|Bridge over the Danube, October 2012|
Last week was a good week, I observed lots of things and didn't get too tired. This was probably because events prevented me from playing badminton: a social event organised for new starters, a Diabetes UK meeting, and a planned dinner with previous dietetic colleagues that ended up not happening. This week I have already played badminton three times, and now I am very tired.
The large and important departmental meeting about convergence of the hospital diabetes services from two sites to one was more interesting than I was expecting. There was general consensus about the principles of a re-modelled service, which was the point at which I made my getaway. Those who remained endured another two hours, and those I spoke to next day seem to agree that I departed at the perfect time, because no further progress whatever was made.
The local Diabetes UK meeting was its normal unfriendly event - would it kill any of them just to say hello? The subject was Driving and Diabetes, and the talk was given by someone from Diabetes UK. It was mostly about the change of law in 2011, the circumstances in which the DVLA can take away your driving licence, and what you can do to get it back. I left before the raffle.
My colleague RSB has been working hard to devise a timetable to allow us to cover all clinics in an equitable manner. I'm not entirely sure why this has been so difficult to do. At the moment, my only disappointment is that it looks as though I will be covering an ante-natal clinic on a Friday afternoon, which means seeing all those women who are newly diagnosed with gestational diabetes. Given the nature of the condition, it is possible that there will be any number of patients from 'none' to 'all' of the clinic list, and may make my Friday afternoons run rather late.
As well as this clinic, I will be doing general adult clinics. These will mostly contain patients with Type 1 diabetes, because the newly formed Clinical Commissioning Group (which replaces the Primary Care Trust) has demanded that Type 2 patients are discharged into the care of their GPs in the community. RSB will take care of the pump clinic and patients using continuous glucose monitoring, the main ante-natal clinic and the young persons' clinic. Given time and more experience and I may well need to cover these when he is away. But not yet.
I observed a pump clinic this week. Attendance is optional, but it is for patients who use an insulin pump instead of multiple injections to control their blood glucose, and runs for two hours once a month, covering a different topic each time. An insulin pump delivers insulin subcutaneously via a metal or plastic cannula that remains in place for 2-3 days at a time, and has a number of advantages: no need for separate injections, a little bit more discreet, and potentially greater accuracy in insulin dosage and delivery, ideally leading to better control and fewer instances of unwanted high or low blood glucose levels.
For example, secretion of insulin in someone without diabetes consists of a continuous background trickle that may vary according to levels of stress or hormones or time of day, plus increased bursts to match the surges of blood glucose following digestion of carbohydrate foods. For someone with insulin-dependent diabetes who doesn't have a pump, the background insulin is supplied by a once- or twice-daily injection of a medium- or long-acting basal insulin, and the post-prandial insulin is injected as a bolus of short- or rapid-acting insulin, ideally shortly before eating. The background dose can't be changed easily, as it is released slowly over many hours. Although the action profile of the basal insulin is relatively flat, there is a period of maximum effect, and if not matched precisely to carbohydrate intake this peak can be at an inconvenient time (e.g. during the night) and cause hypoglycaemia.
With a pump, both background (basal) and bolus insulin is rapid-acting insulin delivered from the same reservoir in the pump. The pump rep who also attended the clinic answered lots of my questions, and also described the research they have done to map the requirement for background insulin through the day, which can be set up on their pumps. This means that a circadian profile of a trickle of insulin varying hour by hour can be delivered to mimic the 'normal' insulin profile for any individual, to try and minimise nocturnal hypoglycaemia. A step forward indeed.