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.

A morning in clinic

Sissinghurst, June 2012

I have a patient booked at 9am. When I looked forward over the clinic list yesterday, he needs an interpreter. I am still new to these hospital systems, is one booked? I asked office admin to check. Office admin called back a bit later, asking "Which language?" The records say ‘patient attended with interpreter’ but don’t say what language. A bit of detective work and deduction and I come up with a theory, but this morning, office admin regret to tell me they couldn't arrange an interpreter. Plan B: do as much as possible with drawing and hand gestures and make a new appointment, with interpreter.

I am expecting a busy morning. The nurse in charge says hello, and tells me that one of her colleagues was exhibiting symptoms of diabetes, they persuaded her to check her blood glucose, it turned out to be higher than it should be. A diabetes consultant happened to be in the clinic at the time, he agreed to see her, and now he's writing to her GP. Her blood glucose this morning was too high again, so it's looking likely that she has diabetes. I offered to talk to her after clinic about her diet.

RSB drops in to say hello. He’s officially off work on holiday today, but has some work to do towards a diploma and is more likely to get it done if he’s sitting in an office rather than at home. He admires my new purchase – a door wedge, Robert Dyas, £1.69 (I won’t bore you with the annoyance of small crowded rooms with spring-loaded doors propped open with bins and chairs). I resolve to treat him to a doorstop of his own. He offers to help with a difficult patient later on, and for the interpreter patient he suggests Language Line, which is a service where the interpreter is on the phone to both the therapist and the patient.

The nurse in charge says the receptionists have all the Language Line instructions and equipment. The receptionists fish it out of a drawer and say it’s fairly straightforward to set up, they will come and help when the patient arrives. They also mention that the difficult patient has rearranged his appointment – this is good, the slot with the interpreter was only 30 minutes which would be tough to manage, and now there will be less pressure. I reminisce about clinics at my previous job, where 30 mins would have been luxurious – most consultations had to start winding up at 10 mins. Now I can have a roomy 60 minutes if I need it.

I call up to RSB to let him know he won’t be needed for the difficult patient. The patient needing the interpreter is now 15 mins late – looks like he’s not coming. This is a huge relief, although I always feel slightly guilty about feeling glad when someone doesn’t come. Now I only have two more patients to see this morning, plus the possible new diabetic colleague. I talk to reception about re-booking the interpreter patient, and they are surprised he hasn’t come, because they have seen him a number of times before and say that he always attends his appointments. We look a bit harder at the systems, and it looks as though his appointment was changed from two days ago. If the change was made very recently and he was sent a letter with the new appointment rather than being contacted by phone, the letter would probably not have arrived in time.

Next patient – looks like another DNA. I dig a bit deeper, and it looks as though three out of the four patients this morning were switched from two days ago (the fourth is the difficult patient, who we already know won’t be coming). I am now not expecting a busy morning. I ask office admin when the appointments were changed. It was back in January, so that’s not it. I now have time to talk to my nursing colleague about what would be best to eat, and then the last patient does actually turn up - one out of four.

P.S. RSB was delighted with his door wedge.

More tales from the hospital

Harris hawk coming in to land

I have been trying to make friends with the reception staff at my outpatient clinic, partly because they seem to be nice people, but also because they can make the difference between a well-managed clinic and a chaotic nightmare. Last week's clinic gave me some opportunity to chat. The night before the clinic there were eight patients on the list, not a full clinic by any means, but a reasonable number to get through. By the time the clinic started, there were only seven - one had already called to change the appointment. The first patient was early, so I could see her early, and it's always nice a) to get ahead at the start and b) not to make people wait. But the next one didn't turn up, and after the third patient, the list on the computer had shrunk to just four - the others having presumably rung in on the day to cancel. The fourth didn't turn up either. So just two patients in the whole clinic, and although I bring down some stuff to do in case of DNAs, I had nowhere near enough to keep me fully occupied.

So I went out to chat to the staff on reception, not least to ask them whether it was just my clinic, or whether everybody was experiencing the same effect - perhaps it was caused by the first truly sunny, warm day of summer, when people might prefer to go the park rather than a hospital clinic? I asked them their names, and even gave them a box of chocolates that one of my two patients had given me. It was entirely unreasonable to have accepted the gift, because I had taken no part in the treatment plan - this was the first time I had seen the patient and all I needed to do was to discharge him, as he was doing fine. But it proved impossible to refuse.

This was the first time I'd been given anything by a patient, and then I was faced with the dilemma familiar to anyone who is trying to lose weight or maintain weight loss. If I took the chocolates to the office to share, then I would definitely eat some, but I don't want to eat them. So the answer was to give them to the reception staff, which is win-win because then I don't get any and they like me more and may be prepared to help out on the odd occasion when I might need them.

So far I haven't needed to ask any favours, but the other two basic grade Dietitians have both had the problem of patients brought by ambulance not being picked up before the end of the clinic. If this happens, then obviously someone has to stay with them in case they need help and so that the ambulance staff can find them. This should not have to be the Dietitian whose clinic they attended, who is unqualified even to help them to the toilet. Some arrangements have been made to bleep an alternative person to take charge, but this doesn't work reliably, and the Dietitian may be delayed for some time. If it happens to me, I want the reception people on my side trying to think up solutions, rather than walking away telling me it's my problem.

The outpatient clinic is only a brief interlude from working on the wards. One day last week, I was talking to a patient who was telling me that he was taking two supplement drinks a day. All of a sudden his eyes went a bit unfocused and he stopped responding. At that point my mind went into overdrive, fuelled by a burst of adrenaline I could actually feel, along the lines of "Oh my goodness what should I do he's died" but after just another moment I touched him on the arm and he started to respond again. He had a very poor prognosis so I wasn't about to leap on his chest and start compressions, but with hindsight, drawing the curtains round the bed and calling for a nurse would have been the next move. It was one of the more interesting experiences that I've had on the wards so far.

Not keeping up

Mr M and Lola II's garden, April 2012

I am so behind with everything - all the blogs waiting for me in my Reader, audio books unread, and loads of podcasts just sitting there. This is partly because of sharing rides to and from work, so I have to do conversation rather than listening to podcasts or books, and partly because I have decided not to spend so much time sitting at the computer. I'm not sure in what way the rest of my life has benefited, because I don't seem to get a whole lot of other things done, but it seems like the right decision.

Work continues as ever with patients on the wards and in clinic. Last clinic: ten patients were on the list the day before, only nine were left by the morning of clinic and eight remained when one phoned to cancel. Five turned up. This is typical. The reception staff say that Tuesday is the worst day of the week and car parking is so bad that perhaps people arrive, drive around for 15 minutes not being able to park, get fed up and just go away again. The reception staff don't know why Tuesdays are particularly bad. At least I didn't need any interpreters, for once.

On the wards, the Friday before a Bank Holiday weekend seems particularly difficult as ward staff realise that if patients are not seen on Friday then they will not be seen for another three days at least. All my NG-fed patients seemed to be pulling their tubes out, which made me worry that they may not be fed over the weekend. On the other hand, quite a few were transferred out to Intermediate Care, Rehabilitation or other hospitals and one or two were put on palliative care, the End Of Life Care Pathway, or just died.

I have been working with a student for two weeks - not all the time, just three mornings or afternoons a week. It is difficult. I am not a natural teacher, and I am trying hard to find the right level of encouragement compared with correction or instruction. I have only been a qualified Dietitian for three months, and am still finding my own way of doing things, making it difficult to pretend that I know what I'm doing all the time. And as I have said before, it's not so long since I was having a hard time being a student on placement. But we do our best.

You may have noticed the infrequency of my blog posts nowadays. One of the most frustrating things is that I am unable to report much of what goes on, since it involves individual patients or students or colleagues. The golden rule is that I can only write stories that these individuals would not be able to recognise as being about themselves. To do this, I can either change so many details that the point is lost, or write something so generic that there is no recognisable story left. Both of these are clearly unsatisfactory.

A new Dietitian is starting this week, and my wards will change around. My line manager is going on maternity leave and a new Dietitian will replace her later in May. Maybe then I will have some new stories to tell.

Outpatient clinic

Lakeside, May 2011

Outpatient clinics are stressful, from my point of view, anyway. I don't know whether the patients find them quite so difficult, since all they experience is the frustration of almost always being seen later than their appointment time. Although parking at the hospital is enough to make anyone feel cross when they finally reach their clinic waiting room.

My clinic runs from 9.00 a.m. to 12.30 p.m., at least in theory. New patients get half an hour, follow ups only fifteen minutes. Four minutes late and you might have lost a quarter of your appointment time, except I'll probably have to run late because there's no way I can complete any sort of sensible consultation in eleven minutes. Four minutes early and you're probably going to wait for half an hour because the people before you were late or were particularly chatty or had complex conditions that needed some extra time.

I sit in my clinic room with the patients' cards and the computer showing the clinic list. I have reviewed the cards in advance so I have an idea of what I'm going to encounter, and have a chance to research any conditions I haven't come across before (this is starting to seem pointless; see below). Every minute or so, I press the 'Refresh' button, which re-loads the list and shows if anyone has checked in at the reception desk.

It is 9.18, and it seems my 9.00 patient has DNA'd (Did Not Attend) and my 9.15 is late. I click 'Refresh'. The updated screen shows that at 9.17, the 9.00, 9.15 and 9.30 patients all turned up together. Oh boy. What a great start to the morning.

Or, it is 8.58 and my first patient is at 9.15. I click 'Refresh'. The updated screen shows that the 9.30 patient has already arrived, so I can see him at 9.00 and get ahead. What a great start to the morning!

Here are some examples of consultations, which have been changed from the real ones, but are close enough to give you an idea.

The referral states that the patient has IBS (Irritable Bowel Syndrome) with symptoms of diarrhoea. I'm a bit shaky on the guidelines, so I make sure I have copies ready for us to go through. The patient arrives: IBS is old hat, the latest diagnosis is colitis, which is what the subject of the consultation will be. And we discover that I don't know what you actually do with golden linseeds.

The referral asks me to advise on a diet that will help a type 2 diabetic reduce blood sugars. A typical day's diet history is faultless in terms of sugar, saturated fat and complex carbohydrate intake, and when I check the results on the computer the last tests were done in 2010 and show all blood results within the desired range. Both of us are confused.

The referral states the patient has a Syndrome that I've never heard of. I do a fair amount of research in advance into what it is - it turns out to be a relatively rare endocrine condition marked by excessive hormone production - and I fail to find any relevant dietary guidelines. We will have to work it out together. The patient DNA's.

The card shows that a very overweight patient wants to lose weight, having tried for ages without success. The patient arrives and announces that thanks to a support group, 5 kg has already been lost, and motivation remains to lose more. All I have to do is say thank you for taking the trouble to come and let me know! And write to the GP.

The card shows that the patient needs in-depth dietary advice, and only speaks Urdu. It is 30 minutes before the patient's appointment at the start of the clinic, and I have no idea whether an interpreter has been arranged, or what to do if there hasn't. The admin team arrives and saves the day, showing me how the system shows that an interpreter has been booked. We manage very well, although some concepts don't translate well - I was very confused about 'fish fingers' until it became clear it wasn't the conventional sort.

After the clinic, I have to make sure that all the notes are written up on the cards, and each patient is 'outcomed' on the computer (a nice example of verbing of nouns) so that follow-up appointments can be arranged. Letters are written to the referrers of new patients, if there has been a change in treatment and a new prescription is needed from the GP, or if the patient has been discharged. This week's ambitious target was to try to get all of this admin done on the same day as the clinic, and I managed it!

The manager of the department is very supportive, and encourages using pro forma letters. She didn't exactly say that we didn't have to write when a patient is discharged, but gave the strongest impression that it wouldn't be considered unacceptable. I am still suffering from having to take days off as Annual Leave or forfeit them altogether, meaning that I have to squeeze five days of work into just four, but I'm still writing discharge letters; I think it's the right thing to do.