Unrelated items

Norfolk, July 2011

Have you noticed how long it is since there was a post on what I've been reading? This is because I don't seem to have time to do reading nowadays, or, more accurately, I use the time previously allocated to reading for less intellectually strenuous activity: watching DVDs or doing mindless puzzles. Working all day makes the active acquisition of knowledge in the evening much less attractive. Even novels don't make the cut at the moment. And if I were reading, there'd be even less time for blogging, and that's getting very little of my attention at the moment as well.

I still haven't worked on all the pictures I took while I was on holiday in May/June, to get them ready for display here. I've just had a quick look, and there are about twenty pictures from Sissinghurst that are fit for the purpose, some of them very lovely indeed, and a few from the weekend when we returned to the Falconry Centre. That was a lovely trip, because the weather was just about perfect for the falcons (not really breezy enough for the heavy birds like the eagles and vultures) and I very nearly saw a falcon stoop to the lure, i.e. plummet from a great height catching its prey on the way down. I missed the full flight because I lost the bird into the sun for a second, and couldn't spot it again until it opened its wings in the last stages of the stoop. But I'm planning another trip to the Centre in a couple of weeks, so I hope the weather remains fine.

I'm still Not Very Well. This is separate from the touch of sunburn that I acquired at the Falconry Centre, which is gently fading; it started last Saturday with a sore throat and progressed to congestion and an odd pain in my back when I breathe in too deeply. I think it is a chest infection, but am not sure. It is the first illness I've had (apart from broken leg) that has stopped me playing badminton. I've even taken time off work, which has helped with the reading and blogging (see above).

At work, I seem to have the same number of patients and referrals as ever, while my two colleagues report that their workload has dropped off significantly. Even their clinics are poorly attended, while for the first time ever in my clinic this week, everybody who was listed actually came. If it had been a full clinic, the medal would have been mine. As it was, there were still seven patients, while my colleagues have had two or three. What with feeling ill as well, I was feeling rather persecuted, but taking a day off has restored the balance somewhat. I will be sharing out my caseload a bit more equitably soon.

So now these unrelated items have been related, and I shall return to my sick bed, or perhaps the sofa.

Another week in hospital

Norfolk, October 2011

The wards allocated to me at the moment are tricky, and the patients are time-consuming. I don't know why they should be any more difficult, but somehow they are. The wards also seem less organised, and I trust the nurses less to do the things I need them to do, like ensuring that the supplements and feeds that I prescribe are available to give to the patients when they need them. The patients, as always, are rather poorly. There is, however, a much larger proportion that are able to speak, and a significant number that actually recover enough to come off tube feeds and supplements.

The clinics remain my favourite part of the week, and I can now add Russian and Polish to the list of languages spoken by patients that have needed interpreters in my clinic. None of us has yet earned the certificate and medal for a full clinic with no DNAs. In one clinic (not mine), there were just two patients, although at least they both turned up.

We have had some input from the Dietitians working in the morbid obesity service, describing what they do and the thresholds and criteria for referral and for surgery. The thresholds are pretty high to be eligible for surgery, and the waiting list is long. They expect to carry out between 100 and 150 bariatric operations during the year. We asked whether patients in their clinics are successful in losing weight, and the answer without hesitation was, depressingly, "no." I am not sure whether they meant patients who have surgery or those who don't.

There has also been an employee 'Wellbeing' event, where various stands were set up to publicise various health-related services to staff in the hospital. I volunteered to cover the dietetic stand for the Community Dietitian, for just a couple of hours while she was at a meeting. Among the stands describing counselling, orienteering, catering and much more, our little stand was in a cluster next to two gorgeous squaddies advertising British Military Fitness courses on one side (outdoor fitness training military-style) and Health At Every Size on the other side.

The HAES program originated in the US but has been taken up by a local Dietitian whose research contradicts established wisdom (aka evidence-based opinion) on weight reduction. She suggests that dieting has been proven not to work - the vast majority of those who lose weight gain it again shortly afterwards - and yo-yo dieting often leads to gradual increase in weight over time. So the HAES approach is to address the person, their self-worth, happiness and general health, and let the weight sort itself out once people start to appreciate the barriers to change that they face in their particular and individual circumstances.

I can certainly see some value in this approach, and can imagine pointing some people in their direction - people who are simply unable to lose weight by conventional means (eating differently) and are not likely to be helped by three-monthly appointments of 15 minutes with a well-meaning but ineffectual Dietitian. The other attraction to the HAES stand was their scales, which were covered in pink fluffy fabric and had descriptions rather than numbers for your weight: 'Hot', 'Ravishing', 'Beautiful'.

What else this week? Badminton, watching DVDs from the sofa, Lola II visiting last weekend and The Boy this weekend. I have had a cold developing since Saturday. We went to the Falconry Centre yesterday, the first genuinely warm and sunny day since May, and I am now rather pink, mostly on one side.

Diabetes

Garden wall, Royal Tunbridge Wells, May 2012

I've been trying to squeeze in some personal development time alongside the demands of the wards and my clinic, in the specific area of diabetes. So far there have been three opportunities. The first was observing part of a session of 'structured education' aimed at people with Type 1 diabetes, then I sat in on part of a specialist diabetes clinic with a Dietitian, and the last was part of our clinical supervision in the department.

The National Institute for Health and Clinical Excellence (NICE) publishes guidance describing good practice for various health conditions, including diabetes. One of the elements of good practice for diabetes is 'structured education', where people with either Type 1 or Type 2 can attend tailored programmes covering the important aspects of the medical condition, its treatment, and best management by healthcare staff and the patients themselves. The programme for Type 1 diabetes has been developed locally, comprising four full days delivered once a week over four weeks to a group of up to eight people. I attended the start of Day 2.

Since the first session on the previous week, participants were supposed to check their blood sugar at least four times a day (before breakfast, lunch, dinner and bed) and bring the readings along to the second session along with what was eaten that day and any activity within the day. Looking at highs and lows through daily readings over a week can allow better adjustment of insulin: basal (background) dosage of long-acting insulin, bolus 'ratios' of short-acting insulin to match carbohydrate intake, and adjustments for out-of-range high or low readings, activity, stress or illness.

I've seen this type of activity before, so I'm getting more familiar with the 'basal-bolus' regimen of insulin management. The learning points for me at this type of session were more about ways to work with the people involved. The reason they have been invited onto the course, and the reason that they agree to attend, is usually because of 'less than ideal' blood glucose management, so it is fascinating to see the issues they bring to the session. Most straightforward are the ones who just haven't been given the information before, so didn't know how insulin could be matched to carbohydrate intake and activity. They suck up the lessons on carb counting, and off they go. The interesting ones are those who have already been given the tools and knowledge, but aren't carrying it through to daily life. That's what guided most of my questions to the Dietitian later - how do you deal with knowing that your input may make no difference? How do you manage your own frustrations?

The same sort of questions arose in the clinic, where I sat in on three consultations. It is a sobering thought  that diabetes doesn't distinguish between people who are educated and numerate and those who live chaotic lives and can barely carry out the calculations required to keep them healthy. Timings of injections, blood sugar readings, calculating carbohydrate per portion multiplied by the ratio of insulin to carbohydrate or working out how much carbohydrate to eat based on a fixed insulin regime - these are not easy or straightforward decisions. Even knowing which foods have carbohydrate and why it matters is quite challenging for many. Add to the mix the range of lifestyles that exist in all the various strata of society, and the unpleasant and life-threatening consequences of getting it wrong - it seems to me that sometimes the Dietitian just has to work out what the most important single piece of information is, because not much more can be done in some cases.

In clinical supervision the basic grade Dietitians get together each month with a more senior Dietitian, and talk about a topic. We had a short Q&A with one of the diabetes Dietitians and a Clinical Nurse Specialist in Diabetes. This was much more relevant to everyday life on the wards, and related mostly to enteral feeding. If someone on insulin is being fed via a pump at 100 ml/h for 15 hours, when should they be given their insulin, and what type should it be? The answer is generally half of their dosage of short-medium acting insulin at the start and half in the middle of the feed, and the background dosage consistently at the same time each day (it is not critical when this time should be). The dose halfway through the feed may be at a time like 3 a.m. if the pump is running overnight, so it may be worth reconsidering the timing - and the hundreds of other considerations that might affect things - medication, hydration, how likely the nurses are to give the right amount of insulin at the right time, and so on.

People with diabetes in hospital wards have a lot to contend with, especially if they are not allowed to manage their own medications. Hospital food may not turn up when it should, it may not be what was expected, it might be very difficult to judge the carbohydrate content, their appetite may be variable, and blood sugar control is notoriously difficult when the body is stressed, even without additional factors like vomiting. If the nurses are administering insulin, then they should be very aware of whether food has been eaten or not, and what it consisted of, but it is hard to imagine that every nurse would take all these factors into account. There is a 'nurse-friendly' option of 'sliding scale' administration (or VRII, variable rate insulin infusion) whereby blood glucose is measured hourly and short-acting insulin is given based on the reading obtained. While this is likely to prevent severe blood glucose highs or lows, it isn't very patient-friendly, demanding many blood tests a day and preventing any prophylactic control of blood sugars. On VRII, even if you know you've eaten four scoops of mashed potatoes, you can't anticipate the increase in blood glucose, but have to wait until it happens and then treat it.

There has been a campaign on the wards to raise the profile of diabetes and its management in hospital, but whether the principles are always put into practice is doubtful, given the multitude of competing priorities that the nursing staff have to deal with. And the reality of where each patient was coming from. I was asked by one nurse to see a diabetic patient who was 'always eating the wrong things', resulting in higher than desirable blood sugar levels. When I reviewed the patient's notes, it turned out that he was over 80 and had had some previous bad experience with hypos. At that age, the short-term risk of dying from a hypo far outweighs the long term risk of organ damage from high blood sugars, so I told the nurse that I would behave in much the same way as the patient if I were in his shoes and left him alone.

A couple of giraffes

By way of an addendum to Lola II's post, here are a couple of giraffes for your edification:

Lola II (courtesy of Mr M and Excel)

Lola I (courtesy of FitDay.com)

Nearly 20% off? Bargain!

Hello, Lola II here.

Back in 2006 I had booked a New Year’s holiday to Lapland for a week. I would be doing snowshoe walks, husky sledging, cross-country skiing and more. When I told friends, they said “Oh, you’ve got to be really fit to do cross-country skiing". So to ensure that I got the most out of my holiday, I joined the gym at my place of work. The experience was not an awful lot of fun, although it did give me a chance to listen to the radio whilst pounding the cross-trainer, looking out of the 22nd floor window onto the London ants below.

I went on holiday, had a wonderful time, loved the cross-country skiing and also found I could fit into my clothes better, and I felt great. My exercise regime lasted until the work gym moved to a windowless concrete room in the basement that smelt of damp.

Five years later I visited my GP for a poorly wrist. When my appointment was approaching its end, what does the foolish Dr Lady do? She asks “is there anything else I can help with?”. Well, she was asking for trouble, wasn’t she?? In my view, you should never ask a question if you don’t want to hear the answer.

What was my answer? Well I remember that my rambling moan about my excessive weight was accompanied by a liberal sprinkling of crying, and generously handed to her with a hint of desperation. Dr Lady did exactly what I would do in the same situation; she ran out of the room.

She did come back, however, and when she did, I saw wings and a halo…. “Here are vouchers for your first twelve sessions at WeightWatchers”, she said. That day I emerged from my doctor’s surgery with a very handy wrist support and a booklet of hope.

Before...

My Body Mass Index (BMI) starting point was on the fine line between overweight and obese. Although I may have looked ‘cuddly’ on the outside, I think my internal organs were getting some heavy-duty hugging of their own from my excess, unnecessary and dangerous fat.

...and after

Eleven months later I’ve reached my goal of a healthy BMI [insert clapping and cheering here]! I've lost one fifth of my original weight (hence the blog title). That's almost a leg!

My experience of losing weight has almost been enjoyable. Sticking to the WeightWatchers' plan, and seeing it work, felt like a miracle most of the time. Lola I has certainly made it a lot nicer by being very enthusiastic at every turn, and seemingly delighted to discuss weight and all things associated with it at the drop of a hat (or pound).

I set myself some SMART goals at the start:

• What was I aiming for? - to fit into my clothes comfortably, for there to be less weight on my knees, for my ankles to stop aching, and to like the way I look.
• How would I know when I got there? – this goal went through a variety of ideas including being able to fit into Mr M’s clothes so that I would never have to shop for clothes again. I’m still not ruling that one out. I ended up deciding that I wanted to be able to fit into a dress I bought in Seattle eight years ago. It was a little tight when I bought it, and it would be great to finally wear the beauty.
• What would I do when I got there? – this one was tough. My reward was not supposed to be food-related. My fantasy goal was a cheeseburger and chips. My real goal was to go clothes shopping. And guess what? I did both! One ended up giving me indigestion and a very uncomfortable night. The other gave me two pairs of trousers, two tops and a skirt. I know which one I’ll be repeating.

With thanks and love:-

Here’s my moment on the podium where I can publicly thank those who have helped me reach my goal. I would like to extend my thanks to:

Lola I - Lola, you’re my inspiration. You worked hard to lose all that weight, to the point where Mr M and I didn’t immediately recognise you the other weekend, you looked so smart, slim and younger. You’ve been supportive the whole time, saying just the right thing when I lost pounds, gained a few and, best of all, you celebrated with me one week when I lost just 200g. It never came to it but I feel sure, had I contemplated losing a limb in order to reach my goal weight, you would have come up with the perfect reason not to.

Mum & Dad – Your enthusiasm has been lovely, telling me how proud you are of me.

Mr M - When people have commented on how well you’ve been supporting me through all this, you say that you contributed to my weight at the start of this experience. Though that has a hint of truth about it, I defy anyone to be more supportive than you. For eleven months you have calculated the points in the food you’ve cooked for me, you’ve asked me if I want to share things (apparently I don't have to eat the entire plate of food!). You maintained the perfect balance of keeping all the chocolate and snacks away from me, with not commenting when I go and retrieve items when it's an emergency. You’ve been so supportive and helped me to reach my goal, I’m telling EVERYBODY!

Where is she? Hiding behind the lamp post!

Grand Round

Sissinghurst, Kent, June 2012

The Grand Round is the name for a series of lectures on Tuesday lunchtimes, where doctors have the opportunity to present an aspect of their work to other doctors, who can ask questions and generally expand their medical knowledge. All are welcome, and I went along after my outpatient clinic, because the host was one of the respiratory doctors, and a major part of my work is now on the respiratory wards. SOB, sputum and productive coughing, you remember.

[Note: I was hoping to win the Outpatient Clinic Award with a full house of nine patients in my morning clinic. When the first two didn't turn up and I only saw one patient in the first hour and a half it was clear there would be no medal for me. Then three patients arrived at exactly the same time...]

There are two parts to the Grand Round - a main presentation, and then a case study, which can be on a completely different subject. The main presentation on this occasion was about tuberculosis, and particularly its rise among the hospital population.

TB seems to be a condition that bears comparison with HIV infection in the 1980's. Sufferers are stigmatised, and the diagnosis is whispered rather than spoken out loud. Masks are worn in side rooms where patients are isolated for TB or suspected TB on my wards. During the recruitment process, there was great emphasis on ensuring that my TB immunity was up to date, and I had to have an additional blood test despite the clear evidence of the BCG vaccination scar.

It turns out, according to the doctor giving the presentation, that risks of infection on casual contact with an infected person are minimal, and rise only with prolonged close contact, in a family or workplace situation, for example. Perhaps this will be addressed one day in the same way that the status of HIV patients changed when Princess Diana shook hands with one without wearing gloves. Air travel is safe.

But there are risks, and the main issue with TB is drug resistance. The bacterium seems to be tricky to eliminate, and standard treatment with multiple antibiotics is unpleasant and prolonged, leading to low compliance and the emergence of resistant strains. Multiple drug resistance (MDR) is growing, and new categories of resistance have been defined. EDR TB is extensively drug resistant, where second line antibiotics have to be added on top of the first line treatment, and TDR TB is totally drug resistant to all first and second line treatments. Cases of TDR TB have been recorded in all countries that monitor cases of TB.

The 'good' news is that standard treatments for TB can take place in the community, with hospital admission only needed for MDR TB or where circumstances suggest that the patient will not comply fully with the six months of treatment required. Masks are only indicated where MDR TB is diagnosed or suspected, which is why I've had to grapple with how to put the blessed thing on - I'm pretty sure I've been wearing it upside down.

The main challenges include patient compliance with lengthy treatment. A few patients need Directly Observed Therapy to ensure that they complete the full course and don't contribute to the drug resistance problem by stopping the medications and allowing the more resistant strains of bacteria to survive. Observing patients taking their drugs is obviously entirely possible, but keeping a patient occupying a hospital bed purely to ensure compliance is an expensive way to manage a disease. Another challenging issue is how to deal with family and workplace contacts who may have the latent or overt disease. Clearly close family living in the same house should be investigated, but what about co-workers? Or the extended family who may have visited or hosted the infected person? Or fellow commuters who travel on the same bus or train every day?

And lastly, what are we to do with Total Drug Resistant TB? Even the specialists don't know. That session ended on a downbeat, with the answer to the question "Can TB be eradicated from the globe?" being an emphatic "No." It is a growing menace in some parts of the world, particularly the former states of the USSR and the Indian subcontinent.

It was an interesting talk, and given that it was non-technical I was able to follow the arguments pretty well, although details of the antibiotics used in treatment passed over my head. The case study that followed was a different story. It was about a man in his early 30's admitted to hospital with shortness of breath and little previous medical history to raise any specific concerns. It felt a bit like a pub quiz for doctors - "Name That Medical Condition Based on These Observations," especially as the presenter went through it bit by bit, pausing to ask the audience what they would have done at various stages. I think dad would have enjoyed it.

My all-time favourite doctor had come into the lecture theatre half-way through the first presentation. He's still the only consultant who has asked my name and background, has held an ordinary conversation with me on the wards, and acknowledges my existence when occasionally meeting in the hospital corridors. For that, he has my eternal gratitude, and come to think of it, my respect. Anyway, he sat next to me, and was one of the few to actually respond from the audience with some ideas about what the diagnosis might be for the patient in the case study. We'd got as far as presentation at A&E and a preliminary X-ray with some clouding in the lungs when the audience was first asked for its opinion, and at this early stage my favourite doctor offered up 'pulmonary embolism' (i.e. a blood clot in the lung).

The case study progressed, and I sank further and further out of my depth, with abbreviations, ECG plots, blood gas saturation figures and respiratory rates (and that's just the things I know the names of). The ECG was particularly amusing, as I sat there looking at some squiggly lines, presuming that everyone else in the room knew what on earth was meant when the presenter described some of their features. I did cotton on that when oxygen saturation of the blood decreased despite the patient being given oxygen, things were not going well. The key diagnostic that was eventually carried out was a CTPA (pulmonary angiogram = imaging of the blood vessels in the lung), which (apparently) revealed a load of blood clots in interesting places. I looked at the images on the screen, and had to take their word for it. Pulmonary embolism it was, thrombolysis ('clot-busting') drugs were administered, and the patient lived to tell the tale.

"A lucky guess," murmured my favourite doctor as we stood up to leave. But I like to think he's pretty smart really.

Olympic torch relay

Can you see the Torch?

It's proving impossible to find enough time nowadays to blog as often as I'd like. Last weekend, instead of sitting inside mucking about on the computer like I usually do, we decided it was time to do something constructive around the house. Then there is the shopping and laundry and cooking and cleaning and washing up that I can't do during the week any more, and the Olympic torch went through Leamington town centre last Sunday. While I'm not particularly interested in the Olympic torch relay itself, I do like to see what's going on, so we walked into town. All the activities advertised in the Pump Room Gardens had packed up and gone except for a few lone stalls, but there were lots of people lining the torch route.

There it is!

What then happened went roughly like this:

• policemen
• motorbikes
• motorbikes
• big bus advertising something red that I couldn't quite see
• motorbikes
• a green bus advertising Lloyds TSB bank
• an open top bus with some dancers on top and someone saying something into a microphone that I couldn't hear
• a bus with blacked-out windows driven by a grumpy looking driver
• motorbikes
• a bus advertising Coca-Cola with some more dancers on top and another inaudible microphone
• motorbikes
• more motorbikes
• some healthy-looking runners in grey outfits
• some cyclists
• someone on pogo stick legs who could bounce really high (I want some of those)
• motorbikes
• a big truck that turned out to be holding the BBC Torchcam
• Olympic flame
• runners in grey outfits
• motorbikes
• cyclists in costumes getting caught up in the dispersing crowds.

The whole spectacle took about 15 minutes to go past, with the actual torch occupying about 15 seconds, of which I managed a brief glimpse. Verdict: underwhelming. Unless you are particularly keen on police motorcycles. Or jumping stilts (£160. I just looked them up).

News from the garden: Mr A replaced one of the posts holding up the veranda while I tried to combat the annual patio weeds and deal with all the other overgrown plants. Sad to say, our ceanothus is a shadow of its former self following the frost damage, and although it had some new leaves and a few flowers, it isn't looking too good at the moment. The wisteria, on the other hand, is making a bid to take over the whole end bed - next year the whole garden, then the world, I imagine. I attempted to teach it some manners last weekend, and we'll see who is the winner. This weekend it is just too wet for gardening, and I need to get some admin done.

Before and after

 Mr A has also demonstrated some unashamed size prejudice with his birdwatching activity. He so much prefers our sparrows, robins and blackbirds compared to the magpies and pigeons that he has cut down the struts holding up the roof of our bird table to prevent the larger birds getting at the food. We are now frequently entertained by the double-decker effect of a small bird scoffing away on the table while a larger bird struts up and down on the roof looking over the edge but not managing to get in. He can't stop them picking up the seed that spills onto the grass below, so they aren't totally excluded.

I will try not to leave such a long pause between posts in future, but I can't promise anything. This full time job situation is so inconvenient sometimes...