Mental Health

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.

Festive seasoning

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!

What I've been reading

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.

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.

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.

Procrastination

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.

Consultations: doing and observing

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.

Work, food, birds

Cotswold Falconry Centre, July 2012

I always want to start posts nowadays with excuses - no, reasons - explaining why there's been such a long gap, I've been busy, blah blah blah. I should just accept that I haven't got the same amount of time nowadays, and an awful lot less that I'm allowed to write. If only I could tell you about some of the patients. There's a lot to tell, but what makes them interesting is also what makes it impossible for me to write about them. Even the woman who came to my clinic thinking that it was another clinic would recognise herself if I gave any more details, and that's my test nowadays for whether I can or can't relate the story. So, I can't. Even if it was a man.

Generalities are fine. So I can say that two weeks ago was extraordinary - I had almost no referrals all week, to the extent that I could spend half a day in the library reading about diabetes, and catching up with paperwork, and throwing a lot of accumulated stuff out. Then last week, the tables were turned. One of my colleagues was off sick, and we were just keeping our heads above water even when we discovered at very short notice that she was supposed to be giving a talk on Wednesday, and even though I had a full clinic (11 patients) booked in on Thursday morning (4 DNAs in the end). But on Thursday, the wards decided to go into overdrive, and we received 15 referrals (I think it was 15 - my other colleague had to deal with the inundation during the morning - I was in clinic).

For some reason, Thursday was also the day that I found myself involved in three separate complaints about catering. Afterwards, we decided that in an ideal world I should have just said "This has nothing to do with me; you need to talk directly to catering yourselves." But, as a health professional trained to help people, my instinct is to try and help, even though one complaint was simply that the ward catering staff wouldn't give larger portions to a patient who clearly needed and wanted more to eat. It was very frustrating for all involved.

In the end, you can only do as much as a person can do, and our colleague returned on Friday, and we just about got through everything as best we could. But the team of six is down one anyway since our team leader left, and the most senior of the remaining five of us is covering not just that post but also providing paediatric cover, as we only have one paediatric dietitian for the whole hospital. And one of the remaining five isn't supposed to do anything except stroke, and she had a student with her all week as well. The end of the working week on Friday was a huge relief.

Mr A and I had a treat on Friday night - a return visit to Queans, the restaurant where we first went to celebrate our birthdays earlier in the year. This time we had a voucher which Mr A had earned by doing some work for a neighbour. It was a lot of money, too, enough for dry martinis and three courses for each of us and a bottle of wine. It is a lovely place to spend the evening.

Then on Saturday I volunteered to help out with end-of-season cleaning and clearing up at the Falconry Centre. As a Friend of the Centre, as well as not having to pay to get in, I am invited to a summer barbeque and two cleaning events, one at the end of the season in November when the Centre closes, and the other in February just before the Centre opens again. I'm not entirely sure why I volunteered for this, and most Friends do the sensible thing and just come to the barbeque, but there I was on Saturday, spending a few hours sweeping up leaves in the pouring rain, and getting almost as wet while cleaning the insides of the cages where some of the birds are kept overnight and through the winter.

The birds don't fly at all out of season, mostly because there aren't enough visitors to justify opening the Centre. They don't need to fly - given sufficient food, they are happy to just sit there for a month or two, growing new feathers and thinking whatever birds think when they have nothing to do. There were about six of us volunteers in all, a friendly group, and I'm kind of glad I did it, even though I really didn't have to. I might even volunteer for the February opening workout as well.

No fresh news about the new job. I know I'll almost definitely be leaving if all the bureaucracy gets completed to everyone's satisfaction, and it is likely to be at the end of December all being well, but there are no guarantees. Then another similar vacancy was advertised, much nearer to home, permanent, but only 4 days a week. I mentioned it at work, and was surprised when the consensus was that I should apply, despite being halfway through the process of moving to a different job. So that's my Sunday fully occupied, along with my usual treat of a trip to the greengrocer.

Update on insulin

Sissinghurst, June 2012

Another outing to the local Diabetes UK group, with its primary focus on fundraising and unfriendliness. It turns out that the positive interaction in the last meeting was an aberration caused by the lack of a speaker - this time they were back on form, and completely ignoring me once more. I am tempted to write to the Chair just to let them know how off-putting their meetings are to someone who's not one of their particular friends.

The reason I attended (and didn't leave) was because the speaker was the doctor who had previously provided the update on treatments for Type 2 Diabetes a year ago. This time his subject was insulin, and here is what I learned.

Just to recap - insulin is a protein, constructed from two crosslinked peptides made of 51 amino acids. It is secreted by the pancreas into the bloodstream, stimulated by glucose from digested food, and transported along with the glucose to liver, muscle, and fat cells. Insulin is the facilitator, the key to the door that allows glucose to enter the cell and to fuel metabolism. As an aside, nerve and brain cells also use glucose as fuel, but they don't need insulin to facilitate entry.

Insulin has some other functions in the body, as well as allowing the uptake of blood sugar. It inhibits the breakdown of fat in adipose tissue, stimulates the uptake of amino acids that form the protein in our bodies, and also stimulates the passage of potassium from the blood into cells. It is an anabolic hormone.

The diagnosis of Diabetes Mellitus relies on measurement of blood sugar being above a particular threshold, which could be for a number of reasons. In Type 1 Diabetes, blood sugar is high because the pancreas has stopped producing insulin, so there is none in the bloodstream, and the circulating glucose therefore can't be admitted to cells. For Type 2 Diabetes, blood sugar is high because despite the presence of insulin in the bloodstream (sometimes large amounts of insulin), the cells have become resistant to its action. After a period of time, people with Type 2 Diabetes sometimes stop producing enough insulin, and then will need insulin injections. People with Type 1 Diabetes generally need insulin injections immediately on diagnosis.

So the main substance of the short lecture was all about types of insulin. There are two main types: Human and Analogue. In the past, bovine and porcine insulin was sourced from the pancreases of animals, but very few people use these now. Since the invention of genetic manipulation techniques, insulin that is indistinguishable from human insulin is made by bacteria - this, obviously, is Human insulin, and its peak of action is within 6 to 8 hours from injection (Actrapid, Humulin S).

Real human insulin secreted by a pancreas into the bloodstream acts within 30 minutes - the different profile of the same molecule when injected is due to that mode of delivery - into subcutaneous fat, which delays things a great deal. For this reason, the insulin molecule has been tinkered with to create Analogue insulin, which has a slightly different sequence of amino acids, or has had additional atoms or strings of atoms attached to it, to change its action profile. Short acting Analogue insulin can work within 2 to 4 hours (Novorapid, Humalog, Apidra), which is nearer the profile of pancreatic insulin (but still slower than the real stuff).

The aim with all these developments in injectable insulin is to try to mimic the action of insulin secreted by the pancreas in the non-diabetic person. As well as the spurt of insulin that is triggered by carbohydrate being turned into blood glucose, there is a particular profile to the way that the supply of insulin tails off after a meal, and also a background trickle of insulin that is released into the bloodstream steadily for 24 hours a day. For this reason, other insulins have been developed. The first product combined insulin with zinc. Six insulin molecules grouped around the zinc atom forming a hexamer, and slowed the release of insulin to provide a longer-lasting hit. Nowadays, this is achieved by the addition of protamine, and these medium-acting insulins are called Isophane or NPH insulins (Insulatard, Humulin I).

There are also pre-mixed insulins, both Human (Humilin M3) and Analogue (Novomix 30, Humalog Mix 25 and Humalog Mix 50) that contain some short- and some medium-acting insulin. The number indicates the proportion of short-acting (25, 30 or 50%) to long-acting (75, 70 or 50%) insulin. And to replicate the trickle of background insulin, two analogue insulins have dominated the market for some time (Lantus/Glargine, Detemir/Levemir). Neither is perfect, they still have mild peaks of action rather than being flat through the day, and Levemir doesn't quite last 24 hours so some people have to inject it twice a day.

The speaker also brought news of new developments not yet available. There is a new insulin (Linjeta) that may act almost as quickly as human insulin by including EDTA, which binds to zinc and prevents the formation of the hexamer, allowing the insulin to diffuse into the bloodstream more quickly. [At this point I asked why zinc was included at all, and the speaker thought it was necessary to ensure the stability of the product in storage before injection.] Another new insulin (Degludec) is hoped to provide the desired flat profile of background insulin by attaching a fatty acid side chain to the insulin. And a third development (Insupatch) is intended to speed up the release of insulin for people using insulin pumps by including a small heating element around the cannula, which increases the blood flow through the insulin-containing area of subcutaneous fat.

I'll have to go to the next local meeting, unfortunately, because being pre-Christmas, the speaker is a Dietitian. I'm not yet sure whether I'll mention the unfriendly nature of the meetings to any of the committee, of whom there are several present, wearing badges. They show no more inclination to talk to me than anyone else in the room.

A new job

Cotswolds Falconry Centre, September 2012

As I mentioned in passing, I had an interview last week, for a post as a Specialist Diabetes Dietitian. Are you on tenterhooks? You shouldn't be, because by now you should know that whatever my finest qualities may be, they do not include an aptitude for the job interview situation.

The interview was fine. I showed enormous enthusiasm for diabetes, which was quite genuine - in fact, my next blog post will contain a report about the latest meeting of my local Diabetes UK group, which I attend in the evening in my own time. The Lady Shoes, however, damaged my feet to the extent of making them painful for several days, despite only wearing The Shoes to walk from the car to the HR department, then to the interview and back to the car. Those hospital corridors stretched for several miles, or so it seemed.

The interview was on a Thursday, and when I hadn't been contacted by the weekend I was fairly sure what the outcome would be - all the interviews were taking place on the same day so there was no reason for delay if I had been the successful candidate. So when I phoned them for feedback on Monday morning, I wasn't expecting any more than feedback.

But it wasn't quite so simple - I was told that no, I hadn't got the permanent job, but there was another, similar job, which was temporary, and would I be interested? I certainly would, and there it ended, because there was talk of sorting out funding, and when the f-word is spoken in the NHS context, things can move exceedingly slowly.

But they called within the week, and offered me the temporary job! It lasts for nine months, with the hope of extending beyond that time and/or making the job permanent, which I gladly accepted. It's a long commute, and I'll be truly sorry to leave my current colleagues who are all wonderful, but working on the wards isn't what I want to do in the long run, and I've thought for some time that diabetes is where I'd like to be.

Looking at my current contract, I see that my notice period is only 4 weeks. There are still some formalities to go through - the Criminal Records Bureau check and the references - but it is possible that I will be in a new job before Christmas.

What makes me smile (apart from having a new job) is the thought that in my first successful interview I came third (there were three jobs on offer) and now, in my second successful interview, I came second. Perhaps the next time I try, I'll be the first choice.

What I've been reading

Run
by Ann Patchett

"A student at Harvard, Tip is happiest in a lab, whilst Teddy thinks he has found his calling in the Church, and both are increasingly strained by their father's protective plans for them. But when they are involved in an accident on an icy road, the Doyles are forced to confront certain truths about their lives, how the death of Doyle's wife Bernadette has affected the family, and an anonymous figure who is always watching."

This was a nice enough book, the writing was attractive, but the story didn't seem to go anywhere that made me think more deeply about anything. It didn't develop, there wasn't a beginning, middle and end, it just started, continued and stopped. So while I was happy to read it all and wasn't at all bored, I didn't find it very satisfying.

The Tell-Tale Brain
by V. S. Ramachandran

"Our brains are the most enchanting and complex things in the known universe - but what happens when they go wrong? One of the world's leading neuroscientists has spent a lifetime working with patients who suffer from rare and baffling brain conditions. He tells their stories, exploring what they reveal about the greatest mystery of them all: how our minds work, and what makes each of us so uniquely human."

This started well, even though it covered some of the same ground as his other books - he expanded on the subjects of phantom limbs and neural mapping with the idea of mirror neurons and autism, and it was all rather interesting. Then he extended his reach into aesthetics and art - what it is about humans that gives us self-knowledge, consciousness, and appreciate art and culture. That's when he lost me. But the first half of the book is OK.

Spilling the Beans
by Clarissa Dickson Wright

"Clarissa was born into wealth and privilege, as a child, shooting and hunting were the norm and pigeons were flown in from Cairo for supper. At the age of 21, she was the youngest ever woman to be called to the Bar. Disaster struck when her adored mother died suddenly. Rich from her inheritance, in the end Clarissa partied away her entire fortune. It was a long, hard road to recovery along which Clarissa finally faced her demons and turned to the one thing that had always brought her joy - cooking."

Interesting enough, although poorly written. I mooched it (from Bookmooch) because I heard a snippet of an interview with her when it came out, which sounded fascinating. She has indeed had a full and varied life, and the book is certainly an account of all the things she has done, but with little attention to language it is not a great deal better than a list. I would be disappointed if my writing were like this, although sometimes I suspect it could be.

Cruising

View from our cabin, Budapest, October 2012

This will have to be short. Life is busy at the moment, and I'm only writing this because badminton has been cancelled tonight - there are two matches on, which means no spare courts for ordinary club. It doesn't happen often, but actually it's quite handy tonight because of all the stuff I should be doing. Except I'm not doing it, I'm writing this.

I have been away. You would hardly notice nowadays, given how rarely I get round to blogging, but for a week, the entire Lola clan (ten of us altogether) spent quality time together closeted on a boat on the River Danube sailing from Budapest to Linz and back again. We stopped at Esztergom (Hungary), Bratislava (Slovakia), Dürnstein, Melk, and Vienna (all Austria) and from Linz we took a coach trip to Salzburg. It was all organised by Riviera Travel, and I have to say there was little to complain about other than an excess of luxury.

Some of the party (me, Lola II, mum) were trying very hard to maintain our sylph-like figures, and practised some level of self-denial in the food intake department. Others (Mr M, Mr A) seemed to regard the multiple-course gourmet menus as a challenge. Given that scurvy is an ever-present threat when it comes to the male of the Lola species, I thought we were in trouble when Mr M's stance on the 5-a-day matter was backed up by an interesting letter from the ship's captain, placed under the door of our cabin. It reads as follows:

"THIS IS YOUR CAPTAIN.

MARMALADE DOES COUNT AS A PORTION OF FRUIT.

YOUR CAPTAIN

PS I DOES NOT NEED TO PROVE I IS YOUR CAPTAIN."  

Mr A thinks it might be a forgery, but we never did get to the bottom of the matter.

Another highlight was the ship's pianist playing Beethoven's Moonlight Sonata, which we had asked him to do because it's dad's favourite piece of music, but he said he would unfortunately need the music. Unfortunate is right, because, anticipating such an eventuality, we'd brought the music. All I can say is that it was recognisably the right piece, but as Eric Morecambe might say, some of the notes were not necessarily in the right order.

Some of us tried out the open-air jacuzzi on the sun deck. Others had a go in the sauna and steam room. We lounged in the lounge, sunned ourselves on the sun deck, played card games and word games, read books, and variously walked and wheeled ourselves around the various sights of continental Europe that were presented to us. It only rained on the very last day.

There was a mountain of work awaiting me in the hospital on my return, and the interview is tomorrow. What I should be doing at the moment is looking at potential interview questions, devising cunning strategies to present my weaknesses as strengths, and coming up with the perfect answer to the question of why I applied for this job. I will have to remember to take make-up to work with me, and I also have to construct a suitable outfit. This includes working out what combination of outerwear, footwear and hosiery will allow me to a) drive, b) walk and c) appear tall, confident and presentable rather than a just scruffy person wearing clean clothes and Lady Shoes with heels that are a bit too high.

Dietetics and more

Sissinghurst, June 2012

Events move apace in the Dietetic department, while I blog about inconsequential matters like my reading habits and creatures made from meat and pasta. There has been laughter! tears! patients! clinics! and a few interesting developments.

Wards

We have swapped wards again. If you have been following the saga since the beginning, I started with the stroke and elderly wards, followed on with respiratory and urology wards, and now have cardiac rehabilitation and neurology. Next rotation, I may get the orthopaedic and labour wards. Admissions at the start were for reasons of 'general deterioration', then it became 'shortness of breath', and now 'chest pain' or 'headache'. Or I get patients transferred over from Critical Care or the stroke ward. But in the end, patients are just patients and the dietetic treatments they receive are pretty similar, whichever ward they're in. A combination of artificial feeding, nutritional support and frustration.

Neurology and neurosurgery are slightly more gruesome than any of my previous wards. Head injuries and intracranial bleeds are not pretty, and often affect personality as well as physiology. There are loads of new and very obscure abbreviations both in neurology and cardiology, and sometimes even the nurses are a bit vague about what they stand for (I don't tend to bother the doctors with my questions). Strangely enough, I have found the doctors' handwriting is an order of magnitude worse in neuro notes. But the cardiac wards win the prize for the most badly kept folders, to the extent that sometimes it isn't possible to find what the doctors have written over the past days or weeks, or you have to look in three different places to get the full story.

Complaint

I have been involved in a complaint about treatment received by a patient a few months ago, and had to revisit the notes I took at the time and at the decisions I made and documented. It wasn't too bad, although there's always something to learn. In future, I intend to pay a bit more attention to making sure everything is done as it should be when a patient is discharged home.

Staffing

You may (or may not) remember that there are three of us 'junior' Dietitians, all on partly or wholly temporary contracts. We are occupying posts that belong to three other Dietitians who have been filling posts left unoccupied by three further Dietitians who are on maternity leave (it's actually not quite as simple as this). Until those latter three decide what they would like to do, and until a plan is agreed by The Authorities, none of us knows what the future holds. There's a further 'senior' Dietitian who is on a temporary contract, filling in for yet another Dietitian on maternity leave, who is my team leader. This temporary stand-in has now found another job and will be moving on in just three weeks' time, leaving a very short term vacancy at quite a senior level.

It is all very complicated, and I may not have explained it very well in the above paragraph, but the immediate upshot is that we will be short of bodies at the coalface very soon, and the Dietetic Manager is taking steps to try and make sure that we will all be able to cope. For a dreadful minute or two, I thought this meant that I would lose my clinic, but a swift reorganisation has restored it to me, albeit on a different day, and I am very relieved. There will still be extra work to do, but I think we will cope.

Job application

I have applied for yet another job, and heard today that I have been offered an interview. Just for a change it is not in the middle of a holiday, although it could have been - Mr A and I and all the family are going away for a week very soon. In the past, this might have disrupted the flow of this blog, but nowadays it will hardly be noticed. The interview is for a job that I would very much like to have, but it is quite a long way away and would involve a significant amount of commuting.

Other news

I have been to London to meet up with children I went to school with (who are now adults with children of their own) and our former clarinet teacher and her husband, who do not seem to have aged in the slightest. Then onwards to Lola II's and Mr M's house where we always intend to do things like go for a walk but end up just mucking around. I can't even remember what we did in the end, but I'm sure it was lovely. Oh yes, we went out for Japanese food, for the first time in ages.

What do points mean?

Yes, I have won another prize from a blog, through the medium of my favourite joke. To see it, you will have to visit this page and look in the comments. I received a bag of Jordans Superfruity Granola, and three Jordans Absolute Nut bars, which arrived last week. I have tried one of the bars (delicious! but 260 calories per bar), but we haven't opened the Granola yet. I'm sure it will be jolly tasty.

The frankfurter octopus

Not my original idea, but something I saw on the Interwebs long ago, and have been itching to try ever since. The frankfurter octopus turned out to be delicious, yet at the same time vaguely disturbing.

Ingredients: frankfurters, spaghetti. Optional: ketchup, mustard. The finished meal included a salad, although you won't see much of that in the subsequent pictures I took. 

What I remembered of the 'recipe' was very straightforward: stick raw spaghetti through frankfurters. What I didn't remember was how much spaghetti, and along which axes? So I constructed a selection of different mutant strains.

The main problem was that the more attractive species, with spaghetti radiating perpendicular to the frankfurter axis, was the more difficult to fit in the pan. Longitudinal was more practical, but appealed less to my aesthetic preference for outlandish sea-creatures.




Both varieties cooked to perfection, and, with a dash of ketchup and mustard, provided Mr A and me with a comforting autumn supper, and leftovers for work next day.

Nutrition Team

Brixham, August 2012

One of the roles of the senior Dietitian is to take part in the Nutrition Team ward rounds. The Nutrition Team is a multi-disciplinary group that takes referrals for more complex nutritional issues, such as parenteral nutrition (PN) - feeding a person intravenously. They are also called in when there are difficult judgements to be made about other types of feeding - an example might be when someone with a number of serious conditions is no longer able to manage normal or textured food. It might be neurological, such as Motor Neurone Disease, or due to a stroke or dementia, or an obstruction or non-functioning bowel, or some other restriction to intake. It might be a patient who is simply not eating, because of nausea, vomiting, diarrhoea or other effects of a disease, or possibly because of a psychological disturbance - we find these cases very difficult to deal with, because the patient can eat, but doesn't. Is it appropriate to intervene? If so, how invasive should we be? If not, how do we justify our inaction?

The core members of the Nutrition Team are a Gastroenterology Consultant, a Nutrition Nurse, a Dietitian and a Pharmacist. The round that I joined also had a number of others in attendance: a Specialist Registrar, a Senior House Officer, two medical students, and me. It was a pity that I'd chosen that particular day to join the round, because the group was really too big and unwieldy, and the Consultant had to attend a meeting so was missing for most of the round, which led to a bit of a leadership vacuum.

All of the cases on this round were for PN. A couple of the patients were in Intensive Care, and I'd never been there before in this hospital. It seemed less spacious than the equivalent wards I'd seen on placements (although this might have been because of the size of the group), but otherwise equally well equipped with a myriad of machines that go 'ping' keeping people alive in various states of incapacity. The rest of the patients we saw were on other wards where PN can be supported, which are more familiar environments, but still difficult to manage with a group of nine people.

In terms of what was dealt with, these were far more complex cases than I've been expected to deal with so far as a lowly graduate with little experience. The patients had mostly had gastrointestinal (GI) surgery or an inflammatory bowel disorder like Crohn's Disease or other complication of the GI tract. One or two were in hospital because their intravenous lines had become infected, which raises the risk of serious illness given that pathogens might be introduced directly into the bloodstream. The parenteral feed has to be treated much more carefully than standard intravenous fluids (which is why not every ward can support PN) and nursing staff must be properly trained to administer it aseptically. The Pharmacist was part of the group because of the need to tailor the composition of the feed in terms of nutrients and electrolytes, which is their job. We can either buy standard bags of parenteral feed, or have them made up specially in the Pharmacy department.

So I mostly hung around at the back of the group, watching and listening and trying to understand the reasoning behind some of the discussion about rates and timing and composition of feed and bowels and surgical procedures and how blood test results related to everything, drawing on my knowledge of the forms and functions of the different parts of the GI tract. The senior Dietitian and the Nutrition Nurse tried to help me out by explaining some of what was going on, but that just added to the noise and chaos of the huge group milling about the nursing station on the ward.

The main thing I learned was: given that the small intestine is mostly used for nutrient absorption and the colon for water absorption, there is a difference in nutritional impact if different sections of the gut are removed or non-functioning. If an opening (ileostomy) is made at the far end of the small bowel, nutrient absorption may be unaffected but the patient may lose a lot of fluid and electrolytes. Higher up, and PN may be needed because there isn't enough absorptive capacity to meet the nutritional requirement. Nutritional supplements may actually make things worse by drawing water into the bowel to counteract their high concentration (osmolarity).

I found the experience a little too chaotic for comfort, but I should be able to observe again another time when the group is smaller.

What I've been reading

The Sixth Lamentation
by William Brodrick

narrated by Gordon Griffin

"What should you do if the world has turned against you? When Father Anselm is asked this question by an old man at Larkwood Priory, his response is to have greater resonance than he could ever have imagined. For that evening the old man returns, demanding the protection of the church. His name is Eduard Schwermann and he is wanted by the police as a suspected war criminal."

It's either the book's fault or my fault, and I don't know which. The problem was either that the story's not very engaging and a bit too complicated, or else it's that I left a huge gap between reading the first two thirds and the last third. So I had probably forgotten some of the key points from earlier on, and being an audio book I couldn't skim through the first half to catch up (see below). And some of it was hard to believe factually, and most of the relationships weren't very realistic, and altogether I wish I hadn't bothered. But I rarely leave a book unfinished.

Feet of Clay
by Terry Pratchett

"There's a werewolf with pre-lunar tension in Ankh-Morpork, and a dwarf with attitude and a Golem who's begun to think for itself. But for Commander Vimes, Head of Ankh-Morpork City Watch, that's only the start. He's not only got to find out whodunit, but howdunit too. He's not even sure what they dun."

Slightly different from the other Discworld books, this is a proper mystery, but he makes the usual mistake (as far as I'm concerned) of introducing loads of characters in the first few chapters to the extent that I can't follow the story at all. Combined with a bit of a break in my reading, it meant that I had to go back and read the start again. It was worth it though, unlike the book above.

Blackout
by Connie Willis

"The narrative opens in Oxford, England in 2060, where a trio of time traveling scholars prepares to depart for various corners of the Second World War. Their mission: to observe, from a safe vantage point, the day-to-day nature of life during this critical historical moment. As the action ranges from the evacuation of Dunkirk to the manor houses of rural England to the quotidian horrors of London during the Blitz, the objective nature of their roles gradually changes."

This is actually the first half of a two-part story, the second half being in the next book 'All Clear'. Connie Willis is the author of one of my favourite books, and has constructed a theory of time travel along with a distinctive style of writing that depends quite heavily on cliffhangers. This can be annoying, but the writing is good enough to mitigate this fault, and she actually conveys aspects of the Blitz in London that I hadn't really thought about before, like the very real fear that German forces would invade, and the knock at the door of the air-raid shelter would reveal German troops.

All Clear
by Connie Willis

"The impossibility of altering past events has always been a core belief of time-travel theory - but it may be tragically wrong. When discrepancies in the historical record begin cropping up, it suggests that one or all of the future visitors have somehow changed the past - and, ultimately, the outcome of the war."

More cliffhangers, more flabby narrative, and ultimately an ending that probably ties the loose ends up nicely. I say 'probably' because the two books contain stories set within at least four different time periods and with five main characters, most of whom use different names in each time period. I wasn't paying as much attention as perhaps I should have, so now I'm not even sure that I understood who was doing what at which time, and I ought to go back and read the two books again. But they are much too long for that. She could have done with better editing, and condensed the whole thing into half the size, i.e. one book, in which case there would have been less period detail, but I would have been prepared to read it again. Maybe some other time.

In the respiration chamber

Intro by Nurse A

09.30

A few weeks ago, you may remember that I was measured in the BodPod in advance of taking part in some medical research. Today is the first day I spend in the 'respiration' chamber, a small room containing a flip-up bed, table complete with computer and phone (internal calls only), sink and toilet. I have intercom access to the outside world (well, to Nurse A) and to the next door cell, which happens to be occupied by a Dietitian colleague from the obesity service, who has also contributed to the research by formulating the menu. Before we were imprisoned, she said that she didn't even like the food on the menu that she herself had created.

The research is concerned with inflammation, measured through inflammatory markers in the blood - at least, I am assuming that is why I will have blood taken five or six times a day, via a cannula. I have never had a cannula before, and I don't much like it. But that is not the worst thing so far.

The worst thing so far is that I am very, very hungry. Somewhat ironically, today is the Day of Atonement, the Jewish holiday where one is supposed to fast until dusk, so it is perhaps fitting that I am hungry. My hunger is also a result of yesterday, which was a difficult day, and resulted in a lower dietary intake than usual, but perhaps I'll write about that later on.

Between 8 o'clock and now, I have had the cannula put in and a (large) syringe-full of blood taken, I have been sealed into the chamber and given a small snack of bread and salami, together with a thermos of hot water which I have used to make an Echinacea and Raspberry infusion (no caffeine today). I have caught up with some personal email and blog-reading (Ben Goldacre's new book is published today) and felt slightly guilty at not doing any work.

10.30

I have now done some work, so that's good. There's nobody policing me so I could easily spend the day watching iPlayer, but I've been given 'Study Leave' to help with this trial, which means I haven't had to take any Annual Leave or unpaid time, so I've brought some stuff to do.

So far I have reviewed the cards from yesterday's clinic, which has earned me the first Band 5 Dietetic Medal ever awarded - seven new patients, no breaks, no DNAs. Everyone turned up, some on time, some early, some late. It was terrible. One patient phoned to say that the air ambulance had come in so all the access roads were at a standstill and someone had driven into the side of his car. And he still came to his appointment. I mildly asked one patient if he'd had trouble parking, and let's just say he wasn't happy. By the last patient, who 'only' had to wait an extra half an hour for me, I was in a pretty poor state, and that patient brought a host of complex issues which I was in no condition to address effectively. And to cap it all, a patient needed ambulance transport home, which causes immense administrative problems.

Unlike most weeks, when I could easily have stayed to make sure the ambulance thing happened as it should, yesterday I absolutely had to go because I was giving a presentation in Nottingham in the afternoon, and had arranged to pick up an ex-colleague to do it with me. So the Dietetic Manager had to come and help me out, and in the process saw the state of my cards after that clinic, as I attempted to tidy up and complete all the admin before running away. I reached the room in Nottingham where I was giving the presentation at the exact time that I was due to start. So not exactly late, but it all added to my stress levels, and I reached home again at 6.30 p.m. having had nothing to eat and virtually nothing to drink since breakfast.

The outside window

So that's why I've been so hungry today, and why I have to finish up properly and write all the clinic letters before all the patients get muddled in my head. And I've just negotiated my first urine collection, closing the blinds to the main room and next door cell, successfully catching and decanting it all into the right containers, not even kicking it accidentally all over the floor, then realising I hadn't closed the blind at the outside window...

11.30

The first blood collection since I've been in my cell. I wondered how it would be done, given that I'm inside and they're outside, but the technique is surprisingly low tech. There's a plastic bag attached around one of the air lock ports, with a hole cut in the bottom. I put my arm in through the bottom of the bag and hold the plastic tight around my upper arm forming a seal. They open the air lock and fiddle with the cannula outside, then when they're done I pull my arm back in and they shut the air lock again. I thought I was going to have to do it all myself.

I've also had to fill in a couple of questionnaires about sleep and snoring, because I think there's something about sleep apnoea in the research as well. And every two hours I have to rate how hungry/satisfied/full I am, and how much I think I could eat. I am, obviously, still very hungry, and the next meal isn't until 1 p.m. It's due to be a big one, though.

Still doing research and writing letters associated with yesterday's clinic. I shouldn't have felt guilty about not doing work in here - I think this job on its own will take most of the day, and would have been really hard to fit in around the ward work I would normally have to do. Luckily, my colleagues report that yesterday was quiet on the wards, with very few referrals - let's hope today's the same.

12.30

Still no lunch. I am effing starving. One slice of bread and a bit of salami since 8 p.m. last night. I am drinking Echinacea and Raspberry infusion in the hope it will quiet the rumbling a bit, even though I will eventually have to deal with the consequences. I will definitely close the blinds properly next time, though.

Another setback - cannula not working for pre-lunch blood test, meaning another needle stick in the other arm. The researcher Dr P comments that this often happens before lunch, and he hadn't previously realised the effect of food on ease of blood-letting. So the cannula's still in, and we hope it will work at the 3 o'clock bleed.

13.30

I've had a large lunch, and I'm definitely not hungry any more, but feeling almost light-headed with the amount of fat consumed. We are being fed deliberately high fat meals - hence the salami first thing, and now lasagne and a chocolate eclair (mmm, my favourite). I ate my meal while watching the first episode of a new series of Never Mind the Buzzcocks, on iPlayer.

Now it's back to the clinic cards. It's taking ages, but that's probably got something to do with me breaking off every now and then in order to blog. And Facebook...

14.30

Nothing new to report. Still digesting enormous lunch, feeling sleepy now. No more blood taken yet, but clinic cards finished at last.

15.30

That was close - Dr P nearly couldn't get blood out of me via the cannula, and threatened to remove it and put another one in the other arm. But he managed it, the cannula's still there, and we'll see what happens at 5 p.m.

My afternoon snack arrived - a sliver of a pork pie, hardly worth the effort. I was still full from lunch, anyway. I wonder how they arrived at the quantities and the timing of the food? I saw my allocation written out before I came in, and it showed that I require only 1516 calories for a whole 24 hours of no activity. Obviously if I'm not imprisoned in a hermetically sealed room I can have more, but it's not very much, is it? It's actually exactly equal to one McDonalds Double Sausage and Egg McMuffin with large fries and a large milkshake, according to the McDonalds Nutrition Calculator.

I seem to have done very little in the way of work in the last hour. Where does the time go?

16.30

A thrilling new herbal infusion for the second half of the day - Blueberry and Apple. I'm starting to think I might be able to eat again, which is lucky because my second main meal is coming up at 5 p.m.

Having no mobile signal, and an internal telephone only, I have been maintaining contact with the outside world through Facebook and email - both highly asynchronous and unsatisfying. Then I noticed a Skype icon on the computer desktop - and bingo, I had a nice chat with mum, who was the only person online. With any luck there will be more options tonight.

17.30

The second main meal was a bit pathetic - chicken korma and rice, but a tiny portion compared with the huge 1 o'clock lasagne. These meals seem very unbalanced in terms of size and timing. I'd prefer something more substantial earlier so I didn't spend the whole morning ravenous. And this is the '5 meal-a-day' leg of the study; my second incarceration involves just two meals containing the same overall quantity as in my five meals today, with the first at 1 p.m. I shall definitely make an effort to eat more the night before than I did this time. During this supper I watched the first episode of the new series of The Food Hospital, which took a lot more time than eating the meal did.

The cannula just about performed its job at 5 o'clock, which I am relieved about. We think that on my next imprisonment we'll try the other arm.

18.30

It's actually 7 p.m. and I have no idea what I did in the last hour. Took my cardigan off. Had some more Blueberry and Apple infusion. Remembered to close ALL the blinds. Read a bit about diabetes from some of the uni notes I brought with me. Had a further half a chocolate eclair, the last food I'll see until tomorrow morning.

The cannula finally packed up, so I had to have a needle stuck in the other arm, but that vein wasn't playing along either so Dr P had to go for a third try. It seems my veins are single use only, but at least there's only one more blood test needed. I told Dr P I'd be a terrible heroin addict; he said that he reckons I would manage somehow.

19.30

Stopped reading about diabetes. Sat and stared at the wall, thinking about this and that. Checked Facebook. Checked email. Checked work email. Checked other email. Tried to Skype Mr A twice with no response but he's probably in the kitchen, so I've emailed him asking him to Skype me. More Blueberry and Apple infusion. Lola II, where are you? I'm a little bit bored now, but I've lined up the first episode of the new series of The Thick Of It on iPlayer. I've already watched more TV today than in the last six months.

Mr A Skyped me, but the initial conversation turned out to be very one-sided as he doesn't have a camera and his microphone wasn't working. I spent some time making rude signs at him, just because I could. Change of hard disk later (only a few minutes) and he's back, telling me about his day down in London on his first paying training job for ages. It went well. He torments me by suggesting he'll soon be sitting on the sofa and can help himself to drink and snacks.

21.30

Last lot of blood taken, best ever, using an old-fashioned syringe, took 10 short seconds rather than minutes of jiggling sharp implements in nervy flesh. Watched the episode of The Thick of It, and now I'm starting to feel hungry again. I definitely wouldn't run this meal schedule by choice.

Dr P has shown me the 'sleep machine', which sounds very sinister, but looks as though it will just be measuring my breathing rate and oxygen saturation. That's the end of his working day - I'm left to my own devices, with an emergency call bell to the nearest ward and the on-site Security telephone number. If there's a fire alarm or other emergency, I can just open the door and walk out, although Nurse A said she'd probably want to go into one of the chambers if there really was a fire. It's pretty bombproof in here.

08.00

Trying to sleep with a large box strapped to my chest (the sleep machine controller is about as big and heavy as a packet of four bars of soap), a strap around my waist, a finger-pinching monitor and nasal specs up my nose and around the back of my ears wasn't easy. Add to that the facts that it wasn't quite warm enough and I wasn't particularly tired, having done nothing but eat, read and type all day. I did sleep, and everything stayed in place except the finger monitor lead fell off the controller, but next time I need more blankets.

This morning first thing I followed the supplied instructions to provide a resting BMR measurement - staying awake but unmoving for a measured hour. I listened to a podcast, so that was no hardship. Now I'm waiting for the staff to get back to work and release me from my cell. I hope there's no more needling to do, but they have offered me a shower and I really need breakfast soon. Then it's back to the office and work - today I have a department meeting at lunchtime about student supervision and training, and clinical supervision in the afternoon when I present the difficult case from clinic in case anyone has any good ideas on how to manage treatment.

09.30

They didn't let me out until after 9 o'clock, but there were no more needles, and I saw the trace on the computer of my 24 hours in terms of oxygen, carbon dioxide and movement within the room, which is captured by sensors. They should be able to tell me more about my metabolic rate by the next incarceration event, which is in two weeks' time. Back in the office, the wards have been making up for lost time, and I had rather too many referrals waiting. Luckily, some of them turned out to be duplicates, one had already left hospital and another couple were for renal or oncology colleagues.

So what have I learned from my day in the tank? I enjoy solitude, don't like waiting for my meals when I'm hungry, miss my decaff tea, have veins that are not suited to repeated withdrawal of blood, need only around 1500 calories on an inactive day, and have a reliable bladder capacity of almost exactly 500 ml.

Electronic referrals

Sissinghurst, June 2012

We have a new computerised referral system. The old referral system involved the telephone and pieces of paper with words written on them. Nurses on the wards would phone our office, and the admin team would write some scanty and usually misleading details about the referral, on paper forms kept in a file. When each of us had seen a referral intended for us, we would tick the form to show we were dealing with it, and go off and deal with it. This involved the admin team in answering the phone quite a lot, but on the plus side, they would do some basic triage and reject inappropriate referrals or bleep us if they thought we needed to know about a referral straight away.

The new referral system has been added to one of the many hospital systems that exist. The most surprising things about the introduction of this system were a) that we were told on the Friday that it would start on the following Tuesday, and b) we were given no information about how it would work or what we should do to pick up referrals or manage them once we had them. You can imagine that it has been a pretty steep learning curve, both for us and for the nurses on the wards. The main people to benefit have been the admin staff, who no longer have to write anything on the referral forms, but do still have to tell the nurses who continue to call the office that we don't accept telephone referrals any longer.

It has been an interesting experience, working with a new computer system that has not been designed or adapted for our use. I am still ignorant of the purpose of the change - why ditch a paper system that worked perfectly well for a computerised system that seems to work no better? It is possible that some numbers can be extracted more easily from the computer than from reams of paper forms, but which numbers are they, and what do they mean? If numbers were at the bottom of the change, then surely we would be given some instruction on how the system should be used, so that the numbers extracted would mean what they were intended to mean.

As an example, the nurses on a ward complete one section of the online referral form, and we then open the entry and can see what they have written. The referral has three options for status: when it is created it is 'Open', then it can be 'Under Review', where it sits on a viewable list, or 'Closed' when it still exists and can be viewed and edited, but is no longer on the special list, which only shows referrals that are Open or Under Review.

So we can assume that 'Open' means the referral is a new one. The next thing that used to happen was that we would tick the referral form and do a bit of background research before seeing the patient. We might see the patient several times, before they either died, left the hospital, or didn't need our input any more. At which point should we change the status to Under Review, or Closed?

The system has been in use for nearly two weeks, and the consensus about this has shifted several times. The latest informal discussion concluded that ticking the form in the book corresponds to changing the status to Under Review and typing our initials as the first entry. Actually seeing the patient prompts a change to a status of 'Closed', even though we may continue to see the patient many more times. And now, each time we see a patient, we are supposed to write something on the electronic record as well as writing on the record card.

I imagine that someone will gather the numbers about how many of these referrals are made, and perhaps the time between the various changes of status. That 'someone' will have little information about what these numbers or times mean, otherwise they might have specified what they wanted and told us how to operate the system in advance of going live.

The overall effect of this new system, after nearly two weeks of operation, is that the admin staff have considerably less to do now that phone referrals have almost stopped, but there has been an equivalent increase in workload for nurses and doctors who are now making the referrals online, and we Dietitians having to make additional notes where we didn't before. And our head of service is getting some data that she didn't have before.

There is a positive side to this, however. In time, we will be able to see whether a patient has had previous contact with a Dietitian on a ward, which is very useful information that we don't have at present. We might also be able to see details of what was done on that previous occasion without having to track down a physical card that might be archived in a warehouse somewhere. The electronic referrals also have scope for the nurses to provide a good deal more relevant detail about a patient than they used to on the phone.

The negative aspects, apart from those outlined above, also include the fact that access to computers on the wards is very limited - the doctors are usually using them to look up blood results, scans and x-rays and results of investigations. This has made it quite difficult for nurses to actually do the referrals online.

If you have read this far, you either know me personally and imagine that this blog entry will get more interesting by the end, or sufficiently obsessive not to be able to stop reading until you have finished. Or, in the case of Lola II, you will have skipped the majority of the boring bits and reached here to finish off, which is not a criticism of Lola II, but in this case a very sensible way to deal with a fairly tedious text. Well done for getting here! Next time, perhaps there will be something more interesting. Unfortunately, the most interesting bits are about patients, and what makes them interesting is precisely what makes them impossible to write about.