus and it was still really hot, and we still have much to do. We must shop for household food, and I still have to buy euros for the trip to Belgium, and we need to order the Chinese food for Sunday when we are having a family get together in honour of our visiting US cousin. But now it is supper time, and Lola II is dishing up the pasta, and I must publish this.