Sums

Rosemarie's  assigned GP had supposedly made out a prescription for 7 days of saline drip, and had backed that up and stated that the plan was to keep her on the drip until her rehydration was complete and she was taking sufficient food and fluid orally. 

I had a worm of doubt on Sunday night, seven days after this started, looking at the depleted bag hanging there and wondering whether a new prescription had been written (over the weekend? In anticipation?, but the District Nurses had a habit of coming late so I told myself there was nothing to worry about. And anyway the blood test results should be back Monday and should show reduced sodium levels. She was eating a little and starting to rehydrate orally so it may not be critical if she missed a day.

Monday morning found me phoning the Care Home to check the drip had been replaced Sunday night. Of course it hadn't. The nurse had seen the entry I had asked to be inserted in the diary and had phoned the Rapid Response Team to check. Rosemarie was not on their list of jobs. But they would Sort It Out.

Just as I was getting ready to leave for the Care Home Rosemarie's assigned GP rang me. The results of the blood test were back and showed her kidneys were fine, and her sodium level was down to 145 which suggested she was rehydrated. Excellent. Oh, so he was taking her off the drip. Not so much.

We spoke at some length. 

The inescapable conclusion I came to was that his starting point was that subcutaneous drips should only be used in the short term and should be dispensed with as soon as possible. Everything else, including the data, was secondary. I had encountered this before so we went through the same objection handling. Why was it bad? Irregular delivery and risk of sodium build up. But she had been on the drip for two weeks and her sodium level had reduced significantly. Risk of infection. The nurses checked the site every visit and changed it regularly, and there was no indication of any infection. New one: if she was taking a lot of fluid subcutaneously it would reduce her 'thirst' and she would be less likely to want to take fluid orally. Good. Some numbers at last. 

Let's do some sums.

The dietician was adamant that Rosemarie needed about 1900 ml of fluid a day (possibly more if she was fighting an infection), and she could expect to get half of that from her food if she ate her three meals a day (which she hasn't since about the beginning of March).

So, on a good day we may get 800 ml fluid into her orally and maybe another 150 ml in the sweet desserts she is willing to eat. On a bad day that total would be 500 ml max. So 1000 ml via the drip takes those figures into the right area (nearly 100% on a good day, 75% on a bad day) and allowing for some variation in the exact daily amount she needs, would definitely contribute to her rehydration. Most days she should still be thirsty though, and indeed it is usually quite possible to keep feeding her fluid if you are patient. The problem is how long it takes. 

Thickened fluid is best fed to her on a spoon, maybe 5-10 ml at a time. The SALT recommended giving her three goes at swallowing before trying another spoonful. So we are talking maximum 10 ml every 30 seconds. If you could feed her like a machine that would mean a 200 ml serving would take a minimum of 10 minutes to give to her. But of course she is not a robot: she clearly gets bored with the process and signals this by clamping her teeth together and moving her mouth away from the spoon. Wait five minutes and she is quite happy to have a few more spoonfuls. The real time it takes to give her 200 ml safely is between 30 and 40 minutes, if she is alert and co-operative (much more likely since we stopped the Clonazepam).

So what happens when we take the drip away? On a good day she will have 50% of what she needs and on a bad day 25%. This does not seem to be the recipe for continuing improvement. Everything is predicated on the hope that she will start drinking like a fish. To replace the fluid from the drip orally she will have to spend an extra two and a half hours drinking. We need to find a safe way to speed that process up.

There is also some doubt about her rehydration. A sodium level of 145, according to my research, is the level at which you should begin to worry, the upper limit of what is normal. The GP said that her previous blood results showed similar levels of sodium, and that could indicate it was her natural level.

Or it could indicate that she has been chronically under hydrated, as we have suggested over many months.

I stood back from the head shaped dent in the wall and asked if at the very least we could have another blood test soon so we could see what the impact of removing the drip was. He agreed.

So there is no longer a drip standing sentry by her bed. The room seems bigger somehow. 

No raging thirst has materialised in the last two days. She is eating a bit better but she is not increasing her fluid intake. 

She looks better, smiles more, interacts more, looks at the pictures a lot and seems more alert. 

But the sums suggest a less pleasant truth. At the moment all paths lead downwards.