A tough week

Victoria Park, Leamington Spa, April 2013

My feet have hardly touched the ground for a week. Getting back from holiday led to a concentrated effort to get some of the more pressing jobs done around the house on Sunday, although there is plenty left to do. I was also anticipating a very full work schedule for this week, and copious amounts of preparation did seem to calm my frayed nerves, which enabled me to deal with everything.

Monday

I managed to navigate successfully to a Community Centre in the city to deliver the first session of my first Structured Education course. Structured Education describes evidence-based courses for groups of people with diabetes, delivering curriculum-led content designed to empower people to manage their diabetes more effectively. It is an intervention that, according to NICE, should be offered to anyone with diabetes, on the basis that the evidence suggests they those completing the course will be healthier, will need less time and resources, and therefore cost the NHS less money.

There are a number of different, validated Structured Education courses, and I guarantee I will be writing more about them in future. They are invariably known by an acronym or abbreviation: DAFNE, JUGGLE, BERT1E, EDWARD, T2ONIC, DESMOND and X-PERT - and there are more. Some are licensed nationally (and internationally), some have been developed by one diabetes centre in order to avoid paying licensing fees. In order to qualify for delivery within NICE guidelines, they must collect and collate evidence to demonstrate that they do in fact deliver positive results in terms of better diabetes management.

We deliver the course in pairs - one Diabetes Specialist Dietitian and one Diabetes Specialist Nurse. I was also being observed by my team leader to make sure I followed the teaching plan as documented (some of the other courses are very much more rigorous in their educator qualifications and peer review). Nine participants plus three carers were expected, and I was daunted by the prospect of such a large group, but as for all events of this sort, not everyone turned up. It went well, and I would almost go as far as to say that I enjoyed it.

Tuesday

On a different university campus I attended a preliminary meeting that introduced several Dietitians and Fitness Instructors to a European research project. It is a multi-centre, multi-national, 3-year project with the primary objective of discovering how two different dietary interventions affect the progression of people in a pre-diabetic state (with Impaired Fasting Glucose and Impaired Glucose Tolerance) to Type 2 diabetes. Secondary end points, no less important, incorporate two different exercise programmes alongside the dietary interventions, and also include assessing weight loss, CHD risk factors, quality of life and more.

The dietary interventions involve two diets that have previously been studied in other European projects (Diabetes Prevention Study and DioGenes): high protein and low glycaemic index (GI) compared with moderate protein and moderate GI. The hypotheses to be proved or disproved are a) that a high protein, high GI diet will be superior in preventing Type 2 diabetes compared with moderate protein, moderate GI diet, and b) that high intensity physical activity will be better than moderate intensity. I have provisionally put myself forward to conduct the dietetic aspect of the group sessions required within the project, but there are many barriers to my involvement, not least being that I am working full time at the moment, and I may be moving away from the region before the three years of the project are up.

Wednesday

The regular ante-natal clinic. I didn't have a great deal to do this time, but I was pleased that my thoughts about the treatment for one person I saw turned out to be supported by the more experienced members of the MDT. If blood glucose readings show high fasting levels first thing in the morning, this suggests adjustment to medication - if your blood glucose is on target when you go to bed but high in the morning, there isn't a lot of scope for fixing things with dietary intake.

I also went to see the convener of the Masters module. The date is approaching when the case study has to be handed in and I'm rather suffering from the pressure of it. It doesn't help that I can't do a great deal on my work PC because it uses such old technology and has various restrictions that prevent effective academic work, and I haven't had any Internet access at home all week because of some fault that can't be rectified easily because the landlord rather than the tenants has the contract with the ISP. I did get some very useful advice on where to focus my efforts with the case study, and with only two weeks to go before the deadline the pain will soon be over.

I also took a trip to the Islet Research Laboratory in Worcester in the evening, but I'm saving that report for a separate post.

Thursday

I attended a 'cross-site' dietetic meeting where Dietitians from the four corners of the Trust gathered to discuss various matters of import, and some other stuff. While we all sit under the umbrella of Dietetics, different disciplines are scattered in many places: Dietitians dealing with inpatients, home enteral feeding, paediatrics, hospital catering and diabetes all reside in different areas as well as being separated over the two hospital sites.

Some of the meeting was useful and interesting; some was not. The most interesting part was a discussion about Prescribing. At present, Dietitians are not legally able to prescribe Prescription Only Medicines (POMs), although we can prescribe nutritional supplements and tube feeding products which come under the heading of 'Borderline Substances.' Following a long drawn out process, Physiotherapists and Podiatrists have achieved a change in the law to allow them to prescribe (after a suitable Masters-level qualification has been awarded), and the BDA is following in their footsteps to try to bring about the same change for Dietitians.

If/when this comes about, it will make a great deal of difference in many dietetic settings. Most pressing is parenteral (intravenous) nutrition, where Dietitians make all the decisions about what should go into the parenteral feed and at what rate and for how long it should be administered, but have to find a doctor or a pharmacist to sign and take responsibility for the prescription, despite knowing nothing about its import. There are many other inpatient situations where it would make a big difference for the timeliness and efficiency of treatment if the Dietitian were able to prescribe, but in my line of work it would mean that a Dietitian could initiate and modify diabetes treatment. This would include tablets, injectable medications and insulin.

At present, it would be illegal for me to make or even to recommend any changes to the administration of a patient's insulin. We get round this by making sure that all I do is discuss what might be done and suggest that the patient decides whether to make a change or not. For example, repeated low blood glucose levels in the early hours of the morning in the absence of other factors might suggest that the basal rate of insulin overnight is too high. I could ask the patient what they thought they might do about that. Decrease the basal rate? That sounds like a good idea.

There are four defined levels of prescribing rights, starting at a Patient Specific Direction which allows a non-prescriber to supply and administer a specific dose of a named drug via a specified route for a named patient. Next up is the Patient Group Direction (PGD), which allows for a wider range of options to supply and administer specific drugs to classes of patients. The diabetes service in my Trust is working to draw up a PGD - it isn't entirely straightforward. What we hope to gain in future is firstly 'Supplementary Prescribing', which is fairly limited but allows prescribing of POMs according to a clinical management plan agreed by doctor, patient and prescriber. The end goal is to become 'Independent Prescribers', where no permission is needed from anyone.

Both supplementary and independent prescribing allow for complete access to the entire formulary of medicines available for prescription in the UK. It is not surprising, therefore, that there is significant work to be done to elicit approval of prescribing rights for Dietitians, including the amendment of an Act of Parliament. It is a worthy goal, but even if achieved it would only be available to a very few of the most senior Dietitians, not least because of the cost and difficulty of the Prescribing qualification, and the burden of such serious responsibility.

Friday

A much easier day ends a week in which my weekday house suffered the breakdown of the fridge freezer (it was replaced but all my frozen food was lost) and no Internet access. I have had to spend significant time after work and in the Medical Library during the week in order to research my case study and do all the other online tasks that are essential in this modern world. I am not optimistic that home Internet service will be resumed next week, but you never know.

Holiday in Yorkshire

Memorial garden, Hornsea, September 2013

Day 1

HOT:
Lovely long walk to local town along well-marked footpath.
Delicious smoked salmon and scrambled egg lunch in cafe that doubles as craft shop and haberdashery.
NOT:
Getting rained on quite a lot during long walk back.
Water not hot enough for restorative bath.

Day 2

HOT:
Firing up the wood burning stove for a toasty day indoors (and lashings of hot water).
Finally finished the sleeves on Lola II's dress, and tacked the hem ready for trying on.
NOT:
Hole in the toe one of my favourite pairs of socks.
Excruciatingly slow Wifi access at rented cottage.

Day 3

HOT:
Lovely long walk to (different) local town along beach.
Interesting local museum and even more interesting owner of local fish shop.
NOT:
Getting even more soaked than on Day 1 during long walk back.
Turns out what I thought was a footpath was, on closer examination very much later on, a contour line.

Day 4

HOT:
Indoor day and wood burning stove again.
Getting notified of invitation to interview for job.
NOT:
Worked on another job application (different job, also part time).
Nice but very ordinary local restaurant for dinner. Should have returned to local pub.

Day 5

HOT:
Another interesting local museum and 900-year-old church.
Mr A's fish and chips - perfect.
NOT:
Drizzle. Lots of it.
My fish and chips - greasy.

Day 6

HOT:
Lovely breakfast at local cafe due to running out of milk at home.
Another fine walk, in the sunshine for a change.
NOT:
Having to get the car fixed - very nasty noise from front wheel bearing.
Going home tomorrow.


The week brought some unfortunate car maintenance and quite a lot of rain, but at least we weren't camping this time. The rented cottage was extremely comfortable, and we both got some work done, given Mr A's looming exam and my job applications, but managed to eat and drink in handsome style as well as reading, listening to the radio and watching a number of DVDs. Overall, a successful holiday.

What I've been reading

Heavy Weather
by P. G. Wodehouse

narrated by Jeremy Sinden

"Distraught when an author withdraws his manuscript from publication, the publisher, Lord Tilbury, sets about retrieving his fortunes, never guessing that his final obstacle would be in the rotund form of a prize pig."

This is a sequel following on from a book I haven't read, which I feel made the experience less satisfying. Nevertheless it has all the typical Wodehouse tropes - confusion, obfuscation, mistaken identity, conclusions drawn from inadequate evidence as well as a story where the deserving and undeserving get their rightful outcomes, as usual. Not his best, but not his worst by any means, and the narration was top class.

Blood, Sweat and Tea
by Tom Reynolds

"Have you ever wondered about the people inside an ambulance, maybe fighting to save the patient's life? Or have you considered that the ambulance may be another 'matern-a-taxi' ordered by a woman who can't be bothered to book a real cab and who then complains she can't smoke on the way to hospital?"

I used to read the blog (Random Acts of Reality), which the author has now stopped updating. This book was offered as a free download with my/Mr A's new Nexus tablet, and is a very easy read, essentially still in blog format, with a 'chapter' per post. The life of a paramedic in the London Ambulance Service as it is described in this book is not one that I would like to live, but is gripping nevertheless.

Packing for Mars
by Mary Roach

"From the space shuttle training toilet to a crash test of NASA's new space capsule (cadaver filling in for astronaut), Mary Roach takes us on a surreally entertaining trip into the science of life in space and space on Earth."

This contains material on the more earthy questions that occur to one when thinking about the full range of bodily functions that need to be catered for in zero gravity. It also contains extracts from the transcripts of the astronauts that do not tend to be included in the serious business of space travel news. She throws in a few hilarious comments of her own, and it makes up an amusing and fascinating story.

Death in the Stocks
by Georgette Heyer

"An English bobbie returning from night patrol finds a corpse in evening dress locked in the stocks on the village green. He identifies the body immediately. Andrew Vereker was not a well-loved man, and narrowing down the suspects is not going to be an easy job. The Vereker family are corrupt and eccentric - and hardly cooperative."

A proper whodunnit of the old school, complete with characters that are three-dimensional and believable, and a plot whose solution is only revealed a couple of pages from the end. I even managed to suspect the right perpetrator, but even that wasn't the main delight in reading this book, it's just well written and a pleasure to devour.

Ramblings

Munich Stadtmuseum, March 2013

It's been a while, peeps. It feels like I'm always starting with the same line: "It's been busy... I haven't had time..." like Garrison Keillor does when he says "It's been a quiet week in Lake Wobegon, Minnesota, my home town" and you know you'll be listening to something ordinary for a few minutes, in the mellow marshmallow voice that could make a shopping list sound interesting.

Anyway, it's been busy, and I haven't had time. Work, more work, and my MSc module is taking up a lot of spare time. Badminton is available two evenings a week now, which is good for my health and should be good for my waistline. Cycling was going well (three days a week and getting up that hill regularly one time out of three) except this week the garage door has broken, so I can't get the bike out at all.

Yesterday I had a flat tyre, which loomed over me all day alongside dark hatred of car mechanics. But in the end there were silver linings to this black cloud: firstly RSB showed considerable enthusiasm in the idea of helping me change the wheel, which turned out to be because he hadn't ever done it before, leading to the second silver lining - he did all the work while I just stood and directed operations. And the third benefit - when I mentioned my predicament, one of the doctors recommended a garage where there were friendly and helpful people, who I hope will not do as much damage to the old and venerable car as the last garage did. (She's still not right even after all the messing around with the brakes.) I left the wheel there and arranged to pick it up today.

When I went back to the garage today, it was the work of a few moments to replace the repaired wheel. It occurred to me that one of the other tyres looked a bit soft, and behold! when they checked it, it was in much the same state as the one that had just been fixed. So the spare wheel is now on a different corner of the car, and I will return to the garage again tomorrow, and with luck that will be all the garage visits for a while. Except that the car's really not right yet, so maybe there will be more.

So that's where some of the time went. Of course much of my time is spent actually doing work, and I had a more than usually successful clinic recently. I managed to work out why one patient had recently started having daily hypos (she was on a reducing dose of steroids) and I was very pleased with that, because it's something I might once have missed. I have also taken over the ante-natal clinic from RSB, so now I see a few women with Type 1 and Type 2 Diabetes as well as all those with Gestational Diabetes.

Since attending the third and last training session on Care Planning I have been trying hard to follow through with my resolution to try not to give advice. It seemed to work very well indeed for a patient who wants to lose weight. In the 'not giving advice' endeavour I am inspired by Lola II who does a job in which it is absolutely forbidden to give advice no matter how much you want to, even if you know exactly what everyone should do. I think that would kill me.

Not all my consultations have gone so well. I had to deal with a couple who had been having an immense row immediately before I entered the room, and I'm not sure whether I handled it well or not. Sometimes I feel at the end of a consultation that I haven't contributed anything positive to a person's situation. And the DNAs keep (not) coming, and now that I am more established, I wonder if it was something I said.

I have nearly finished my induction - a recent mandatory training session on CPR was more enjoyable than I expected; I passed the online assessment for Consent procedures, and there's only Manual Handling left to do. I was asked to feed back my thoughts on induction, and I welcomed the opportunity to let off a bit of steam. When the induction process is completed just two weeks from the end of the original nine-month contract, it cannot be considered fit for purpose.

Outside work I am also struggling with time, as I am very behind with home admin because of being away all week. When I get back, Friday night is very much a rest night with Mr A, and then it's usually a trip to the famous veg shop on Saturday, sometimes a supermarket trip as well, house cleaning, laundry, and anything else that's going on. Two weeks ago there was the first Warwickshire Pride festival in the Pump Room Gardens; last weekend Lola II and Mr M visited so we could all go to the Leamington Food and Drink Festival. And I've submitted a job application.

Yes, after more than six months without any sort of vacancies for adult diabetes dietitians (there have been loads of paediatric diabetes vacancies due to a quirk of NHS funding), a job has been advertised, in the same Trust where I worked before but a different site. It is a permanent post - hooray - but only 20 hours a week. After a good deal of vacillation and discussion with Mr A and with previous, current and potential future employers, I decided to apply. And you know how much time that takes (perhaps you don't? It is A Lot Of Time). And there are two other part-time opportunities on the horizon, although they are both in the region where I work now, far from home.

There was also a night out with the Dietitians. Not a big one - we all meet after work, have a very early dinner and then it's all over by about 7pm, which suits me perfectly because I'm starting to feel the pressure of not enough silent time on my own. [Silent time on my own is all that keeps me sane.] I'm having some silent time on my own tonight, because today I have decided that it is more necessary than badminton. This is rare and unusual, but it is the right decision. I maintain my sanity, and you get a long and rambling blog post. We are all winners.

Cycling to work

On a sunny day in the middle of August, I thought I'd record my journey to work in a series of photographs. Here is my photo-story.

The trusty steed - actually, not that trusty, being a very standard sort of low cost road bike. It could do with a few more gears, only having six, of which I mostly use five.

All is quiet at this time of the morning (sometimes not so quiet at 3 a.m.) Gentle uphill slope to start the ride, no problem there.

From this angle, you can't really see the gradient, but I would like to point out that we are above the roof level of the houses at the bottom. This is the killer hill that I have to climb on the way back. It does not look as menacing in the picture as it does in real life.

A short section where I ride along the pavement alongside a busy dual carriageway without the benefit of a cycle lane. So far, I haven't met a pedestrian along this stretch.

The cycle path alongside a different dual carriageway, this one not so busy. Cyclists who can keep up with traffic tend to cycle on the road, because the pavement is badly distorted by tree roots, and pedestrians often stray into the path of cyclists due to the rather narrow lanes.

We enter the university campus, with that helpful cycle path bypassing the barrier and keeping us cyclists separated from the nasty cars.

At this point, I leave the roads and cycle paths, and head down to the lake for the prettiest part of the route.

No separation of bikes and people, but there aren't many pedestrians at this time of day. There are a few more on the return journey, but we tolerate one another pretty well.

Ooh, isn't it pretty? A little bridge over a narrow part of the lake can be glimpsed through the trees.

An alternative route would take me up past this university building, which involves a fairly long uphill and then downhill section. I prefer the slightly longer route by the lake, which takes less effort, although I'm told by Mr M (who went to university here) that in winter the lake route is closed at dusk, so I may have to do the hilly route instead.

Back on the road through the university campus, and coming up to the road works.

The narrowest section through the road works, where cyclists are asked to dismount, but we rarely do. I just change down to first gear and ride at walking pace behind pedestrians, especially those who are wearing earphones. It seems more polite than trying to attract their attention by shouting.

Destination in sight now, but the biggest and busiest dual carriageway so far is in the way. No matter, the cycle path continues on the pavement for a few meters...

...to the traffic-light controlled cycle crossing across the dual carriageway.

And onwards goes the cycle path - carrying on straight ahead would take me all the way to the city centre, alongside the canal if I want to. But I turn left at this point, into the hospital grounds.

Last stretch towards the main hospital building.

There are several of these bike cages in different locations around the hospital, accessed by swiping an authorised staff ID card both in and out, and containing rails that bikes can be locked to. They also provide a bike pump, and I think there are some basic tools in there too.

And... relax. The journey to work seems to be very slightly downhill all the way, which means I arrive without too much fuss, but the way back is therefore very slightly uphill for most of the time, with that vicious hill at the end. My legs do seem to be finding it easier each time, though.