Sunday, 31 March 2013

What I've been reading

Image of the book cover
The Thread
by Victoria Hislop

narrated by Sandra Duncan
"Thessaloniki, 1917. As Dimitri Komninos is born, a fire sweeps through the thriving multicultural city, where Christians, Jews and Moslems live side by side. It is the first of many catastrophic events that will change for ever this city, as war, fear and persecution begin to divide its people."
During the first month of the big commute, the only reading I was doing was in the car - at home I was too tired to concentrate on complicated words. This was good to listen to, superficially a love story, but it also taught me a little bit about the history of Greece since the 1920's.

Image of the book cover
The Hare with Amber Eyes: A Hidden Inheritance
by Edmund de Waal
"When Edmund de Waal inherited a collection of 264 tiny Japanese wood and ivory carvings, called netsuke, he wanted to know who had touched and held them, and how the collection had managed to survive."
This was a book that I finished reading because I am faintly obsessive and hate to leave a book unfinished. No doubt it is a work of art, like the things it describes, and I could appreciate the quality of the writing, but it wasn't my cup of tea. Sister D gave it to me when she had finished reading it on our trip on the Danube, and when I asked if it was good, she kind of shrugged. I should have known from that reaction.

Image of the book cover
Appleby at Allington
by Michael Innes

narrated by Gordon Dulieu
"Sir John Appleby dines one evening at Allington Park, the Georgian home of his acquaintance Owain Allington, who is new to the area. The evening comes to an end, but just as Appleby is leaving, they find a dead man, electrocuted in the son et lumiere box that had been installed in the grounds."
An author that was recommended to me by Hugh, a regular reader of this blog (while I am a regular reader of his weekly circular). He is right, it is old school detective fiction in the style of Dorothy L Sayers' Lord Peter Wimsey and Francis Durbridge's Paul Temple, both of which I like. This was just right, although the narration was a bit slow, with some heavy pauses. A proper whodunnit with a satisfactory conclusion, even if not an outstanding work of literature. But as I found with the previous book, literature can be a bit tedious sometimes.

Image of the book cover
The Wonderful Wizard of Oz
by L. Frank Baum

narrated by B. J. Harrison
"When a tornado crashes through Kansas city, Dorothy and her dog Toto are whisked far away, over the rainbow, to a strange land called Oz. Plucky Dorothy and Toto embark on a magical adventure to search for the Wizard of Oz and along the way encounter the Tin Woodman, the Scarecrow and the Cowardly Lion."
Another freebie from the Classic Tales podcasts, and he didn't do too badly with the narration of this one - no difficult names or foreign words. Surprisingly similar and yet distinctly different from the movie version, Dorothy inherits white shoes rather than ruby slippers, and I'd forgotten the bit where the wizard flies off in a balloon, although Lola II tells me it's in the film. Easy listening, but engaging enough for adult reading.

Image of the book cover
The Man Who Knew Too Much
by G. K. Chesterton

narrated by B. J. Harrison
"The eight adventures in this classic British mystery trace the activities of Horne Fisher, the man who knew too much, and his trusted friend Harold March. Although Horne's keen mind and powerful deductive gifts make him a natural sleuth, his inquiries have a way of developing moral complications."
Another English author narrated by the American, but not too bad - the mistaken emphasis on the wrong syllable of Westmorland can be forgiven. These are in the style of Father Brown but much more political and less straightforward 'whodunnit'. It was a very useful filler, because I finished the Appleby book before my next monthly audio book credit arrived!

Tuesday, 26 March 2013

Weekend trips and a holiday

View of the docks with the Liver Buildings in the distance
Liverpool Docks, February 2013
Most of the posts for a couple of months have been about work. There has been a great deal of life outside work, as I have hinted a few times. There was a trip down south to see Mr A's family, there was Lola II's and Mr M's film festival, there was a trip to Liverpool to celebrate Lola II's birthday, and there was a whole week on holiday in Berlin and Munich. Last weekend was mercifully empty (except for a tiny little badminton match) and this weekend I can relax again, although there is a plan to meet up with Lola II for nonsense and silliness (and lunch).

Mr A's dad and sister are fine, and his mum is now living in a brand new nursing home that seems very comfortable and modern, with some interesting ideas for its residents, all of whom have dementia. There is a garden with raised beds, there are the activities you might expect such as music and crafts, but there are also different seating areas - some with tables, some with sofas, some quiet, some with a view of the garden, and an interesting representation of an old railway carriage complete with luggage rack and suitcases. Mr A's mum seems as well as can be expected.

The film festival was a treat! There was a big screen, floor lighting, there were trailers, there was ice cream, an usher(ette) with a torch, a projectionist and a very appreciative audience in the three screenings I attended. The trailers were particularly good, and you can see them all in the YouTube Gulloebl channel - I have picked my favourite 'Gulloebl Chinema' trailer to show here. Mr M and Lola II must have spent ages setting it up and filming the trailers, and gave up a whole weekend to various enthusiastic film-goers. I hope they do it again, it was brilliant, although the surprise of the trailers will be hard to repeat. But if anyone can do it, they can!

Lola II and me in pyjamas and both on the Internet
The trip to Liverpool was good too, although somehow the weekend seemed shorter than it has in previous years. There was a bit of trouble with the hotel room - instead of our usual little guesthouse or B&B, Lola II had got a great deal on a large centrally-located hotel. I arrived first and checked in, but when I got to the room it had a double rather than twin beds. I thought I would phone reception rather than trek back to the desk, but the room phone had been pulled out of the wall. Back at the desk, they gave me another room, but neglected to re-program the keycard, so I couldn't get in. After a third trip to reception, I returned to what was indeed a twin room this time, but there was an odd, unpleasant smell, and when I took my shoes off, I discovered a large wet patch of carpet by the door.

Dock buildings with a glimpse of Ferris wheelThe third room was fine, and reminded us both of Great Aunt Sylvia's flat in Golders Green. What looked like a wi-fi router was up in a corner of the ceiling, so we had fine Internet reception - there was hardly any need to go out. But out we went - down to the docks, dinner in a lovely sushi restaurant, into town for a retro clothes fair, and an art gallery to finish up.

Tower of outsize models of Ritter Sport
Then my most recent holiday - Berlin and Munich with Mr A. Neither of us had been to Berlin before, and as Mr A described it to a friend, we were looking forward to a week of "good food, markets, and museums about death." Which was pretty much how it turned out. We saw many sights in both cities, rented bikes for a few hours in Berlin and rode around the Tiergarten and along the canal to a large stretch of preserved Wall, interspersed our walking with museums about death, ate sushi, and did indeed visit a couple of outstanding markets.

In Munich the outstanding attraction (apart from the company of the friend we stayed with) was the Deutsches Museum - a museum of science and technology that is both enormous and wonderful, and where we spent six hours and would have stayed longer had the museum not closed. In Berlin, one of the highlights was the Ritter Sport Museum, devoted to the local chocolate, and containing a Tower of Ritter Sport, which amused me a great deal.

No more trips or holidays are planned at the moment, although I'm thinking I might return to Tunbridge Wells for my Solitary Holiday again this year, mostly attracted by the lovely apartment I stayed in last time and the wonderful sushi restaurant. Mr A and I are thinking about a camping trip to France and possibly a trip to South Wales, and he has a scheme to go biking in Bulgaria. But for the moment, while the snow accumulates on the daffodil buds, we sit on the sofa and stay snug and warm.

Large grey/black blocks commemorating the Holocaust in a Berlin square

Friday, 22 March 2013

Counting carbs

Close up of passion flower
October 2012
I am still on my own at work, and it's not going too badly. I like the job more every day, and my steep learning curve continues. I feel privileged to read and hear the accounts that patients share with their doctors,  nurses and other healthcare professionals, even if they are not complimentary. Patients are angry, sad, depressed, anxious, overwhelmed or struggling, and luckily for my state of mind they are occasionally happy, positive, grateful or just demonstrate a very welcome sense of humour. They are always interesting, and sometimes interested.

I am now working with several patients on carbohydrate (carb) counting, which means that the patient estimates the carbohydrate content of everything they eat. I try to start with a brief description of digestion, then ideally find out what the patient tends to eat on a typical day. This allows me to understand their choices a bit better, and tailor the rest of the consultation to suit that person - for example, if the usual diet contains couscous and tofu, I might go about things differently compared with pie and chips.

Carb counting is usually something that adults with diabetes tend to learn after they've been diagnosed for a little while, a few months at least (although there are exceptions). So they ought to know already which foods do and don't contain carbohydrate, although it always pays to check their knowledge at this stage. Even within my short experience, I've found a surprising number of people who have been choosing their insulin dose according to the quantity of food on the plate, rather than considering only the carb-containing foods. For example, a very large cooked breakfast including bacon, eggs, sausage, black pudding, beans, mushrooms and tomatoes with a mug of tea with a splash of milk contains very little carbohydrate, and the amount of fat and fibre in the meal means that no quick-acting insulin needs to be injected.

So we establish appropriate knowledge of carb-containing foods, then move on to quantifying the amount they contain. I can provide different types of written information, and we have food models, pictures of food on plates and packets of food complete with nutritional labels. Then I can refer back to the typical day's diet, so the patient can have a go at estimating the carbs in their typical day. That's the first stage, and sometimes that's all that happens to start with. The patient goes home, and for a period of time just estimates the amount of carbs in their food without changing anything else.

The next stage is to apply this knowledge to insulin dosage. Essentially, to maintain good levels of blood glucose, carbohydrate intake and rapid-acting injected insulin need to be closely matched. This is a simple statement, but it's never that simple. There are different insulins, people react differently to the same food. Other factors impinge - stress, activity, alcohol, hormones, medications, illness, previous dietary intake, dosage of long-acting background insulin, the sex and size of the patient, previous blood glucose readings, injection sites, quality of insulin, quality of injection devices - there are a myriad of possible factors that will mess things up. But to start with, we work with just a few numbers.

At this second stage, having checked whether the patient's carb estimation is reasonably accurate, they might choose to start adjusting insulin dosage. This is done using two ratios: the amount of carbohydrate that is matched to a unit of insulin (or vice versa), and the change in blood glucose level that can be brought about by a unit of insulin. There is also a target range of blood glucose that people aim for, which is chosen individually and may depend upon the time of day - let's say for the sake of argument that it is between 5 and 8 mmol/L. We will further assume that the background insulin is at the right level, although this is an assumption that can rarely be made in the real world.

The patient tests blood glucose before a meal, and estimates the carb content of the meal. If the pre-meal test is within range, then the insulin to carb ratio is used to calculate the amount of rapid-acting insulin to be injected. For example, if the ratio is 1 unit to 10g and the meal contains 50g of carbohydrate, then 5 units of rapid-acting insulin are needed.

If the pre-meal test isn't within range, then a correction can be applied. If the pre-meal test shows blood glucose is high, then extra insulin can be given, and if low then an amount can be deducted. For example, if the pre-meal test is 15.2 mmol/L and the correction dose is 1 unit to 2 mmol/L, then 3 or 4 extra units of insulin will be needed along with the insulin to match the carbohydrate in the meal. If the pre-meal test is 4.3 mmol/L, then one fewer unit of insulin might be given - 4 instead of 5 units for a meal containing 50g of carbohydrate.

In an ideal world, this would result in a relatively steady blood glucose level that may rise immediately after a meal, but would return to within the target range by the time the next meal is due - no higher, and no lower. A higher blood glucose may make the patient feel ill, and increases the risk of diabetic ketoacidosis and long-term complications. A blood glucose below 4 mmol/L may make the patient feel ill, and needs immediate treatment to mitigate the risk of hypoglycaemic coma and, in the worse case scenario, death.

Together with a specialist nurse, this week for the first time I helped a patient to start carb counting. The nurse prescribed the insulin, but I suggested the ratio and correction dose. Ever since that consultation I have been worrying that my advice was flawed, to the extent that I have been trying to contact the patient to check that all is well. So far, I haven't managed to get in touch, and all I can hope is that if anything had gone wrong, the patient would have contacted us.

Saturday, 16 March 2013

I am on my own

Mr A on a bridge in the mist
Bridge to Esztergom, October 2012
It's been... HOW long? Anyone would imagine that I didn't love writing these posts. I really do, but I haven't even managed to get to badminton this week, so it must be serious. And last week we were on holiday, in Berlin and Munich. Maybe there will be a post about that, but I somehow doubt it.

My colleague, RSB, was away last week, and will still be away this coming week. So I returned from a week's holiday to a proper caseload, with real patients to see in real clinics, and no safety net. There are plenty of people to help out if I needed help, but they are at the end of a telephone. And it was fine.

I'm starting to relax with the job now, a little more confident in my ability to deal with whatever walks in the door. I've got used to asking before anything else in a consultation: "What is it that you want to talk about?" and finding that it isn't at all what I expected. There have been two patients with eating disorders, several others who have cried, and some who haven't. The most satisfying have been where the patient has said "I didn't know that" after I've told them something, and that's happened twice. Because I'm pretty new at this game, and some of them have had diabetes for all their lives, I feel very glad if I manage to pass on some of my acquired knowledge.

I have been working on a document that is called "All About Diabetes". It is both for reference, and a learning tool, so that I can be sure that I not only know about everything I need to, but can also explain it when I need to. My first Gestational Diabetes clinic was on Friday, so now I am pondering about how I can cut down the amount of time it takes to do all the necessary explaining to a woman who is more than 26 weeks pregnant and has been told earlier the same day that she has diabetes. I need to cut it down because I ought to be spending about half an hour with each patient, and on Friday there were only three patients and I was an hour and a half late home. Although it didn't help that the last patient was an hour late.

So this is what I need to cover:
  • What diabetes is
  • The patient's normal diet
  • Which foods contribute to blood glucose, and which don't
  • Which foods should be avoided altogether and why
  • Any questions
It doesn't sound much, but the 'Any questions' section can go on for a long time. And the patient may have a partner or family member there who also has questions, and their first language may not be English, and the mum-to-be may be in floods of tears as well. I've worked with all of these already, and that's probably why I'm feeling at the moment like I can manage whatever is thrown at me. I'm sure there will be days when it is clear that I can't.

There are other aspects to the job outside the consultations with patients. I have now been to a meeting involving all dietitians within the Trust, and discovered that there are absolutely loads of them, and also learned more than I currently need to know about intestinal failure. I am still getting to grips with the admin, and the computer systems, and finding my way around the hospital and between sites - at the end of one day I wasn't paying attention to which staircase I went down, and managed to get so lost that I couldn't find my way out of the building. I have also managed to arrange a large service and MOT for the car, which felt like quite an achievement. But I haven't managed to go to badminton, so there is still room for improvement.

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