Sunday, 5 June 2011

Vignettes from C placement

Lady with alcoholic liver disease. She hadn't drunk anything alcoholic for six weeks, after 35 years of half a bottle of gin a day. Dark yellow face against the white pillows. They'd drained ten litres of fluid out of her the previous day - accumulation of fluid in the abdomen is one of the symptoms of decompensated cirrhosis - and her eyes were huge, black and yellow. I explained that the liver is the organ that deals with the food we eat and because hers was damaged, we needed her to try and eat as much as possible.

"Could you tell me about the liver damage?" she asked weakly.

"I'm afraid I can't, you'll have to ask the doctors when they come round," I said. Who knows when they would come round.

She probably wasn't going to be able to eat enough to avoid malnutrition, even with our concentrated oral supplements. A feeding tube is indicated in these cases, but doesn't always get placed.

Man admitted after being found on the floor 24 hours after he'd fallen in his home, and about 36 hours after he'd been discharged from a different hospital because of a fall. He was painfully thin and slight, black blotches in the wrinkled skin under his eyes. He lived alone, and carers who visited four times a day had found him in the morning.

"I'm a dietitian. I've been asked to see you about your eating and drinking. Is it all right if I have a chat to you now?"

"They won't send me home, will they?" he said softly. "Don't let them send me home."

Lady with chronic obstructive pulmonary disease who can hardly breathe, despite nasal oxygen. She is desperate to be discharged because they won't let her smoke. She refuses all offers of nicotine patches. She can't go home with oxygen unless she agrees not to smoke.

Our conversation is short and punctuated with silences while she gasps for breath. I provide her daughter and her niece with leaflets about how to enrich her food, because she will have difficulty eating, given that she can hardly breathe.

Her sister comes to visit one morning. "Where can I find her?" she asks.

Her name is on the board, and I had seen her a couple of days ago.

The nurse interrupts. "When did you last see her?" the nurse asks her sister.

"On Sunday."

"Would you wait just a minute?"

This is not good.

Man admitted for a fundoplication operation. This is because the sphincter at the top of the stomach that prevents stomach contents being regurgitated up the oesophagus isn't working - the muscles spasm and it remains closed so food can't enter the stomach. He'd had a couple of dilation operations over the years but now a more drastic operation had been done.

He was by far the youngest person I'd been asked to see in the hospital, and was alert, coherent, and able to talk. What a treat. The surgeon had asked for dietetic input so that he could follow a totally fluid diet for four weeks while the operation site healed. Luckily, the patient liked milk.

It took the rest of the afternoon for me to come up with something suitable, that would be acceptable for him to follow for four weeks. Even so, we agreed that it wouldn't be much fun. At least it would be only four weeks.

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