Thursday, 31 July 2014

Half a century

Empty barrack with columns, beams, paned windows
Block C, Bletchley Park
I can't believe it's a week since I last wrote something. Maybe time is passing more quickly, or more likely, there's much less that I feel like sharing publicly.

I have reached my half century without serious setbacks, and I feel most thankful. I enjoy what I do most days, and have been taking a bit more care to pursue activities that are both mentally and physically satisfying. Watching films and reading books as well as working, learning, writing and listening to music fulfil the intellectual criteria, and I've continued to play badminton twice a week even through the recent heatwave, when drinking more than a litre of water over two hours is often not enough.

Then there's the running. I completed my challenge of learning to run, and wrote about doing two Parkruns, so I knew I could run for 5 km. Looking back, I wrote at the time that I wouldn't rule out doing more, and in the last couple of weeks I've been out running on my own and did another Parkrun, and faster than before. It's incomprehensible. I still don't really like running, but I'm still doing it, even when it means getting up early at the weekend. If you'd told me even six months ago that I'd be running for the joy of it, I would have laughed in your face. I'll let you know when I've worked out what's going on.

Just to add to all of this, I decided not to let a whole summer go by without skiing, so I took myself off to the Snowdome to have a bit of a practice, thinking that it would be pretty quiet on a midweek day in July. It wasn't that busy, but still a few groups learning to ski. I found I hadn't got as rusty as I expected, and that an hour on the slope was enough to get me back in the swing of things. Time to book the next holiday?

Mr A has got a contract job, which is very good news, but as with all things relating to Mr A, it is stressful. There is a major deadline imminent, and no doubt some other deadlines to follow, which always puts the pressure on. He has, however, been getting some very good results in his latest Open University module. No particular news to report from Lola II and Mr M, who continue to get up to mischief at every opportunity. No news from the pub next door, and our house is still shabby but functional. The garden is even more overgrown than before, which is to be expected since I haven't been out there except to pick some mint and unblock a drain after a thunderstorm.

Main entrance to Bletchley Park mansionWe still have no working doorbell, and our (landline) telephone system relies on four handsets with rechargeable batteries, of which three seem to have stopped recharging. The batteries seem to be custom models soldered into the handsets, making replacement complicated. Note to those who telephone the house - if you leave a message we can play it back on the base station and then hunt down a handset that works, or phone back using a mobile. There is very little chance of us actually finding a working handset in time to answer your call. Or if we do, the handset will probably fail within a minute, cutting you off. And our mobile phones will probably not be in the same room as us...

Other recent events: a trip oop north to a barbeque with H&B, which was lovely. The mid-season falconry centre barbeque, which was pretty good considering most people there communicate better with birds than with strangers (I don't necessarily exclude myself from that description). A trip back to Bletchley Park, which has developed enormously since my last visit back in 2008. Re-reading that post, I learned a lot more detail on that visit about the actual decryption methods, presumably because I was part of a small academic group. This time the information was much more general: how the place was run, who was there, how it felt to be one of the workers rather than the exceptional genius of Turing, Welchman and the rest. The entry fee allows repeat visits for a year, and although I was there for about five hours I didn't see all that I wanted, so I'm planning to go back next week before my holiday ends.

Woodworking in the woodland
Mr A and I have also visited our southern friends who have bought a nearby area of forest, and are working to restore it to its original state by gradually getting rid of the planted softwoods and allowing native woodland to regenerate. They are also having fun camping there, and have started to create a mountain bike track and an obstacle course as well as hosting the annual 'Run Forest Run' (which, for those who have not seen the Tom Hanks film, is a rather amusing reference to Forrest Gump).

That's it. I've got stuff to do, packing for my birthday treat: a weekend at the Cambridge Folk Festival, where I have previously spent my 30th and 40th birthdays (and possibly also my 20th, although it's too far back for me to have recorded that attendance). Here's to the next half century!

View of Bletchley Park mansion across the lake

Thursday, 24 July 2014

Outpatients and inpatients: clinics and wards

Groombridge Place, June 2013
The consultant-led clinics have been a bit like a roller coaster for a week or two. One of our regular consultants has been ill, and sometimes another doctor has provided cover, and sometimes the admin staff have had to try and contact everyone to cancel at short notice, and sometimes patients have turned up and been seen or not seen depending on who's available and what's needed.

For one particularly busy pump clinic (where patients with Type 1 Diabetes who are using insulin pumps usually spend much more time with the Diabetes Specialist Nurse than in most clinics), we only had one DSN, and the consultant delegated the clinic to two subordinates, neither of whom was familiar with how to manage a patient using a pump. This meant that the poor DSN had to support the doctors as well as trying to do her own job. The whole thing provided a pretty unsatisfactory experience for the patients - none of whom complained, despite having to wait ages.

The whole scenario was relayed back to the consultant, who overcompensated the following week by bringing three doctors with him. Unfortunately we don't have enough rooms in the building to house all these doctors as well as ourselves, and consequently neither the DSNs nor I were able to see patients and we had to squeeze into rooms occupied by researchers and secretaries. There were also far fewer patients booked into this clinic than the previous week, which meant all these doctors had long gaps between patients. At one point, a patient with a baby and a toddler was dealing with a nappy change in the room I was in, and the only place left for me to sit was in the waiting room.

This is unusual - most of the time the clinics run pretty efficiently and on time, and most times I get to see the people I think I should be seeing. I have taken to advertising the very low carbohydrate lifestyle with a few posters on the wall, and flyers given to the patients that I think might benefit. This has rustled up a few candidates, and I am starting to build towards a group that can meet regularly to share experiences and recipes and generally keep each other motivated. There are plenty of others who don't need or want to follow that diet, and I am still seeing new people all the time. It is always very interesting, even if I sometimes end a consultation thinking that I could have done better. There are plenty where I feel I did well.

And in between all this interesting and rewarding outpatient contact, for the last five weeks I have had to spend a day a week on the wards. I've disliked this type of dietetic work from the start, and now I've come to hate it. I would rather spend hours with a recalcitrant diabetic who has no intention of taking any advice from me or anyone else while ignoring spiralling blood glucose, than 15 minutes trying to get a confused malnourished inpatient to drink a sickly sweet milky supplement because that's all we have to offer. I would rather be resigned to the inevitability of diabetic-related complications than despair at the likelihood of hospital-acquired pneumonia.

I have enormous respect for the nurses and healthcare assistants on the wards, who are frequently doing three or four things at the same time, often unpleasant and involving bodily fluids or orifices or both, and who listen to me with patience and good humour even while I'm telling them what they already know. But despite my regard for ward staff and their dedication to doing the best they can, the institutional setting thwarts most of their best efforts. I heard today about a patient with Type 1 Diabetes - elderly, frail - who kept having hypos while in hospital, so the doctor stopped their insulin. Just stopped it. Two days later, the patient had to be transferred to the main hospital for life-saving treatment in intensive care.

Our health service is amazing - the care that is offered without additional payment in NHS establishments is incredible. But I would do almost anything to avoid having to spend even one night in a hospital ward.

Monday, 14 July 2014

Diabetes services

Sunset over harbour and hills
Greek sunset, June 2014
I've got a half-written blog post that I've been trying to finish, but it's taking ages because it needs a bit of thinking time and I'm just not getting round to it. So I'll do some writing off the top of my head, just to keep things ticking over.

I'm still working five days a week, being paid for about five hours on that fifth day doing general dietetics on the wards, which means mostly nutrition support. The hospital is a small one with only six wards, and holds patients who are not acutely ill and/or who live in the area. They are generally old and not actually needing further treatment but cannot go home until some sort of provision is arranged to make sure they can cope (a 'Package of Care'). Nearly all those who need dietetic input are not eating or drinking well, usually because they have dementia. I absolutely hate it. I have two weeks to go before the Dietitian who has been off sick is due to return, and I shall do everything in my power after that to be completely unavailable for this type of work in future, although there will be a lot of moral pressure to 'help out' if a similar situation happens again.

My real job is still very interesting. I have managed to start two people on the very low carb plan, but unfortunately one did not return for the follow up appointment and wasn't answering the phone when I rang. My first Structured Education course for people with Type 1 Diabetes finished this week. This is designed to give people a lot of information and practical experience of how to best manage their diabetes, and we run it one day a week for four weeks. We had eight attendees, and all of them seemed to get a lot out of it. I found it a little stressful to have so much responsibility for delivering material that is so critical to the course.

At least half of the course is about carbohydrate counting. This is a skill that is fundamental to good control of Type 1 Diabetes for those who want to have the flexibility of eating what they like when they want to. Teaching carb counting is a core skill for a Diabetes Specialist Dietitian, and I would say I have reached an intermediate skill level - not too bad, but I've only been doing it in earnest for a few years. Nearly all of the people on the course have had diabetes for much longer than that.

Despite my nervousness, it went quite well, although I think I can improve with practice. We cover all sorts of ways of estimating the carbohydrate content of food - using food labels, weighing food and using reference tables, using apps, websites and pictures, and plain and simple educated guesswork. The part that makes me a little bit uncomfortable is that while my estimates are based on my experience with a number of different people as a day job, I don't actually act on the data and inject insulin, so I don't get any personal feedback about the accuracy of my estimates. When I get it wrong, it's someone else that suffers. I take this responsibility very seriously, so I often lose sleep worrying about whether someone I've seen in the day is going to end up with very high or very low blood glucose as a result of something I've said.

As well as the course and the individual consultations, there has been some discussion in the Trust and the Clinical Commissioning Group about funding to expand the very low carb programme that we offer. This has caused some controversy, because we haven't any solid evidence for its value in our service. We have lots of anecdotal evidence of patients who have found it life-changing (in a positive way), and we have a spreadsheet with lots of data, but the data hasn't been analysed and there's been no data collection from those who haven't found it helpful, nor have we sought views from anyone who may have experienced negative effects.

There are a number of healthcare professionals in our Diabetes service who are positively messianic about the plan, and they are all in favour of the expansion in funding because they have seen so many people find it beneficial. Having joined the service so recently I am more sceptical, and feel that we must carry out some analysis of our data to provide evidence of benefit and investigate any negative aspects properly. Our Team Leader has very sensibly defused the situation with an eminently rational proposal, including the view that we should be offering people choices rather than putting all our energies into selling the low carb idea.

Whenever I have met up with other Diabetes Dietitians, I have asked them their views on very low carb diets. So far I haven't met any that are offering anything like our plan, but they have all been very interested in hearing about what we do. I would like our next stage to be a proper audit of what we have, if not a research project culminating in a peer-reviewed publication, but I'm not volunteering for the job.

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