Saturday, 24 November 2012

Work, food, birds

Barn owl
Cotswold Falconry Centre, July 2012
I always want to start posts nowadays with excuses - no, reasons - explaining why there's been such a long gap, I've been busy, blah blah blah. I should just accept that I haven't got the same amount of time nowadays, and an awful lot less that I'm allowed to write. If only I could tell you about some of the patients. There's a lot to tell, but what makes them interesting is also what makes it impossible for me to write about them. Even the woman who came to my clinic thinking that it was another clinic would recognise herself if I gave any more details, and that's my test nowadays for whether I can or can't relate the story. So, I can't. Even if it was a man.

Generalities are fine. So I can say that two weeks ago was extraordinary - I had almost no referrals all week, to the extent that I could spend half a day in the library reading about diabetes, and catching up with paperwork, and throwing a lot of accumulated stuff out. Then last week, the tables were turned. One of my colleagues was off sick, and we were just keeping our heads above water even when we discovered at very short notice that she was supposed to be giving a talk on Wednesday, and even though I had a full clinic (11 patients) booked in on Thursday morning (4 DNAs in the end). But on Thursday, the wards decided to go into overdrive, and we received 15 referrals (I think it was 15 - my other colleague had to deal with the inundation during the morning - I was in clinic).

For some reason, Thursday was also the day that I found myself involved in three separate complaints about catering. Afterwards, we decided that in an ideal world I should have just said "This has nothing to do with me; you need to talk directly to catering yourselves." But, as a health professional trained to help people, my instinct is to try and help, even though one complaint was simply that the ward catering staff wouldn't give larger portions to a patient who clearly needed and wanted more to eat. It was very frustrating for all involved.

In the end, you can only do as much as a person can do, and our colleague returned on Friday, and we just about got through everything as best we could. But the team of six is down one anyway since our team leader left, and the most senior of the remaining five of us is covering not just that post but also providing paediatric cover, as we only have one paediatric dietitian for the whole hospital. And one of the remaining five isn't supposed to do anything except stroke, and she had a student with her all week as well. The end of the working week on Friday was a huge relief.

Mr A and I had a treat on Friday night - a return visit to Queans, the restaurant where we first went to celebrate our birthdays earlier in the year. This time we had a voucher which Mr A had earned by doing some work for a neighbour. It was a lot of money, too, enough for dry martinis and three courses for each of us and a bottle of wine. It is a lovely place to spend the evening.

Then on Saturday I volunteered to help out with end-of-season cleaning and clearing up at the Falconry Centre. As a Friend of the Centre, as well as not having to pay to get in, I am invited to a summer barbeque and two cleaning events, one at the end of the season in November when the Centre closes, and the other in February just before the Centre opens again. I'm not entirely sure why I volunteered for this, and most Friends do the sensible thing and just come to the barbeque, but there I was on Saturday, spending a few hours sweeping up leaves in the pouring rain, and getting almost as wet while cleaning the insides of the cages where some of the birds are kept overnight and through the winter.

The birds don't fly at all out of season, mostly because there aren't enough visitors to justify opening the Centre. They don't need to fly - given sufficient food, they are happy to just sit there for a month or two, growing new feathers and thinking whatever birds think when they have nothing to do. There were about six of us volunteers in all, a friendly group, and I'm kind of glad I did it, even though I really didn't have to. I might even volunteer for the February opening workout as well.

No fresh news about the new job. I know I'll almost definitely be leaving if all the bureaucracy gets completed to everyone's satisfaction, and it is likely to be at the end of December all being well, but there are no guarantees. Then another similar vacancy was advertised, much nearer to home, permanent, but only 4 days a week. I mentioned it at work, and was surprised when the consensus was that I should apply, despite being halfway through the process of moving to a different job. So that's my Sunday fully occupied, along with my usual treat of a trip to the greengrocer.

Thursday, 15 November 2012

Update on insulin

Pink flower
Sissinghurst, June 2012
Another outing to the local Diabetes UK group, with its primary focus on fundraising and unfriendliness. It turns out that the positive interaction in the last meeting was an aberration caused by the lack of a speaker - this time they were back on form, and completely ignoring me once more. I am tempted to write to the Chair just to let them know how off-putting their meetings are to someone who's not one of their particular friends.

The reason I attended (and didn't leave) was because the speaker was the doctor who had previously provided the update on treatments for Type 2 Diabetes a year ago. This time his subject was insulin, and here is what I learned.

Just to recap - insulin is a protein, constructed from two crosslinked peptides made of 51 amino acids. It is secreted by the pancreas into the bloodstream, stimulated by glucose from digested food, and transported along with the glucose to liver, muscle, and fat cells. Insulin is the facilitator, the key to the door that allows glucose to enter the cell and to fuel metabolism. As an aside, nerve and brain cells also use glucose as fuel, but they don't need insulin to facilitate entry.

Insulin has some other functions in the body, as well as allowing the uptake of blood sugar. It inhibits the breakdown of fat in adipose tissue, stimulates the uptake of amino acids that form the protein in our bodies, and also stimulates the passage of potassium from the blood into cells. It is an anabolic hormone.

The diagnosis of Diabetes Mellitus relies on measurement of blood sugar being above a particular threshold, which could be for a number of reasons. In Type 1 Diabetes, blood sugar is high because the pancreas has stopped producing insulin, so there is none in the bloodstream, and the circulating glucose therefore can't be admitted to cells. For Type 2 Diabetes, blood sugar is high because despite the presence of insulin in the bloodstream (sometimes large amounts of insulin), the cells have become resistant to its action. After a period of time, people with Type 2 Diabetes sometimes stop producing enough insulin, and then will need insulin injections. People with Type 1 Diabetes generally need insulin injections immediately on diagnosis.

So the main substance of the short lecture was all about types of insulin. There are two main types: Human and Analogue. In the past, bovine and porcine insulin was sourced from the pancreases of animals, but very few people use these now. Since the invention of genetic manipulation techniques, insulin that is indistinguishable from human insulin is made by bacteria - this, obviously, is Human insulin, and its peak of action is within 6 to 8 hours from injection (Actrapid, Humulin S).

Real human insulin secreted by a pancreas into the bloodstream acts within 30 minutes - the different profile of the same molecule when injected is due to that mode of delivery - into subcutaneous fat, which delays things a great deal. For this reason, the insulin molecule has been tinkered with to create Analogue insulin, which has a slightly different sequence of amino acids, or has had additional atoms or strings of atoms attached to it, to change its action profile. Short acting Analogue insulin can work within 2 to 4 hours (Novorapid, Humalog, Apidra), which is nearer the profile of pancreatic insulin (but still slower than the real stuff).

The aim with all these developments in injectable insulin is to try to mimic the action of insulin secreted by the pancreas in the non-diabetic person. As well as the spurt of insulin that is triggered by carbohydrate being turned into blood glucose, there is a particular profile to the way that the supply of insulin tails off after a meal, and also a background trickle of insulin that is released into the bloodstream steadily for 24 hours a day. For this reason, other insulins have been developed. The first product combined insulin with zinc. Six insulin molecules grouped around the zinc atom forming a hexamer, and slowed the release of insulin to provide a longer-lasting hit. Nowadays, this is achieved by the addition of protamine, and these medium-acting insulins are called Isophane or NPH insulins (Insulatard, Humulin I).

There are also pre-mixed insulins, both Human (Humilin M3) and Analogue (Novomix 30, Humalog Mix 25 and Humalog Mix 50) that contain some short- and some medium-acting insulin. The number indicates the proportion of short-acting (25, 30 or 50%) to long-acting (75, 70 or 50%) insulin. And to replicate the trickle of background insulin, two analogue insulins have dominated the market for some time (Lantus/Glargine, Detemir/Levemir). Neither is perfect, they still have mild peaks of action rather than being flat through the day, and Levemir doesn't quite last 24 hours so some people have to inject it twice a day.

The speaker also brought news of new developments not yet available. There is a new insulin (Linjeta) that may act almost as quickly as human insulin by including EDTA, which binds to zinc and prevents the formation of the hexamer, allowing the insulin to diffuse into the bloodstream more quickly. [At this point I asked why zinc was included at all, and the speaker thought it was necessary to ensure the stability of the product in storage before injection.] Another new insulin (Degludec) is hoped to provide the desired flat profile of background insulin by attaching a fatty acid side chain to the insulin. And a third development (Insupatch) is intended to speed up the release of insulin for people using insulin pumps by including a small heating element around the cannula, which increases the blood flow through the insulin-containing area of subcutaneous fat.

I'll have to go to the next local meeting, unfortunately, because being pre-Christmas, the speaker is a Dietitian. I'm not yet sure whether I'll mention the unfriendly nature of the meetings to any of the committee, of whom there are several present, wearing badges. They show no more inclination to talk to me than anyone else in the room.

Saturday, 10 November 2012

A new job

Vulture with outstretched wings
Cotswolds Falconry Centre, September 2012
As I mentioned in passing, I had an interview last week, for a post as a Specialist Diabetes Dietitian. Are you on tenterhooks? You shouldn't be, because by now you should know that whatever my finest qualities may be, they do not include an aptitude for the job interview situation.

The interview was fine. I showed enormous enthusiasm for diabetes, which was quite genuine - in fact, my next blog post will contain a report about the latest meeting of my local Diabetes UK group, which I attend in the evening in my own time. The Lady Shoes, however, damaged my feet to the extent of making them painful for several days, despite only wearing The Shoes to walk from the car to the HR department, then to the interview and back to the car. Those hospital corridors stretched for several miles, or so it seemed.

The interview was on a Thursday, and when I hadn't been contacted by the weekend I was fairly sure what the outcome would be - all the interviews were taking place on the same day so there was no reason for delay if I had been the successful candidate. So when I phoned them for feedback on Monday morning, I wasn't expecting any more than feedback.

But it wasn't quite so simple - I was told that no, I hadn't got the permanent job, but there was another, similar job, which was temporary, and would I be interested? I certainly would, and there it ended, because there was talk of sorting out funding, and when the f-word is spoken in the NHS context, things can move exceedingly slowly.

But they called within the week, and offered me the temporary job! It lasts for nine months, with the hope of extending beyond that time and/or making the job permanent, which I gladly accepted. It's a long commute, and I'll be truly sorry to leave my current colleagues who are all wonderful, but working on the wards isn't what I want to do in the long run, and I've thought for some time that diabetes is where I'd like to be.

Looking at my current contract, I see that my notice period is only 4 weeks. There are still some formalities to go through - the Criminal Records Bureau check and the references - but it is possible that I will be in a new job before Christmas.

What makes me smile (apart from having a new job) is the thought that in my first successful interview I came third (there were three jobs on offer) and now, in my second successful interview, I came second. Perhaps the next time I try, I'll be the first choice.

Sunday, 4 November 2012

What I've been reading

Image of the book cover

by Ann Patchett

"A student at Harvard, Tip is happiest in a lab, whilst Teddy thinks he has found his calling in the Church, and both are increasingly strained by their father's protective plans for them. But when they are involved in an accident on an icy road, the Doyles are forced to confront certain truths about their lives, how the death of Doyle's wife Bernadette has affected the family, and an anonymous figure who is always watching."
This was a nice enough book, the writing was attractive, but the story didn't seem to go anywhere that made me think more deeply about anything. It didn't develop, there wasn't a beginning, middle and end, it just started, continued and stopped. So while I was happy to read it all and wasn't at all bored, I didn't find it very satisfying.

Image of the book cover

The Tell-Tale Brain
by V. S. Ramachandran

"Our brains are the most enchanting and complex things in the known universe - but what happens when they go wrong? One of the world's leading neuroscientists has spent a lifetime working with patients who suffer from rare and baffling brain conditions. He tells their stories, exploring what they reveal about the greatest mystery of them all: how our minds work, and what makes each of us so uniquely human."
This started well, even though it covered some of the same ground as his other books - he expanded on the subjects of phantom limbs and neural mapping with the idea of mirror neurons and autism, and it was all rather interesting. Then he extended his reach into aesthetics and art - what it is about humans that gives us self-knowledge, consciousness, and appreciate art and culture. That's when he lost me. But the first half of the book is OK.

Image of the book cover

Spilling the Beans
by Clarissa Dickson Wright

"Clarissa was born into wealth and privilege, as a child, shooting and hunting were the norm and pigeons were flown in from Cairo for supper. At the age of 21, she was the youngest ever woman to be called to the Bar. Disaster struck when her adored mother died suddenly. Rich from her inheritance, in the end Clarissa partied away her entire fortune. It was a long, hard road to recovery along which Clarissa finally faced her demons and turned to the one thing that had always brought her joy - cooking."
Interesting enough, although poorly written. I mooched it (from Bookmooch) because I heard a snippet of an interview with her when it came out, which sounded fascinating. She has indeed had a full and varied life, and the book is certainly an account of all the things she has done, but with little attention to language it is not a great deal better than a list. I would be disappointed if my writing were like this, although sometimes I suspect it could be.

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