Sunday, February 13, 2011

Variety is the Spice of Life...

- but monotony isn't necessarily the sour grapes of depression, however monotony breeds routine (much more efficiently than could familiarity ever breed contempt, at least in my case) and routine imposes itself relentlessly without deliberation or forethought.

The art is to recognise that if what you’re doing is worthwhile and if you do it the same way (more or less) every day, then you’ve probably worked on it to get it, over time, to be so efficient. Indeed, this is where I am and it’s been noticed in my case by experts and novices alike. I will deal with some of my weird routines as a later addition.

Why am I bringing this up? Well, it’s because routine has a dark, dark side – read on…

Since Pam’s stroke two winters ago, as you know (if you’ve read this upside-down blog bottom to top) she was subsequently fitted with a stomach PEG feeding tube. To use this properly, the tube must be flushed through with water before and after the liquid food is delivered (via the pump). Emma Staniford, the Mildura Base Hospital Dietician, determined that for Pam to get the required fluid intake, the pre and post water flushes should be 3 (not 1) X 60ml syringes each. (A 50ml rated syringe will hold 60ml when full).

Don’t be confused by these figures, the point I’m trying to make is the NUMBER of openings and closings of the clamp on the PEG tube, believe it or not.

Each time a syringe or feeding tube is inserted into Pam’s PEG tube, the tube must be clamped until insertion, opened during insertion (otherwise the insertion won’t go completely in), the liquid (water or food) delivered, then the clamp once again closed. If one is delivering 3 pre-flushes, for example (and that happens 3 times a day, 7 days a week), one finds oneself opening, closing, opening, closing ad nauseum and this quickly becomes monotony, not routine.

Over time I have noticed that I’ll make a clamping error about once per fortnight. For example, I’ll attempt to inject a syringe-full of water and then notice the plunger will not budge. It doesn’t take Einstein to figure out I forgot to open the clamp. Alternatively, I’ll remove a syringe and get my fingers wetted with a slight water discharge from the PEG – hallelujah, I forgot to close the clamp. And so it goes – as I say, I reckon I make a little blue like this about once a fortnight. Now let’s do some maths – 3 pre-flushes, 1 pump feed followed by 3 more post-flushes is 7 openings and closings of the clamp per meal, which is 21 per day. I estimate I make an error about once a fortnight, that's once in every 14 x 21 = 294 clamp closing operations per fortnight. One 7th of these is the serious error of closing the PEG clamp prior to turning on the pump. With the assumption of everything else being equal, this should happen one seventh of once a fortnight, namely once every fourteen weeks. In other words, one serious prang every 2058 closings. Well guess what – if there’s a probability like this that it will happen, you can bet it does!

The significance if this particular clamp-closing error cannot be overstated – as soon as I start the pump, it is a fixed delivery pump and within less than a minute it will have blown the plug out of the (not currently used) medication-input tube on the PEG simply because the liquid food has nowhere else to go and is being force-fed. Here is a picure of what I am talking about - the feed-tube enters from the lower left, the PEG opening (and open plug) is evident and attached to it slightly above and to the left is the plugged medication input. Farther up the PEG tube is the clamp.

I will have replaced Pam’s sheet and blankets over her by then, settled her and retired to the lounge room to answer emails, watch TV or write this blog. About 30min later, Pam will ring her bell to get me to come because she feels ‘wet’. I lift the blankets and see a mini-lake of liquid food soaking into Pam’s buttocks-cushion, the bottom bed sheet, her knickers, her top – you name it. It’s a mini-disaster consequenting from an innocent clamp-closure that would otherwise be insignificant. I say MINI-disaster because I can easily think of a lot worse disasters potentially awaiting us, but this error requires me to get the lifter and get Pam off the bed while I change everything. Isosource liquid food takes FOREVER to wash out of bedding – and remember, Pam still hasn’t been fed!

This error makes me very particular about that clamp for a few weeks if not months, but the mathematics eventually applies itself and off I go making that mistake again and again and again… The last time it happened, I thought, "Enough’s enough! I’m not getting any younger and as I grow older, I’ll cetainly be making this horrible error ever-more frequently, so it’s got to stop NOW!"

Gravity Feeds

Over the many months since the PEG procedure, each morning as I fitted the first food bag and feeding tube of the day into Pam’s PEG input, I would notice that it would gravity feed, quite quickly until I subsequently fitted the feeding tube to the pump prior to activating it. I had heard of gravity feeds before – namely, using the 50ml syringe tubes without their plungers, hand held for each of the 5-tube (250ml) feeds. That idea never really grabbed me – I remember actively suggesting getting the pump in lieu of that labour-intensive gravity-feeding for Pam, if appropriate funding could be allocated. (Funding is another issue I should explain using this blog, but will keep it for a future edition).

And so now here I was many months later with the great brain-wave – would not the bag and feed-tube, manufactured specifically for the pump, suffice for a hands-free gravity feed?
I won’t bore you with what happened next, except to say it worked like a charm. The drip-chamber in the tube was originally used by the pump’s processor to determine whether there was flow or not – and that’s exactly what I now use it for; as a visual aid.

This gravity feeding initially* delivered the 250ml in around 40 minutes c/f the 60 minutes via the pump, but that’s a boon, not a bane. Also, if per chance I inadvertently close the PEG tube as before, the lack of drips tells me straight away and even if I don’t look, there’s no disaster because it’s simply gravity fed.

Just last week, I returned the pump to the Dietician and made an appointment with her to explain what I’d done and why.

*Emma, the Dietician, concerned about Pam’s weight, has now recommended 4 cans of Isosource over the 3 daily meals, so now the delivery via the gravity feed takes around 50 mins, allowing for the extra food per serve – it’s still all good! I’m smiling!

(There are many postings for this blog - please check the Archive for those not displayed here.)

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