Monday, 31 December 2012

Mental Health

Griffon Vulture on the lawn
Cotswold Falconry Centre, July 2012
A study day on 'The role of the Dietitian in Mental Health' was set up for all the students in the region, and I was allowed to tag along. It covered depression, obsessive compulsive disorder, schizophrenia, bipolar disorder, dementia, eating disorders, and touched on phobias, personality disorders and forensic psychiatry. There was also a bit about Huntington's Disease, Chronic Fatigue Syndrome/ME and epilepsy, although I'm not sure why, because these don't seem to be about mental health, they're more like diseases that have their origins in the brain.

The role of the Dietitian in every condition was described as supporting other health professionals who prescribe medications or provide therapy, because although diet is often a part of the whole picture, it is rarely the key to recovery. It is often a matter of making the best of a situation - someone who fears that they will choke on food or has to clean every utensil in the kitchen before eating anything is not going to be cured by a Dietitian, but we can try to find ways to ensure that the diet is as nutritionally balanced as possible within the constraints of the condition.

Another factor is that many of the anti-psychotic medications result in weight gain, and sometimes to a very large degree. Other side-effects include constipation, insulin resistance, disordered blood lipids (e.g. high cholesterol or triglycerides), lowered metabolic rate, or they affect appetite or satiety centres in the brain (and these are just some of the diet-related side effects). Dietitians can offer suggestions on minimising these effects, or try to work around them.

The eating disorder Specialist Dietitian was a very good speaker, with long experience in the profession, and some really useful and practical suggestions that I can use in clinics. Firstly, according to NICE guidelines, Dietitians should not be treating anorexia nervosa without support from other health professionals. This seems sensible, and I have been lucky so far because we have a specialist eating disorder service that we can refer patients to. I have only referred one girl so far, but I received a letter a while later to say that she'd DNA'd two appointments and been discharged.

For bulimia or binge eating disorder, there could be a role for the Dietitian in an outpatient clinic, but it would depend on being able to identify the individual as having one of these conditions. The main message was that these disorders are not about the food; the disordered eating is usually the manifestation of some other issue. Again, it's not the Dietitian's job to fix everything nicely; all we can do is try to minimise the effect on health, perhaps by providing facts or evidence about food, eating and physiology, perhaps by suggesting different options within a disordered eating pattern.

What was clear was that eating disorders are pretty unpleasant to endure, difficult to treat, and the longer they last the less likely it is that they will resolve. Maintaining a stable weight may be the best outcome possible, for both underweight and overweight patients.

Tuesday, 25 December 2012

Festive seasoning

A box of wrapped presents and a card
Thank you, Judging Covers!
The run-up to Christmas has been in turn stressful, enjoyable, frustrating and, at last, relaxing.

At work, there's been a lot to do, and fewer people than usual to do it. Last week was busy, and I was working with a student, which made it quite difficult to keep track of what had and hadn't been done, and what needed doing next. I was out on Tuesday at a study day (more about this in a future post), then on Thursday my clinic was relatively quiet, allowing me to enjoy a social Christmas lunch in the canteen. It was proposed as a leaving party for me and a colleague who is going on maternity leave, but my departure had become a little uncertain. I do now have a confirmed start date in the new job, towards the end of January, but both my current and future managers were fighting over me for a day or two! It was a little disconcerting, and not at all welcome.

I was at work yesterday (Monday), and was interested to find that nothing special was happening on the wards, although I spotted a tired-looking man in a Santa outfit reading some medical notes, who might have been one of the junior doctors. Otherwise, there were a few nurses wearing antlers or halos, but patients' stories today were so sad that it was difficult to spread any festive cheer, because who would choose to be in hospital over Christmas unless they were so unwell that they were forced to?

I'm told that some years there's very little to do in the hospital on Christmas Eve. That wasn't the case this year - there were more referrals than usual. We blitzed it in the morning, only to find that more had come in by lunchtime. Some were, frankly, taking the mickey, like the patient who just wanted a cooked breakfast, and another referred because they had been transferred from another hospital on supplements and the nurse didn't want them to become 'lost in the system'. An admirable sentiment, but not today. Diabetics struggling with blood sugar control and patients who had lost a bit too much weight had to give way to patients not able to swallow who needed tube feeding or textured diet and thickened fluids.

I am having nearly two weeks off work, so I also need to ensure all the information about my current patients and their priorities is made available to the Dietitians who'll be looking after my caseload while I'm away. I feel lucky that I was only 30 minutes late leaving the hospital after work.

At home, the build-up to Christmas has been steady, with some notable highlights. We thought we would like to spend our TV watching points on a tablet PC, so we went to review the options at the only high street electronics retailer that allows our points to be converted to vouchers. The experience was underwhelming, but never mind, we ordered the vouchers and returned to the shop at the weekend - the last weekend before Christmas. We were prepared for crowds, but there were none - neither were there any shop assistants. When we finally found one, and indicated what we'd like to buy, we were told: "There aren't any. We're sold out."

On the weekend before Christmas? The busiest shopping weekend there's likely to be in the year? Not only were they sold out, they refused to accept our money against an advance order, because this is impossible if there are no products in the warehouse, or some other nonsense. So we took our vouchers home, and thought about it.

A similar high street electronics retailer has recently gone bust. If this large retailer is unable to take our money at this critical time of year, we were very reluctant to hang on to the vouchers, which would turn to dust should the retailer join its close competitor in liquidation. So we considered our options.

Mr A's mother is now in a nursing home, and his dad asked our advice on a basic DVD player that she could have. Our DVD player is a suitable one, so we thought we would give her that one and upgrade our own system - but we had more money in vouchers than the cost of a new and better DVD player.

I've never had a printer of my own, and although I've been able to connect to Mr A's printer some of the time, his setup changes so frequently that mostly I have to go up and ask him to print stuff for me (or print personal things at work). So as well as the DVD player, I now have a lovely all-in-one printer and scanner - and there was some money left for a new toner cartridge for Mr A's printer too.

Unfortunately, now that we've had time to look at installing the new DVD player, our TV is such an ancient model that the all-powerful new DVD player doesn't have the ancient connectors that are needed to connect it up. Mr A has spent some time looking at various options, including buying a new TV, but we're most likely to buy just a SCART-HDMI converter and wait until the ancient TV breaks down before replacing it.

Lastly, I know it's a little vulgar to boast about one's Christmas presents, but... I WON ANOTHER BLOG PRIZE! On one of the book review blogs I read, a prize of 12 books for Christmas was on offer. I thought twice about entering, because despite reading every post on the blog, very few books that they review are ones that I think I might read. But I entered anyway, and not long ago a very large box arrived containing my prize. I put it under the Christmas camera-tree to await the big day, and this morning Mr A and I opened it, only to find that the wonderful people at Judging Covers had wrapped each book individually!

I'm looking forward to a completely different type of reading for a few weeks - much less weighty than my usual selections. And in the New Year I'll be driving far more miles every week, so I might at last start to get through more audio books in the car. Happy holidays to everyone, and lots of good reading for 2013!

A box of books

Tuesday, 18 December 2012

What I've been reading

Image of the book cover

A Confederacy of Dunces
by John Kennedy Toole

"A monument to sloth, rant and contempt, a behemoth of fat, flatulence and furious suspicion of anything modern - this is Ignatius J. Reilly of New Orleans, noble crusader against a world of dunces. But his momma has a nasty surprise in store for him: Ignatius must get a job."
To start with, I just found this book odd. Then I was intrigued and repulsed in equal measure - but I carried on reading, wondering where on earth it was leading. About two-thirds of the way through, I laughed out loud at one scene, but still couldn't quite work out whether I could stand the main character for much longer. Supporting characters are drawn sympathetically, but Ignatius is an oaf, a liar, a degenerate, and yet I wanted to know what would happen to him. I still want to know. The author died before the book was published, and I get the feeling that if he had been successful within his lifetime, we would have seen a sequel, and I would have been compelled, almost against my will, to read it.

Image of the book cover

Night Watch
by Terry Pratchett

"Commander Sam Vimes of the Ankh-Morpork City Watch had it all. But now he's back in his own rough, tough past without even the clothes he was standing up in when the lightning struck.  Living in the past is hard. Dying in the past is incredibly easy. But he must survive, because he has a job to do."
What a clever chap that Mr Pratchett is. Once you are a little bit familiar with his characters from one book to the next, things get very much easier, and it's possible to appreciate the wit and skill of the writer. In this book, while his wit and skill are very much in evidence, I wasn't so hooked on the plot, but enjoyed it nevertheless. Another book courtesy of Hugh - thank you very much.

Image of the book cover

Beyond Black
by Hilary Mantel
"Alison Hart, a medium by trade, tours the dormitory towns of London’s orbital ring road with her flint-hearted sidekick, Colette, passing on messages from beloved dead ancestors. But behind her plump, smiling persona hides a desperate woman: she knows the terrors the next life holds but must conceal them from her wide-eyed clients."
I don't know what it is with modern novels. I can't seem to find much to like in any book written in the 21st century, and I find the latter part of the 20th century a bit of a struggle too. This is a book by an author who is 'acclaimed', who has won the Booker prize twice - the first time for Wolf Hall, which I didn't really get on with. Since this was supposed to be very different from Wolf Hall - a ghost story rather than historical fiction - I thought it might be worth a try, but I still didn't find much to like.

Thursday, 13 December 2012


Houses seen through boat rigging
Brixham, August 2012
Each time I post a blog, I think "That was fun, but I wish I had more time to write. Why don't I start the next one straight away?" And then I don't.

This year, and last year, I was the nominated family member to produce the family calendar. This means collecting photos and uploading them and inserting them into the online calendar template and then ordering the resulting calendar for four households. It's quite a lot of work. This year, I thought "I have some pictures left over - why don't I start next year's calendar straight away?" Of course, I haven't.

The car is a filthy mess, and with the occasional early morning horizontal sunshine, I need to clean the windscreen properly on the inside. A job that will take, maximum, 15 minutes. I can't even remember how long I've been meaning to do this. And the interior needs hoovering, but that hardly features on the list.

I stupidly volunteered to be the Secretary of the Monday badminton club, where the only real duty is to get the members of the club registered with Badminton England in October. I finally managed to get it done last week, only to have them come back with an additional job because I'd registered the two under-18's that we have under the wrong code (they are junior club members, not members of a junior club. Doh). I'm not going to predict when that correction will be done.

Thankfully, things that have immovable deadlines tend to get done, like job applications and cleaning when we have visitors. It helps that we have very few visitors. But even things that you might imagine having immovable deadlines don't get done, like Christmas greetings. I would like to wish all who know me a very Merry Christmas and a Happy New Year, because you probably won't be getting cards this year. Postage is extortionate nowadays, anyway.

Things I do spend my time on include watching films with Mr A on the sofa. Last weekend we watched two: The Band Wagon (with Fred Astaire) and Marathon Man (with Dustin Hoffman and Laurence Oliver). Also: reading books, as you will know, and reading the magazines that come from my various subscriptions to professional, charitable and academic institutions. Oh yes, I spend quite a bit of time reading a variety of blogs, and dealing with email. But we all do that, don't we?

At work, we are gearing up for Christmas, with the cardiac wards well ahead of any others in getting their decorations out of storage. There is now tinsel a-plenty in the Dietetic office, shedding shiny strands all over carpets and clothing. We have the office party on Saturday with dinner and dancing, and then a special lunch the following week in honour of two of us who are leaving: one to have a baby, and me.

I have been juggling all these employment options for what seems like months, although looking back it has only been about six weeks. The interview for the nearest job was this morning, and if I had been successful, I might not have had to leave my current job, because there was a possibility of doing both old and new jobs part time. But they were admirably quick in feeding back that I wasn't successful. With near-perfect timing, the HR department from the first job contacted me yesterday to say that all the pre-employment checks had been done and do I still want the job? So I will be contacting them again tomorrow to let them know that I do. So the lunch in honour of two of us who are leaving can actually celebrate two of us leaving, rather than just one.

There has been talk of a buffet lunch in the office as well, and a 'Secret Santa' event where gifts for no more than £5 are bought and randomly allocated among us. There has been some confusion over these ideas, partly because we are running out of dates to hold events. I have, unusually, managed to purchase a Secret Santa gift, but now am slightly concerned that it will not be distributed as planned. The only other time I agreed to take part in a Secret Santa event was when I was working in Birmingham, and I spent a very unhappy lunchtime in shops in the city centre, being jostled by other shoppers, wholly unable to find anything suitable, and getting crosser by the minute.

Work on the wards continues as usual, with the added lottery of odd wards being closed due to norovirus. So far none of my wards have succumbed, but I expect it will happen before the end of the winter. I am quite looking forward to seeing how Christmas is celebrated in a large hospital, especially as I am led to believe that as many patients as possible are turfed out and admissions tend to be few, so there may not be all that much to do. Of course people will continue to have accidents and emergencies, but if we're lucky, not too many will involve malnutrition.

Saturday, 8 December 2012

Consultations: doing and observing

Fern unfurling
Sissinghurst, June 2012
There have been complaints. Actually, there has been one complaint. All right, it wasn't even a complaint, it was a phone call, and there was a visit too, in both of which the absence of new blog material had been noted with some concern. Mild concern. Actually, probably no concern at all, and it was nice to have a chat, and I'm glad that the cat has returned and is getting on with the other three, and everyone is doing well. And that the bees are all right at the moment, and the sheep, and the new mowing machine that doubles as a device to take out your enemies at the knees.

Latest employment news: I have been offered an interview for the job that is nearer, but with the interview still a week away at the time of writing (although maybe not at the time of publishing) I have had to seek advice from my elders and betters about what to do about the first job, the one that I have been offered subject to Criminal Records clearance and references. The advice I was given was "put your head down and keep quiet until they give you something in writing." So that is what I am doing, and they haven't given me anything in writing or even contacted me by phone or email, even though it has been weeks and I'm sure that references and CRB checks are all done. I haven't handed my notice in for my current job, so I won't be starting any new job until mid-January at least.

The interview for the newer job requires me to deliver a presentation on the challenges and opportunities of working in a multi-disciplinary diabetes team in the community. As luck would have it, I had previously arranged to spend some time this week with an experienced Dietitian working in a multi-disciplinary diabetes team in the community, so I was hoping to get her to write my presentation for me. She is much too experienced to let me get away with that one, but she did give me a few ideas that I can incorporate into the work of fiction that will be my presentation. It only needs to be ten minutes long, and I can probably keep up the pretence of knowing what I'm talking about for that length of time.

I had planned to spend the morning in the community diabetes clinic observing the Dietitian and the Specialist Nurse and anyone else who would stand still long enough for me to observe them. I did do quite a bit of observing, but just to prove that things are the same the world over, all the patients booked into the clinic turned up and the Dietitian and Nurse ran out of time, which resulted in me being asked to do a dietetic consultation with one of the patients. It was fine. I like clinics. I was hoping to go out and see some home visits in the afternoon, but there weren't any.

Watching the experienced Dietitian do her consultations was wonderful. It should be compulsory, every year or so, to sit in with someone who knows what they are doing. Managing the flow of the conversation is like directing the flow of water through sand. It is liable to change course abruptly in random directions, and the Dietitian's job is to keep diverting the stream back towards the proper destination, damming unwanted breaches of the riverbank, and eventually ensuring that the conversation and all of its tributaries reach a constructive conclusion, joining the greater body of the evidence-based ocean.

What I particularly noted was that it isn't always necessary to address everything that the patient brings to the appointment. In fact, it isn't even necessary to acknowledge some of it, and when the patient is in fact a little bit 'mental' (a technical term), then it's a very useful tactic to acknowledge only those aspects of the conversation that are relevant to the matter in hand, i.e. diabetes in this case. And I should really think a little bit more before I answer questions, but I'm not sure how I will remember to do this without a big sign in the clinic room saying 'WAIT - THINK' and it might be a bit obvious, not to say off-putting to the patient.

My own clinic has been changed, and I'm on a different day now, so I'm doing follow-up appointments for patients who were originally seen (maybe several times) by a different Dietitian. It is interesting to see how other people do things, and I've been able to report back to her about a couple of patients who have achieved really good outcomes following her advice, and have asked me to thank her. There is no difference in the mix of conditions in this clinic though - mostly IBS and obesity, with a few malnourished individuals thrown in for good measure. I even had to use an interpreter. I have also supervised a student doing consultations in an outpatient clinic, and am encouraged by a) recognising many of the mistakes the student made as being things that I did as a student, and b) being confident that I don't do them any more. At least, not often. I hope.

Last week the Diabetes UK local group had their last talk before Christmas, from a Dietitian. I missed it. I meant to go, but somehow had 'forgotten' to put the date in my diary. I think this was a successful attempt by my subconscious to prevent me from going, in order to avoid unpleasantness, and it meant that I went to badminton instead and had a good time.
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