Vaccinating is exhausting

Coronavirus Vaccination Clinic 2 (the Portakabin), March 2021

You've had to wait for it, but the answer to the puzzle of what's in the bag hanging from my clothes airer relates to the fact that due to overconsumption and lack of willpower I had to go cold turkey on chocolate and snacks. I still had quite a large supply in the house and didn't want to throw them out, which meant that they had to be more inaccessible. Hence, hanging them up out of reach and out of sight. It worked quite well.

I've done a lot of reading in the last month as evidenced by the huge blog post last week, but there's also been a lot of other activity. The physiotherapist is suggesting that the longstanding issue with my hip is probably the source of the problem with my knee, and has changed my exercises. I am finding it increasingly difficult to motivate myself to actually do the exercises. And I have attended a very interesting Zoom webinar about the Libre 'Flash Glucose Monitoring' technology in diabetes, and I wonder if my colleagues already know about the things I learned.

I have been on annual leave from that job and signed up to many vaccination shifts, some of which were cancelled. We are doing far more work compared with that first session when I was shown the ropes - enthusiastic people are coming for their second dose as well as a few unenthusiastically turning up for their first.

We are now using iPads instead of paper forms to track our vaccinations, which I'm sure saves an enormous amount of data input, but relies heavily on our systems finding the individual. This means that the NHS number is quite important, name and date of birth being surprisingly unreliable. Obviously nobody knows their NHS number, but there is a website where it can be found, and so notices were put up asking people to type the long URL on their phones. This is quite difficult, so I suggested to the people doing the clerking that they could generate a QR code, at which they looked very blank.

I've only just started to appreciate the power of the QR code, which is the two-dimensional bar code that can be scanned by a phone camera and take you to a website. It was suggested to me for a diet sheet I was writing where I wanted people to have a look at a set of YouTube videos. The diet sheet would almost always be printed and provided to patients on paper so a clickable link would be useless, and even a shortened version of the URL would still be difficult to type, so I was just going to suggest that people searched on YouTube for keywords that would take them to the videos. A Young Person (now defined by me as someone under the age of 30) who has joined our diabetes dietetic team had the great idea of using a QR code, and it worked beautifully.

Reception in the Portakabin clinic

So I went off and produced some notices with QR codes for the clerks, and even laminated them (because: infection control), and handed them over on my next shift which was more than a week later (because: cancelled shifts). I think they made life a little easier - I wasn't in the same room as the clerks for most of the time so I really don't know how they were being used. But this picture of the reception area shows one of them on display.

Proximity alarms being charged

The other innovation is a proximity alarm worn around the neck, which vibrates and/or beeps when it is within 2 meters of another proximity alarm. These are given to patients when they check in and are supposed to make sure they stay 2 meters apart from each other. Obviously staff aren't wearing them because we can't vaccinate from 2 meters away, but we have extra face shields or goggles as well as masks and we test ourselves regularly using lateral flow kits.

The hardest thing about the shifts is the need to be standing up for six hours (with half an hour allowed for a break). The shift starts early and finishes at 2pm, then this week I had my weekly shop to do afterward, and needed to make some soup while I had time and before all the veg went mouldy. By the time I'd finished all that it was 5 p.m. and I was shattered, so I thought I'd have a nap. I became conscious again two and a half hours later, had some supper and went back to bed.

Tech support

The wet room, July 2020

One of the things that I thought I would do more of when I reduced my Diabetes working hours was volunteering, alongside all the volunteer work involved in the LTRP and the Buddhist group. And it remained no more than a thought until last week, when I supported Lola II and her co-trainer as they delivered their Community Mediation Skills course.

Lola II puts a lot of work into these courses, and I'd heard a lot about them over the years, so I had suggested that I could help a while ago. I imagined running around getting people drinks, moving them between rooms, ordering lunches, that sort of thing. What with one thing and another it turned into quite a different role, which was mainly tech support. And a bit of making drinks and getting lunch, but only for the three of us.

The challenges began for Lola II before the course started, not counting all the work she put into the migration from a face-to-face to an online course. The main reason she had chosen to deliver from a venue rather than from home was to make sure that the WiFi was reliable - there's nothing worse than dropping out in the middle of assessing someone's mediation for a qualification. A few days before the course was due to start the venue got in touch to say that their WiFi had been hacked and had therefore been taken down completely, but they had some sort of solution that involved dongles. They tried it out, and thought that it would work.

It very nearly did work except for some difficulty with passwords, but thankfully all was in place at the point where it was needed. The first three days of the course ran last week, and I got a lot of practice in some of the more arcane aspects of the Zoom program - while I'm familiar with the basics of Interactive White Boards and Breakout Rooms, I found out some of the more advanced features by means of ticking various checkboxes and seeing if it worked.

We were just starting to relax into Day 1, with technology that seemed to be working for the participants and for us, when the fire alarm went off. Thankfully it was a test and it stopped quite quickly, but that was certainly something I hadn't anticipated. By the end of Day 3 all was running smoothly, and the best part was that the participants seemed to be fully engaged and enjoying themselves. I'd learned a bit about mediation as well. 

October 2020

Then the second lockdown happened. Thankfully, the team at the venue are still prepared for us to continue with the second three days of the course, and I'm hoping it will go even more smoothly. There will be a fourth person in the room which may create a problem of noise leakage from one computer to another, but we've been promised screens and we'll have to hope that it works.

My abiding memory is sitting with Lola II and her co-trainer in the room with each of them talking to participants in a separate online Breakout Room, and feeling like I was in the Matrix - I could unplug either of them and they would fall limply to the floor.

Flfs 3 and 4

Lots of other things have also happened, including Flfs 3 and 4 coming to tile the wet room at long last. It looks great. Despite having known about my availability for months, Flf 1 is unable to come back and finish the job this week and I am back with Lola II next week. I am not happy with the delay, but it will make it all the better when I can finally stand up to shower.

At work I acquired a telephone headset and also a telephone compatible with it, which has made my telephone clinics much more comfortable. We have continued to collaborate on the Diabetes Structured Education courses intended for delivery within our NHS Trust and also the adjacent one, and it has become clear that an online option has to be created since this Covid thing isn't going away any time soon. I'm very glad to say that I'm not involved in the education side of the diabetes service any more but I have to remain on call in case of non-availability of other members of staff, so I will have to find out more about all this.

And I attended some online training in the use of the Libre Flash Glucose Monitoring System which was arranged so long ago that it has had to be postponed twice. It was finally delivered via Zoom, and was surprisingly good - I learned quite a lot about the Ambulatory Glucose Profile, which is a longwinded and misleading name for a diagram that shows glucose results for the last two weeks in an easily interpreted graphical format that has been standardised between all the different devices on offer. I might write more about this if I have the strength, but I've had just one day off in the last nine days so I might save that for another time.

November 2020

New approaches to diabetes management

Lily, June 2018

There is much in the diabetes news about developments for people with Type 1 diabetes (Flash Glucose Monitoring using the Libre device) and Type 2 diabetes (Very Low Calorie diets leading to diabetes remission). The Trust where I work, however, is not forward thinking, innovative or dynamic, so we still haven't done much to make either of these available to our patients.

In our little team we were hoping that the doctors and/or the Clinical Commissioning Group (CCG) would feel the pressure from patients and organisations like Diabetes UK with all the media announcements that FGM (an unfortunately acronym) technology is now available on NHS prescriptions. Not in our area, it isn't. It has made it onto the local 'Formulary', which is a list of things that can be prescribed, but no protocol or procedure was forthcoming which would make it actually possible to prescribe it. In the end we gave up on the idea that the doctors would do anything at all, so the nurses and I have tried to come up with our own local protocol to put forward for approval Trust-wide.

It is quite an interesting process, because the device is so different from what you normally get when you hand over a prescription to your pharmacist. The Libre consists of a handset as a one-off device at the start, and disposable sensors that last two weeks at a time. At the moment we also believe that users should have some initial training (or at least guidance) about how to make best use of the device. The CCG has defined the criteria that have to be met before the device can be prescribed at all, and other criteria that have to be met if it is not to be withdrawn after six months. A bit different from a prescription for a 10-day course of antibiotics or a tube of ointment.

The criteria for prescription are quite restrictive - Type 1 only, appropriate blood glucose monitoring 8 or more times daily, and one of the following: where success with the Libre would avoid the need for an insulin pump; impaired awareness of low blood glucose; more than 2 admissions a year; or where a third party is needed (e.g. learning or physical disability). And the prescription has to be for a six-month trial period, during which we have to collect data on eight different indicators, and if fewer than two indicators have improved then the trial is discontinued and no more sensors on the NHS.

The Pharmacists have said that they don't want to have anything to do with it, thank you very much, which is fine for the first prescription - we would be happy to handle that, given that we want to have a role in starting people off with some training. After that, though, we aren't in a position to be dispensing sensors every month, so we've got to try to persuade the pharmacists to take that job on. And the Procurement people will have to decide how exactly the handset and sensors will be ordered and recorded, and the Finance people will need to define how the budgets will work and how we will charge the cost to the CCG (because although it's prescribable, it comes from a different budget than for 'normal' prescriptions). And the Doctors are clinically responsible for the prescription so they have to fulfil the criteria set by the CCG. So all of these people have to approve our proposal.

Can you imagine trying to arrange a meeting with people from five different professional groups, at least three of whom are not in the least interested in the extra work that this might entail?

We have started by finding a date convenient to ourselves and our paediatric colleagues (at least the paediatric nurses; I doubt whether there will be a dietitian involved). None of the doctors has replied to the invitation, and we know and work with them (update - one doctor thinks he can probably be there). The Head of Procurement has said that he will find someone to attend; Pharmacist representation is still unconfirmed - we don't have any routine contact with these guys, so I'm not expecting much -  and I have no idea about Finance. I'll let you know.

The other issue all over the news is the effect of rapid weight loss on Type 2 diabetes, which in some cases can induce diabetes 'remission' - a return of blood glucose to non-diabetic levels. The research trial that has generated all the stories is not yet finished, but many people seem to want to try the diet. There's also Michael Mosley who keeps making TV programmes, and the family behind 'Fixing Dad' which also led to a TV programme and more, and every two minutes there's something else in the Daily Mail or on ITV about how you can live forever if you adopt some version of a simplistic and entirely unrealistic lifestyle.

The trouble is that the Calorie* restricted diet used in the (unfinished) research trial was not the sole intervention that led to remission - there was a whole team approach within GP practices, supported by the research team, including dietitians. And not everyone who tried it achieved remission. But the main concern for me is that we know weight loss is difficult to sustain, and the research has not yet uncovered what happens to people who lose the weight but then regain it again. If they experience more serious consequences than if they had done nothing then that changes the complexion of the outcome considerably. We just don't know.

It's still worth losing weight, though, and not eating (or drinking) excessive carbohydrate if you're at risk of Type 2 diabetes, or if you already have it. Even if you do it in a more measured way than by cutting down to 600 or 800 Calories* per day.

(* I tried to write 'calories' because that's how we generally refer to kilocalories, but I couldn't, because it's not accurate and I am a pedant. It's either kcal or Calories with a capital C.)

Three out of five of my team of adult diabetes dietitians are new, and with fresh eyes they have pointed out that we don't really provide much support to people who want to lose weight. We obviously can't compete with successful and rigorous programmes like Slimming World or WeightWatchers (now stupidly rebranded to be just WW), but we don't even have any leaflets that could help people think about losing weight, let alone provide the intensive and expert dietetic input to a rapid weight loss programme for diabetes remission. So we're going to have a couple of new leaflets, and we'll follow the course of the research and maybe work out how to apply the results within our practice. At some point. Maybe.