Saturday, 26 January 2013

Moving on

Chocolate fudge cake and Waitrose biscuits
My leaving cake, baked by a lovely colleague
My first dietetic job has now come to an end, and a new era is about to start with a specialist diabetes post. It's been almost exactly a year since my first day as a qualified working Dietitian, which has a pleasing feel to it, and I have learned an enormous amount in that year - maybe not as much as I learned during my degree, but still, important stuff. Most of all, my confidence has grown to the point that I now believe in my own abilities, and most importantly can tell the difference between things that I can definitely do and things that I need help with.

The last week at work was surprisingly quiet, which was wonderful. Added to that, it was also the last week for 'my' student, who was doing a tremendous job and took all the pressure off me, because she was just out on the wards seeing patients. She gave me a card and a present when I left, which was lovely. The quiet week made it easy for me to tie up loose ends and finish the job tidily (and on time!) on Thursday. But I had to phone the office on Friday, because I had been thinking about the patients I handed over and realised that I ought to have prescribed a different feed for one of them.

We had a little leaving presentation when I was given a cyclamen, some chocolate, and a voucher towards a new badminton racquet (which was what I asked for). A large number of people turned up at the pub after work for a drink and a curry, and I was hugged by more people than you could shake a stick at, which was many more people than I usually allow to hug me. It was hard to stop them, so I didn't.

What with my new post being temporary, and not quite full time, and a long way away, I can't rule out the possibility that I may have to return to acute dietetics on the wards at some point. But if I never have to offer another nutritional supplement or calculate and write up a regimen for an enteral feed, I won't be too sorry. In the last week, because it was a bit quiet, I stole some of the other Dietitians' diabetes patients and had some interesting conversations on the wards. But I also had to see the usual patients who are being tube-fed, mostly long-term, mostly for neurological reasons, although there were a couple of acute cases who had been through surgery.

We also had a professional development session on treatment of gastrointestinal failure, which can occur due to surgery, malabsorption (sometimes due to bowel being removed), or just a lack of peristalsis called 'ileus' which can also happen if the intestines are mucked about with or following any serious trauma or surgery. These are scenarios when parenteral nutrition (PN) is called for, and nutrition is given intravenously - it is a last resort, because the risks of infection and other complications are much higher if nutrients are supplied this way. In the meeting, we were all in groups and given the task of prescribing a feed. I was with a community Dietitian and a very experienced renal Dietitian, and found that their knowledge of ordinary hospital dietetics was somewhat poorer than my own, which was a surprise.

On another day, while I was on the endocrine ward, I listened in to one of the diabetes doctors explaining to a student some of the mechanisms used for differential diagnosis of diabetes - type 1 and type 2 and the tests that can distinguish them. The blood or plasma concentration of insulin is rarely measured, because it has a very short half-life in the system, so other indicators have to be used, of which the main one is C-peptide. Insulin is synthesised in the pancreas as a larger molecule which is split into two parts on release into the blood stream. Insulin disappears pretty rapidly, but the other component, C-peptide, doesn't, so it can be measured as a surrogate indicator.

If blood glucose is high and C-peptide is low, then it's either early-stage type 1 or late-stage type 2, because insulin-secreting pancreatic beta cells are being killed off, and insulin treatment is probably needed. If blood glucose is high and C-peptide is also high, then it's type 2 because the problem is not lack of insulin, but insulin resistance. There was a lot more to it, but that's just the bit I took away. He was talking pretty fast.

So all in all I feel very pleased with the prospect of moving forward into specialist diabetes dietetics, but also very privileged to have had the opportunity to see how a large teaching hospital functions. There was rarely a day when I wasn't thankful that I was able to walk away and go home, unlike those I'd left behind on the wards. And what wards! They all have particular challenges - my last batch were cardiac, neuro and vascular, and were as varied as any of the others. The vascular patients were particularly challenging; many had necrotic toes where their circulation had failed, gangrene, horrific ulcers, amputations, and the smell! The only worse smell I encountered was a patient who had very advanced cancer.

I have found the NHS to be a magnificent institution, staffed by people the vast majority of whom are genuinely trying to do their job well, and serving even the poorest without distinction. There are any number of reasons why this is sometimes impossible and we fail, but anyone who thinks that nurses, doctors and all the rest are just marking time and looking forward to the comfortable pension is mistaken. Of course, this has been my experience in this one hospital, and may not be the case universally - the recent history of Stafford hospital springs to mind.

My belief is that the culture within any department, profession or organisation is set by example rather than by rules or policies - if the boss picks litter off the floor and puts it in the bin, then others don't think it is beneath them and follow the example. I can compare the department I have just left with the three others that I met as a placement student - some aspects were better, some were worse. But as I may have written before, I don't think I have ever worked with such a supportive and congenial group of people as those I have just left.

The other difference between this set of colleagues and others is that my interests and passions are shared somewhat further than in any previous job. Of course, I still watch far less TV than most of my colleagues, but I can sometimes steer the conversation towards 'best restaurants in Kenilworth' or 'strangest foods we have eaten' without everyone getting bored. My lunch of celeriac gratin with walnuts is regarded as interesting rather than weird. At my leaving do we had interesting conversations about Michael Mosley's 'Fast Diet', nearest Michelin starred restaurants (Mallory Court), fancy restaurants where we have dined, and cake-making from the Hummingbird Bakery cookbook. I even half wished I'd watched the Great British Bake-off on TV, as it sounded like the least awful of this genre of reality shows.

Mr A has offered to treat me to lunch at the local noodle emporium, Wofon, so I need to get ready. More Lola Life to come in the next thrilling instalment - Specialist Diabetes Dietitian.

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