I start to find out how much I don't know

Sissinghurst, June 2012

It is a nightmare. I Have No Time At All. This evening (the second one I have spent at home since last Thursday) I have managed to contact a friend whom we will be visiting next week, ordered some Euros for that visit, and 'helped' Mr A sort out parking at the airport by generally answering either "I don't know" or "I can't remember" whenever he asked me a question. The only answer I got right was "Terminal 5". I have about 20 emails that need attention, I need to help dad upgrade his computer, most of my savings accounts and utilities are now uneconomical and need switching, and I'm nearly a week behind with blog reading, let alone writing.

I am crazy tired, and it is my own fault. I continue to try and play badminton twice a week for two hours, and this eliminates two evenings from the week. I am challenged by simple tasks like arranging a service and MOT for the car, because I need to drive the car to work, so will have to arrange everything in a city I don't know at all, at a garage that allows me to drop the car off and pick it up without impinging on the working day. The job makes me late home quite a lot, although this ought to change in April when the schedule of clinics will change, and I will have my own clinics with my name on and everything.

Work is interesting and stressful and difficult but full of promise. I have been keeping a list of 'things to write about on the blog' that I thought I would get round to, but (see paragraphs above) I may as well summarise now because that's as much as I can manage.

Things I have learned about diabetes: all about different sorts of insulins, rules for days when you are sick if you use an insulin pump, how to manage exercise and alcohol if you take insulin, how to manage someone who has just been diagnosed with Gestational Diabetes and keeps bursting into tears, what carbohydrate counting really involves.

Things I have been taught that are not about diabetes: how to use at least four different computer systems, how to apply for study leave, where to find at least 100 policies and procedures, what the Very Low Calorie Diet is for, how to wash my hands and not contaminate food.

I would like to write much more about most of these things, except for handwashing and food safety.

One of the most annoying things at the moment is needing to remember at least five different combinations of user names and passwords. I am told that all of the passwords have to be changed regularly, and don't allow you to just change a number e.g. password01 to password02. This policy does not improve security; all it does is force you to write your user names and passwords down. As long as I can remember the password that gets me access to the document with my passwords in it, I should be OK.

All the most annoying things so far involve administrative systems. The induction process has been shocking. My scheduled day for induction is two months after starting my nine month contract, and seems to be a series of presentations about the Values and Vision of the Trust - the mandatory training I was expecting will be at a future date that I won't be told about until induction day. Just as I think I've done everything administrative that needs to be done, I find out about more - I have to email evidence of mandatory training to a random email address. Food Safety and CPR training is arranged by someone who works in Catering. I have to complete a document for my Personal Development Review that I didn't know about on a date I haven't been notified about. I have to book any annual leave at least six weeks in advance, using a form I haven't been given yet, without knowing how many days I'm entitled to. Today I found out that a filing cabinet drawer in the main office contains copies of referral letters for me - nobody had thought to mention it before. And don't get me started about Tracking... I may muster the strength to write about Tracking another time. And clinic procedures: what to do if a patient doesn't attend, or changes their appointment, or does attend, or I am asked to see them by someone else, or I want them to be seen by someone else.

There are some very good aspects of this job, though. Professional development seems to be built into the job, rather than an expensive luxury available only to the lucky few who have to pay for it themselves. This means that I am already booked onto a postgraduate module about diabetes taking place over four days at the university, and there seems to be little resistance to other opportunities that come my way. I have already learned a great deal about diabetes, and have reached the uncomfortable stage of being much more aware of how much I don't know, but I do occasionally have flashes of insight allowing me to feel good about some of the things I do know.

There is so much to write about work that it has almost squeezed out any mention of the fun that has been happening at weekends. Lola II and Mr M staged a film festival, and Lola II and I went to Liverpool for the weekend, and there was much hilarity at both these events. I would love to write blog posts full of amusing anecdotes and illustrated by YouTube clips and photos, but perhaps Lola II will volunteer to document these occasions on my behalf. She is pretty busy most of the time as well.

What I've been reading

Kiss the Dead
by Laurell K. Hamilton

"My name is Anita Blake and I am a vampire hunter and necromancer, as well as a US Marshal. So when a fifteen-year-old girl is abducted by vampires, it's up to me to find her. And when I do, I'm faced with something I've never seen before: a terrifyingly ordinary group of people - kids, grandparents, soccer moms - all recently turned and willing to die to avoid serving their vampire master."

Fourth of my 12 Books of Christmas. It's like nothing I've ever read before. My literary education has clearly been incomplete, because I had no idea there was a well-developed body of vampire literature for adults. I would never have chosen to buy or borrow this type of book, and probably wouldn't read another, given the choice. It started well, and I thought the story and the world that the author had constructed to hold it were interesting. But the story petered out in favour of the explicit sex scenes - I would have preferred the emphasis to be the other way round.

It happened in Venice
by Molly Hopkins

"He cheated, but only once! Evie Dexter has promised to forgive and forget her fiancé Rob - and her efforts to absolve his sins are paying off: in the past ten days she's only called him a two-timing love rat eleven times. Thank goodness her flourishing career as a tour guide takes her to fashionable Dublin, in-vogue Marrakech and cool Amsterdam. So when Evie's offered a luxury visit to the sensual city of Venice she jumps at the chance."

Number five out of 12 books of Christmas, and this one really strays into 'chick lit', which I loathe. It wasn't as bad as it could have been because she writes quite well, but characters were somewhat two-dimensional, the plot was predictable, and (this is becoming a theme) there was too much sex in it - the only book out of the five so far not to have too much sex in it was the self-published one, and that was awful in most other respects. Here, the men are all rich, powerful and attractive, the women are irresponsible, ditzy, self-obsessed and caring only for clothes, make-up, alcohol, spending money and sex. Is it my age? Or was I always like this?

Mort
by Terry Pratchett

narrated by Nigel Planer

"Although the scythe isn't pre-eminent among the weapons of war, anyone who has been on the wrong end of, say, a peasants' revolt will know that in skilled hands it is fearsome. For Mort however, it is about to become one of the tools of his trade. As Death's apprentice he'll have free board, use of the company horse, and being dead isn't compulsory."

Back to the lovely audio books now that I can spend about three hours a day on uninterrupted listening pleasure. And pleasure it is - I'm so glad that I finally managed to penetrate the world of Terry Pratchett, although it still reminds me of Douglas Adams, which is a compliment to both writers. Witty, clever, beautifully crafted, and this book didn't take much time to get started, which is an improvement on the other books of his that I've read. And a happy ending. I couldn't wish for more.

The Naked Sun
by Isaac Asimov

narrated by William Dufris

"The victim had been so reclusive that he appeared to his associates only through holographic projection. Yet someone had gotten close enough to bludgeon him to death while his robots looked on. Now Baley and Olivaw are faced with two clear impossibilities: either the Solarian was killed by one of his robots, unthinkable under the Laws of Robotics, or he was killed by the woman who loved him so much that she never came into his presence."

I know I read this as a child, because I read lots of science fiction back then and remembered the setup for the crime, although I didn't remember the solution. It was published in the 1950's, but you wouldn't know it. There was some interesting comment on the evolution of societies where physical presence is taboo, and another where exposure to the open air has become impossible for its citizens to endure. A good read.

The Devotion of Suspect X
by Keigo Higashino

"Yasuko lives a quiet life, working in a Tokyo bento shop, a good mother to her only child. But when her ex-husband appears at her door without warning one day, her comfortable world is shattered. When Detective Kusanagi of the Tokyo Police tries to piece together the events of that day, he finds himself confronted by the most puzzling, mysterious circumstances he has ever investigated."

Oh. My. Goodness.This is an amazing book, the best I have read for a very long time indeed. I gave it to Mr A for Christmas, along with another that I'm still waiting for him to finish and pass on. I chose it without knowing anything about it, just because I know he has enjoyed Japanese crime fiction in the past. Unusually, it starts with a full description of the crime, and then the police get involved trying to find the perpetrator, but you (the reader) already know who the perpetrator is. So that's not the mystery; in fact, I didn't really work out what the mystery was until very nearly the end of the book. It's really good.

More meetings and pump clinic

Bridge over the Danube, October 2012

It's becoming increasingly difficult to know what I have and haven't written about, especially now that there is so much going on. I have related different stories to family and friends starting and stopping at different points in the saga of getting to grips with a new job and all that entails, and I can't exactly remember what I've put in this blog. It's tedious to keep reading back over previous entries, and I don't have a great deal of time to do it, so I'm just hoping I'm not repeating myself too much.

Last week was a good week, I observed lots of things and didn't get too tired. This was probably because events prevented me from playing badminton: a social event organised for new starters, a Diabetes UK meeting, and a planned dinner with previous dietetic colleagues that ended up not happening. This week I have already played badminton three times, and now I am very tired.

The large and important departmental meeting about convergence of the hospital diabetes services from two sites to one was more interesting than I was expecting. There was general consensus about the principles of a re-modelled service, which was the point at which I made my getaway. Those who remained endured another two hours, and those I spoke to next day seem to agree that I departed at the perfect time, because no further progress whatever was made.

The local Diabetes UK meeting was its normal unfriendly event - would it kill any of them just to say hello? The subject was Driving and Diabetes, and the talk was given by someone from Diabetes UK. It was mostly about the change of law in 2011, the circumstances in which the DVLA can take away your driving licence, and what you can do to get it back. I left before the raffle.

My colleague RSB has been working hard to devise a timetable to allow us to cover all clinics in an equitable manner. I'm not entirely sure why this has been so difficult to do. At the moment, my only disappointment is that it looks as though I will be covering an ante-natal clinic on a Friday afternoon, which means seeing all those women who are newly diagnosed with gestational diabetes. Given the nature of the condition, it is possible that there will be any number of patients from 'none' to 'all' of the clinic list, and may make my Friday afternoons run rather late.

As well as this clinic, I will be doing general adult clinics. These will mostly contain patients with Type 1 diabetes, because the newly formed Clinical Commissioning Group (which replaces the Primary Care Trust) has demanded that Type 2 patients are discharged into the care of their GPs in the community. RSB will take care of the pump clinic and patients using continuous glucose monitoring, the main ante-natal clinic and the young persons' clinic. Given time and more experience and I may well need to cover these when he is away. But not yet.

I observed a pump clinic this week. Attendance is optional, but it is for patients who use an insulin pump instead of multiple injections to control their blood glucose, and runs for two hours once a month, covering a different topic each time. An insulin pump delivers insulin subcutaneously via a metal or plastic cannula that remains in place for 2-3 days at a time, and has a number of advantages: no need for separate injections, a little bit more discreet, and potentially greater accuracy in insulin dosage and delivery, ideally leading to better control and fewer instances of unwanted high or low blood glucose levels.

For example, secretion of insulin in someone without diabetes consists of a continuous background trickle that may vary according to levels of stress or hormones or time of day, plus increased bursts to match the surges of blood glucose following digestion of carbohydrate foods. For someone with insulin-dependent diabetes who doesn't have a pump, the background insulin is supplied by a once- or twice-daily injection of a medium- or long-acting basal insulin, and the post-prandial insulin is injected as a bolus of short- or rapid-acting insulin, ideally shortly before eating. The background dose can't be changed easily, as it is released slowly over many hours. Although the action profile of the basal insulin is relatively flat, there is a period of maximum effect, and if not matched precisely to carbohydrate intake this peak can be at an inconvenient time (e.g. during the night) and cause hypoglycaemia.

With a pump, both background (basal) and bolus insulin is rapid-acting insulin delivered from the same reservoir in the pump. The pump rep who also attended the clinic answered lots of my questions, and also described the research they have done to map the requirement for background insulin through the day, which can be set up on their pumps. This means that a circadian profile of a trickle of insulin varying hour by hour can be delivered to mimic the 'normal' insulin profile for any individual, to try and minimise nocturnal hypoglycaemia. A step forward indeed.

A few steps forward

Brixham, August 2012

Into week two I go, forging ahead with getting more of the policies under my belt (Arson Prevention Policy, anyone?) and still observing other people at work rather than doing any proper work myself. I spend a happy couple of hours walking around the hospital with floor plans, discovering a deserted Cyber Cafe, the ID office, the car parking and security office, and registering with the medical library. I can nearly find my way to most of the important places now.

My parking pass arrives, and mystifies me by being entirely paper with a small hologram, and no accompanying explanation. Given that the car parks are 'pay to exit' with barriers, I can't understand how it would work. I pay a visit to the car parking and security office, which I now know how to find, and they explain that some of the car parks would now accept my swipe cards, while others operated by numberplate recognition. Having made sure to clean my numberplate, I am recognised successfully this morning.

I have decided to call my Room-Share Buddy 'RSB', which can equally represent 'Really Supportive Bloke'. He is proving a delight to work with, and although I am not moving forward towards independent working as fast as I would like, he is reassuring about my progress. We have discussed which clinics I will cover, and agreed a start date of 11 March, when I will be on my own. It is unfortunate that this date is my first day back after a week's holiday that I have planned with Mr A, and is the start of two weeks when RSB won't be around. So I really will be on my own, except for the DSNs, who I'm sure will help if I need it.

On Friday, by coincidence, RSB was scheduled to deliver a talk to Dietitians from the main department, so I joined the merry throng. We were split into three groups and given tasks to complete: one group was looking at medications for Type 2 diabetes, I was in the group categorising different types of insulin, and the third group was sorting out various hypo treatments. We made a dog's dinner of the insulins, highlighting again that I still have much to learn. I have found a checklist designed to ensure that different types of patients are given all the information they need, but it will prove useful for me to indicate how much I don't know.

I attended another CPD session led by the specialist obesity Dietitian, all about obesity in pregnancy - how much weight a pregnant woman might gain, healthy eating advice in pregnancy and whether weight loss should be encouraged for obese women who get pregnant. It was very interesting although not very relevant, as I won't be covering the ante-natal diabetes clinic unless I am called upon due to unforeseen circumstances. More relevant was a session delivered by a rep from one of the companies that sell insulin - more on this in another post, I think, along with a report on the 'structured education' that I have been attending, aimed at people with Type 1 diabetes and delivered one day a week for four weeks.

I had a long discussion with a very congenial chap from IT, and we took about a quarter of an hour to find suitable times for training on three essential systems, after which I still had to move my Occupational Health appointment (again) and send apologies for a meeting that I can no longer attend. I'm sure that computer systems will feature again on these pages before long. I have many strong opinions already about the state of the IT to which I have so far been given access.

Part of the difficulty of scheduling the IT training is the number of meetings that have been deemed appropriate for me to attend. Being part of two separate teams (Diabetes and Dietetics) doubles the number of team meetings, and the Diabetes team seems to have a lot of other meetings, including education and updates from reps aimed mainly at the medical team, and sponsored by pharmaceutical companies. I've been to two of these, but they were rather dry and focused on the presentation of lots of clinical data to support the prescription of their products, and the speakers were soundly heckled by the doctors, seemingly as a form of sport. It does mean a free lunch one day a week (although of course there is no such thing as a free lunch).

We have a large and important Diabetes meeting tomorrow, which all ranks and grades and specialties are required to attend, and which will 'debate' the future convergence of the Diabetes service, potentially onto one site rather than over the current two sites where it is presently located. I am not looking forward to this meeting one bit - it will be highly political, I won't know any of the background and locations and services and personnel, and while I would prefer the future location to be Hospital A because that is easier for me to get to, I have no relevant arguments to support this in terms of quality of service outcomes. The meeting is also scheduled to end more than an hour after the end of my work day, so I will be trying quite hard to sit near the door and leave as inconspicuously as possible.

Specialist Diabetes Dietitian

Sissinghurst, June 2012

Are your fingernails bitten to the quick? Is your breath bated? At last, I have more than two minutes to sit down and waste time on this blog, rather than running about like a mad thing. I have to admit that I didn't help myself by agreeing (having my arm twisted) to play in a badminton match on Tuesday, so that I didn't have more than ten minutes at home and awake and not in the shower between Sunday night and Wednesday evening on my first week in a new job.

So the new job started bright and early on Monday morning, when I reported for duty at Hospital B. The new employer is an NHS Trust which was formed from the amalgamation of two Trusts several years ago, and contains two large hospitals which I shall call Hospital A and Hospital B. My main place of work is Hospital A, but my direct line manager and her manager are both based at Hospital B, which is why I started there.

The first few days and weeks of a new job are always difficult, confusing, alternately crazy busy and tediously dull. Because you don't know anyone, are perpetually lost both literally and figuratively, constantly depending on other people for instruction/direction/advice/signatures on forms, there is very little that can be done independently. What I can do independently is deathly, and consists of reading about a million policies. And when I say 'reading', I mean 'skimming in the most cursory way imaginable'.

So far, then, subjects of particular interest are, in no particular order: commuting, parking, hospital navigation, and administrative paperwork.

The drive to and from work is taking a very long time indeed. Hospital A is nearer than Hospital B, but parking is more challenging, so I have been advised to try the (free of charge) Park and Ride service, which adds about 20 minutes to the journey time (including the bus trip to the hospital). Sometimes I have to travel between hospitals, which takes about 45 minutes on the (free of charge) shuttle bus, but may mean finishing the day at the wrong hospital, in which case it takes up to an hour to get back to the Park and Ride car park, followed by that long commute home. So I have applied for an on-site parking permit, which is reasonably priced but doesn't actually guarantee a parking place.

Hospital B is where I had my interview, and is an old site comprising buildings from ancient times that might have been workhouses, through to modern convention centres, with every era in between represented, and plenty of traditional lino-floored corridors. For just a moment one day, I caught an evocative whiff of that 'old hospital' smell of disinfectant and floor polish, transporting me back to the time when dad once took sister D and me to spend the day in Westminster Hospital while he worked there. The site containing Hospital B is huge, and the Diabetes department is in a separate building at the opposite end of the site from the main Dietetics department where the rest of the Dietitians live. It is probably a ten minute walk between the two.

In contrast, Hospital A is a purpose-built concrete monstrosity. I had to go there a few times for courses as a student, and found it confusing then, but now that I am expected to work there I am finding it almost impossible to navigate. Coming from my previous situation in a modern hospital with a completely logical layout and consistent ward numbering, this is a rabbit warren that makes no sense at all and has me utterly lost as soon as I turn a corner. I have learned just two routes so far: from the front entrance and from the nearest bus stop to the department, and even these are fairly flaky. If I go anywhere else, I have to be accompanied, like an idiot child or a convicted felon.

I am based in the Diabetes department, which is a different area from where the other Dietitians live. I share a room with the Dietitian who got the full time permanent job that I applied for, which is only fair as he had already been working there on the temporary contract that I now have. Our room is only just big enough for two, has no windows, and opens onto one of the main corridors. All around are corridors containing doors to rooms housing Diabetes consultants, registrars, their secretaries, Diabetes Specialist Nurses (hereafter abbreviated to DSNs), and the office containing two admin staff, a load of files and the kitchen/eating area. I have been introduced to a LOT of people.

I'm starting to see the end of the administrative paperwork phase. Apart from the contract and the payroll information, which I am obviously very keen on, there have been forms for the parking permit, the ID badge which doubles as a swipe card for getting through security doors, annual leave authorisation, occupational health forms, local induction, Trust policies and procedures, and - my favourite - my competency has been assessed and verified by signature of my line manager in the use of weighing scales and stadiometers (height measuring devices). Trust induction has been delayed, however, because there is no space for me to attend in February and the dates haven't been fixed for March. Let's hope I'm not involved in a cardiac arrest or have to lift anything heavy in the meantime, because I'm sure I wouldn't know what to do.

So far, so good. People are friendly, I can even remember some of their names, the other three diabetes Dietitians are lovely, and my room-share buddy (I'll have to think of a way to refer to him) even baked some delicious cookies and brought them to a meeting. I haven't even mentioned the job itself, but I'm looking forward to getting on with it with great relish.