Festival

The East Pointers, August 2017

I had plenty to do during the Bank Holiday weekend what with the Shrewsbury Folk Festival, another dental appointment, a trip north and trying to grapple further with the LTRP. I disposed of the debris from the garden before getting packed and ready to go to Shrewsbury. I arrived there around noon, thinking I would be among the early birds, but the steward at the festival campsite said "We've already been open for five hours - you'll probably have to camp over there."

'Over there' was a little bit further from the action, but still very close by. In the past my preferred festival has been in Cambridge, which I first attended more than 30 years ago. Cambridge Folk Festival has grown and grown, from a couple of stages and a bit of camping to a huge event sponsored by Radio 2 where tickets are sold out within days (or sometimes hours). The last time I was there was for my 50th birthday, and it was crowded and difficult to navigate about the site, and overflow camping (which is where I would normally go) is a bus ride or a very long walk away.

Compared with that experience, Shrewsbury was amazing. The overflow camping being very close was a bonus, so I pitched the tent and wandered over to the main site to get my wristband and a programme and check out the layout. The stages are inside marquees which weren't yet open, but I caught a glimpse and was surprised and slightly disappointed to see it laid out with seating! Although I don't like sitting on the ground, I do like dancing. How would this work?

Anyway, there was enough time to wander into Shrewsbury town centre (again, much closer than Cambridge) before coming back to the start of the music at about 5pm. Despite my scepticism, the seating was the perfect arrangement - I didn't have to sit on the ground, but there was a section at the front in the main tent specifically for those who wanted to get closer to the bands and dance. So there I was, for my favourite Oysterband, right at the front in the middle when the lead singer came out into the crowd. I happened to meet him later in the weekend, carrying a pint. I didn't realise it until the close of the festival, but he is a local resident and a patron and supporter of the event.

So it was altogether a great improvement on the Cambridge experience, the weather was fine, and the bands were (mostly) wonderful too. I saw a few Canadian and French bands as well as home-grown talent, nearly all unfamiliar but I'd go and see them again if they happened to be touring. Particular highlights were La Machine, The East Pointers, Le Vent du Nord and Daphne's Flight. And, of course, Oysterband. I'll definitely be going back next year.

The following weekend I went to High Wycombe to see the English National Badminton competition. Unfortunately none of the big name players was there, perhaps because the World Championships had taken place just the previous week, but there was enough to see to keep me occupied for the day. I saw the quarter- and semi-finals on Saturday, but didn't go back for the finals on Sunday.

At work I covered the ante-natal clinic for a colleague who was on holiday. I think there were twelve appointments altogether (one DNA), up to 30 minutes each, for women who have been diagnosed in the past week. This was their first appointment about the diagnosis of gestational diabetes, so they each saw the nurse first. She explained the diagnosis and its consequences and gave them a blood glucose meter and lots of paperwork, then passed them on to me where I said pretty much the same thing eleven times. By the end I had completely lost track of what I had said to whom, but I think it went OK. I don't quite know how my colleague copes with this every week - once was enough for me.

The only other item of note is that my iron count was too low to donate blood this week - oh dear, but also, hooray! All the virtuous smugness of doing a good deed without actually having to go through with it, and my haemoglobin level was low but still within the normal range so I'm not anaemic. I was also given a leaflet giving me all the advice that I am used to giving out to patients...

I am on holiday again

Rugby School Old Quad

I sometimes wonder whether I can keep up with this blog. And then I remember that I've kept it going for 8 years, and I don't think I'll ever stop. I seem to have an almost irresistible urge to write about any mundane or irrelevant aspect of my life, and about 40 people are still reading. Shame on you, 40 people. There are more constructive ways of spending your life than reading this inconsequential stuff. But I suppose it only takes a few minutes to read each entry, and unlike when I was a student five years ago, when I thought it was entirely reasonable to produce a post every other day, nowadays I only manage one post a week if you're lucky. I am devoted to a few other people's blogs that appear far less frequently, so maybe this vanity publishing project will stagger on way beyond its natural lifespan. 40 people, I salute you for your tenacity.

Last week was pretty full on at work - I was supervising a student who wanted to do a little bit more active interaction with patients. There was nothing for her on Monday, but I picked out two patients on Tuesday that I thought would be OK. Unfortunately they were both interesting, unpredictable and challenging, and although she gave it her best shot, they proved a bit much for her. One of them was a bit much for me too. On Wednesday I had to do the ante-natal clinic, which luckily was fairly quiet. When I was advising one of the patients that she shouldn't be drinking too much milk, she told me she'd had advice from one of the doctors that she should actually drink lots of milk. One of my colleagues thinks this might be due to general iodine deficiency in the population, rather than the need for calcium.

But now I am on holiday, again! It's partly so I don't have to go to work on my birthday, and partly because I miscalculated the amount of annual leave I am entitled to, so I was a little extravagant in booking another week off so soon after the last epic holiday. Now I think I only have a week left (not counting the week already booked for New Year), so I have to choose between a) going skiing in 2016 but no days off between now and Christmas or b) a week before Christmas but no days off between New Year and the end of March. A difficult choice.

Anyway, I am in Yorkshire - Harrogate to be precise, on another Solitary Holiday. After Tunbridge Wells for two years in a row I am continuing the theme of Spa towns, and have taken an absolutely lovely apartment where I will spend time reading, writing, watching films and, with luck, sewing myself a dress. I may even go for a stroll around the town, if it ever stops raining. The forecast says that Thursday will probably be the least rainy day, which will be nice because that is my birthday.

Seize the moment to blog

Garden rose, June 2015

It's no use trying to compose careful prose and produce a well-crafted blog post about some aspect of my work or leisure that has made me think of something clever or interesting. There's no time. I have a mountain of paperwork, a backlog from my holiday - I knew there was a reason that I only go away for a week at a time. Then I was away for another two days on a course (that I want to write about) and then my week was stupidly busy and I was away for another weekend. So I'll just bang out some words about anything that occurs to me and have done with it.

We have a problem with our plumbing at Lola Towers. Mr A told me last week that the hot water had stopped running, but then it started again. We put it down to polystyrene balls - a very long time ago, one set of incompetent plumbers allowed polystyrene balls to get into the water system. On reflection, we haven't had any trouble for quite a while, so when the hot water failed again when I got back from my weekend away, I sought the advice of a friend who had that very weekend suffered something similar. Following his advice we ventured up into the loft, where the header tank for the hot water turned out to be empty. That was Sunday night, and I wasn't about to call for an emergency plumber seeing as the cold water was running fine and it was an intermittent fault - by Monday morning the tank had filled again.

I am an organised person, and I have many lists that remind me of things that need to be done. I find it impossible, however, to manage to simultaneously do the things on the list that I find difficult; I can just about manage them one at a time - partly because of the difficulty, but also because I have very little time to myself at work due to multiple patients and full clinics and delivering training off-site, and because there is no mobile phone signal in my office. To make a mobile phone call I have to leave the building and stand outside the door, and then it's difficult to write things down, and I can't refer to my online diary because the computer's inside, and if there's no answer I can't leave my number for them to call back because there's no signal when I go back into my office...

So I try to achieve one difficult task a day, and there are many tasks waiting. On Monday it was a call to a solicitor, and today I managed to call the plumber. (There is also the problem of when to arrange for him to visit, as Mr A and I are both working full time at the moment). Tomorrow I need to call the accommodation we have booked for New Year, on Thursday I need to send a letter of mild complaint to the accommodation I stayed in on Saturday night (Lola II is helping to draft it), and you would not believe how dirty the shower is. And there's that huge pile of paperwork that needs sorting out or else my car will not have a parking permit in August, among other slightly less urgent issues.

Then on Thursday there's the second week of our current carb counting course, so I have to cook some carbs for them to count. That means baking a potato and cooking measured amounts of pasta and rice on Wednesday evening to take to work on Thursday. This is a) to demonstrate the change in weight of raw vs cooked food (rice and pasta increase in weight, baked potato decreases in weight but carbs are unchanged for both) and b) to encourage the participants to weigh/measure these hard-to-estimate starchy carbohydrate foods, so that they will know for example how many carbs are in a standard tray of takeaway rice.

And of course I want to keep up the running, and my elbow is pretty much better so I'd like to go back to badminton, and there's the clarinet choir which is staging a concert in a couple of weeks. And I need to buy a new car, and new trainers, and waste paper baskets, and a bedside lamp, and put the charcoal picture that I drew at Mr M's birthday event into a frame, and re-pot and rejuvenate my house plants, and now the 15-foot rose bush and the enormous wisteria need pruning. I've used weedkiller on the patio weeds, but they need to be cleared, and all the rubbish littering the garden taken to the dump. My email inbox is bulging with messages that aren't important enough to be dealt with straight away but not unimportant enough to be deleted, and I am well behind on reading my blog subscriptions.

At work I have a similar number of issues. I was determined with this change of career that I would try and avoid the frustration of being unable to change the world by keeping my head down and letting the world sort itself out. It turns out that I can't seem to do that. Before I went away to America, I wrote a very apologetic note to my manager, detailing three pages of projects that I have taken on but are being thwarted by various barriers: procedural, technical and human.

I want to have a Internet-enabled data projector in our education room. I want to create a website to support our very low carb lifestyle group. I want to be able to show web content to our patients that is blocked by the Trust, including social media and videos. I want to support a new 'transition' clinic for young people moving from the paediatric to the adult diabetes service. I want to be able to offer patients the option of very low calorie 'diabetes reversal' diets that include meal replacement products. All of these need someone else to do something or agree to something, but instead of getting these things that I want, I have been asked to cover an extra clinic in the community on a Tuesday afternoon, and - the horror! - three half-days of ante-natal clinic over the summer (one of my colleagues has left and there is a gap before her replacement starts). And I have stupidly followed up a very good idea from one of my colleagues which needs me to do even more organising and coordinating.

I appreciate that these are problems that some people would be happy to have in place of the real and serious problems that they are having to deal with, but we all would like an easy life, wouldn't we?

Not at work

Groombridge Place, June 2013

See what happens when I don't have to go to work and I'm not away from home? Blogs happen, that's what. And I am told that Lola II is working towards her contribution to the Wedding Presence camping trip blog post (I think Mr M has done his, although he hasn't sent it through yet). So we are backing up a little now to report news from a week ago...

At work, I agreed to cover the ante-natal clinic, which takes place in the other Trust hospital - we don't have any maternity services where I usually work. As regular readers may remember, I am not a fan of ante-natal clinics, and this was no exception. There are too many patients and not enough time, and I felt rather exploited although the consultant and the nurse took care to thank me very appreciatively. Next time I will be more 'assertive' about time-keeping.

Back at my usual hospital I observed a patient being started with an insulin pump, which took quite a long time but wasn't very complicated really. I think that the hard work starts afterwards, to try and fine tune the background delivery of insulin to match the patient's needs from hour to hour. Being away from work this week I'm missing that part of the job, but I'll try and catch up with a different patient some time, to see the follow up.

And then there were a few things not related to work. It was a red letter day on Thursday: the first time I managed to run 5 km in under 30 minutes (all on flat tarmac). My timed runs on Saturday mornings with Parkrun are getting faster too, but despite planning to go out this week, I haven't felt up to it yet, partly because of the trip at the weekend, to see Landrover Man (LRM) and Bee Lady (BL).

This was actually me gatecrashing one of Mr M and Lola II's wedding presence, and it was lovely as usual. BL provided an extensive food preference questionnaire which also included attitudinal questions to see if she should be sticking with conventional choices or going a bit experimental. After a tour of the LRM/BL mansion and grounds, then the enormous and delicious dinner followed by games on Saturday night, we were looking forward to the usual standard of walking on Sunday. We only got a bit lost once and had to do a bit of off-piste mountaineering (Lola II was very brave and I got stung by nettles) but it was excellent, if exhausting. I had to have a sleep on the motorway on the way home, and was very glad not to be going to work on Monday. I think I felt the effects of the indulgence followed by the exertion for a few more days, but it may be the unaccustomed freedom of not being at work.

[Bee Facts: there were many, mostly about how to manage your hives - BL doesn't like killing a perfectly good queen just in order to limit the number. So she has ended up with ten hives, which is A Lot. LRM was very patient and listened to many, many Bee Facts without much complaint. Unfortunately it isn't quite so interesting to hear about his energy management spreadsheets.]

So this week I have welcomed my tradesmen about whom I have already written, and the latest carpenter says the job isn't big enough and has suggested another carpenter. I have donated blood without incident, and even managed to visit the charity shops for long enough to acquire the clothes that I was after. Yesterday I made an enormous effort and cleared out about two thirds of the clutter that was getting in my way, and then it was time for badminton. Today I had lunch with an old friend, and I am looking forward to the weekend, which holds the annual Food & Drink Festival.

An interlude

Groombridge Place, June 2013

Christmas has come and gone, the New Year celebrations passed, and I have left one job behind and am looking forward to a different one. But in the meantime, it has been by turns restful and hectic.

I was working on the Monday and Tuesday before Christmas Day, and Mr A was in charge of preparations. He did a great job, and we had a delicious seafood medley for Christmas dinner, plenty of sitting on the sofa in front of the fire, watching DVDs, reading some books and even watching a couple of TV programmes. I was back at work on the Monday and Tuesday before New Years Day, but those were my last two days there. I had scheduled patients, but most of them didn't turn up. The most reliable were those with Gestational Diabetes, for obvious reasons. A year ago I enjoyed the predictability of the ante-natal clinic, but ended up tyrannised by the inexorable progress of pregnancy.

We had no plans for New Years Eve until the very last minute. I had anticipated quite a long and busy last day at work, but it wasn't like that at all. The Diabetes Specialist Nurses told me that sometimes it can be crazy busy, but for some reason this year there were few referrals, and we even had time to spend a break together in the hospital coffee shop. I cleared my computer, cleared my drawers, cleared my desk, cleared the room and managed to get away mid-afternoon.

Mr A suggested that we try and gatecrash the party at the Pub Next Door, by pulling rank as Very Important Neighbours. Their ticket-only party had been advertised for a while, but I had thought I would be too tired from the working and the driving, so we hadn't signed up. We found, however, that the party wasn't happening after all, and it was to be a fairly normal night at the pub, so there was no need to call in any favours, we could just go next door as normal customers.

Of course, Smurf couldn't let an opportunity pass for some sort of mischief, so he was dressed as Elvis, in a white shiny outfit and big wig that must have been awfully sweaty at the end of the night. He and the other bar staff were downing shots at a rate that made me wonder how they could still stand up by the end of the evening. Towards midnight they turned the music up and Mr A and I were first on the dancefloor, the traditional countdown to New Year took place, there was a bit more opportunity for dancing and then Mr A and I went home. We have managed to avoid the staid married couple story of 'can't be bothered to stay up until midnight' for several years now, in various interesting and enjoyable settings.

My new job starts in a couple of weeks, and I have Plans of all sorts for the intervening time. I started with planning a trip to London and another trip north, but mentioned to Mr A that it would be a perfect opportunity for a snow holiday. He took up the challenge with gusto.

Mr A has now admitted defeat with both the skiing and the snowboarding. His legs, both broken in his mid-20s, were poorly set and his feet and shins cannot be comfortably accommodated in ski or snowboard boots with any success, even in the boots that were ludicrously expensive because they were moulded to the shape of his legs. But always optimistic, he started looking into the possibility of renting a type of ski bike that we had seen on the slopes during our last snow holiday.

With less than a week's notice, we are now booked for a week in Austria. Since I have a day or two at leisure, I spent a couple of hours practising at our 'local' SnowDome, which was a very good idea indeed. I progressed from just about remembering how to snowplough right through to parallel turns in the space of two hours, which has made me a million times more confident, and means I'm looking forward to our holiday a great deal more.

So I will be absent from this blog for a while, but with any luck Lola II may fill the hiatus. She was planning a blog post a while ago, and she has been on holiday as well, so maybe she will surprise us!

No idea why this is in one of the hospital corridors - the caption is 'Negev'

Gestational Diabetes

Cardiff castle, May 2013

I started writing this post some considerable time ago, which is a little ironic. Not many posts have needed incubation.

Every week, I see a few patients who have just been diagnosed with Gestational Diabetes Mellitus (GDM). And when I say 'just diagnosed', sometimes it's been in the last hour or two. Some have had it before, some take it in their stride, and some are completely freaked out.

For each of these women, I aim to give them basic dietary information in 30 minutes, and then they can have lots more input the following week if they need it when they come back for a scan and a full check-up. When I started writing this post, the shortest time I had managed was about 40 minutes, and when I first started in the job it was more like an hour. Now I've got it down to a well-practised routine.

The diagnosis is made by screening women who have one of several risk factors, including pre-pregnancy BMI over 30 kg/m², a previous baby that weighed 4.5 kg or more, previous gestational diabetes, a first degree relative who has diabetes, or one of several ethnic backgrounds that have a high prevalence of diabetes. Screening is usually done at around 26 weeks into the pregnancy. The fasting blood glucose is measured, then they are given a measured dose of glucose to drink, and after two hours their blood glucose is measured again. In our Trust, if the fasting level is greater than 5.4 mmol/L or the 2-hour level is greater than 7.7 mmol/L, then bingo - the diagnosis is Gestational Diabetes. Even if the fasting level is 5.5 or the 2-hour level is 7.8 mmol/L.

For most of the time when I see people in the general diabetes clinics, I have to respond to what the individual brings to the consultation. It could be anyone, with any type of problem, or no problem at all. For this ante-natal clinic, it's always a woman, it's always gestational diabetes, and the advice is always the same at this initial stage. So it's an opportunity for me to hone things over the weeks, to get the right messages delivered as well as I can do it.

My first inclination was to do a bit of research, to make sure that my advice is based on the best available evidence. Two documents were the obvious starting point: the NICE guidelines, and a Diabetes UK document, both from 2008. I also found a couple of academic papers.

There are two main reasons that diabetes in pregnancy needs to be addressed. High maternal blood glucose means that the baby will receive more glucose than necessary via the placenta, and will secrete higher levels of insulin to compensate. Any energy that isn't needed for growth will be laid down as fat, generally around the middle and the shoulders. This can complicate delivery, with a higher risk of the baby getting stuck (shoulder dystocia) and trauma to the mother. The other issue is that after the baby is born, its blood glucose will drop to normal levels, but it may still be producing a lot of insulin. Hence there is a risk of post-natal hypoglycaemia, to the extent that the baby might need a glucose drip for a day or two until it sorts itself out.

After delivery of their baby, mothers are offered a six-week follow up glucose tolerance test, and the good news is that for most mothers the diabetes will have gone away. According to the US National Diabetes Education Program, however, 5 to 10% are found to have diabetes at this point, usually Type 2. Those who don't have diabetes at this stage still have a seven times higher risk of developing Type 2 later in life than if they hadn't had GDM.

I work with a specialist midwife in the clinic, and we take it in turns to deliver our messages. She covers the clinical information, and provides a meter so that the mother can test her blood glucose seven times a day: before each meal, one hour after meals and once before bedtime. Seven times a day, every day until the end of the pregnancy. Some women have had to do this before, some women take it in their stride, some women... well, you can imagine.

So what is my dietary input? In 30 minutes, I cover the following:

• An explanation of Gestational Diabetes, and how food affects blood glucose.
• Reassurance that they haven't developed GDM through eating too much sugar or too many pies.
• The treatments available (diet, tablets, insulin, in that order) and that if you progress to tablets and insulin it's not necessarily because you're doing anything wrong, but this is a progressive condition.
• What is their 'normal' or 'typical' diet? [I love a good diet history, you find out such interesting things]
• Foods that don't significantly affect blood glucose (protein, fat, vegetables/salad, diet drinks, sweeteners, vinegar, herbs, spices) and those that do (sugary and starchy carbohydrates, including fruit, milk and yogurt).
• The difference between sugary and starchy carbohydrate in terms of their effect on blood glucose, and the difference between a lot and a little carbohydrate.
• What a reasonable portion size of carbohydrate should be.
• Check that they are aware of advice on food safety and hygiene, avoiding liver, pate, uncooked shellfish and eggs, blue, soft and unpasteurised cheese, limiting intake of certain fish (swordfish, marlin, tuna), and the suggested restriction on caffeine.
• The benefit of activity on general health and particularly blood glucose control.
• And... any questions, at which point I have an eye on the clock and hope that they are completely overwhelmed with the information so far and will keep their questions for another day.

One of the reasons for clock-watching so closely is that the only time the midwives can run this clinic is on a Friday afternoon, when up to four women are scheduled. Run over a few minutes on each, and we're not going home on time. I can fill an A4 sheet with drawings, graphs and lists of food in clear handwriting faster than you can imagine.

The evidence behind the dietary advice for GDM principally supports a focus on a healthy balanced diet containing low glycaemic index carbohydrate food that is digested quite slowly. I often use the analogy of a sink with a blocked drain, where the level of water in the sink is the blood glucose level. Turn the tap on full blast and the sink overflows; put in the same amount of water (carbs) at a slow trickle and the level will only rise a little. It is all meant to limit the period of time when blood glucose is above the optimum level.

Women often ask how much carbohydrate is enough, or whether cereal A or B is better. I can give a generic answer based on population studies and determination of glycaemic index and glycaemic load (which is the index multiplied by the amount of food). The easiest way to address this question, however, is to point out that they will be testing their blood glucose before and after meals, and after just a few days they will know what 'too much' looks like. 

My dietetic advice differs slightly from the usual 'healthy eating' messages, because short-term glycaemic control is much more important than long-term cholesterol levels, for example. So a high protein, low carb cooked breakfast isn't such a bad thing for the few final weeks of pregnancy, because eggs, bacon, sausage, mushrooms, tomatoes and baked beans hardly contain any carbs at all. Crisps are a comparatively good choice of snack compared with sweets, cake or chocolate, but nuts are even better (as long as there is no history of nut allergy in the family). Reduced fat houmous with vegetables is probably the best choice for a snack that I can think of - low in fat, high in fibre with minimal effect on blood glucose.

Follow up in clinic consists of reviewing the blood glucose numbers recorded, and seeing a) if there are any above the target levels and b) whether these are occasional and random or frequent and showing a pattern. The woman may want advice on better choices for a particular meal, or she may have been experimenting to find the best type and amount of cereal for breakfast. There has been only one woman I can remember who seemed to deliberately ignore dietary advice and who changed nothing. Most are prepared to put up with everything because it's usually for only three months, and it's clearly worth it for an easy delivery and a healthy baby.

An account of the past week or two

National Botanic Garden of Wales, May 2013

Let's start with some good news. Here are some bad things that haven't happened: the boiler hasn't broken down. The car hasn't needed any attention for nearly a week. There have been no work-related disasters.

My list of everyday tasks expands and contracts but never goes away. There has been progress of sorts - we have a date for installation of a new boiler, I have a certificate to prove I am not a criminal, and I have even managed to get proof of previous employment in the NHS back in the 1990's. This is useful because the amount of annual leave that one is entitled to depends on duration of employment, and it doesn't matter when that employment took place, so I should get a few more days holiday as a result.

On the down side, I haven't had any firm offer of employment so I haven't been able to give my notice in, and it is now looking as though I will therefore have to work through Christmas; I am nowhere near dealing with the Will or the Power of Attorney that I have been determined to set up for several years now, and there are some other jobs that look like they will be pushed further and further into the future. Income tax self-assessment form? Forget it.

The employment situation becomes ever more complicated. Why is it never straightforward? I got a call last thing on Friday as I was driving home last week, saying that there were more hours available to add to the 20 hours in one of the prospective new jobs, and then the voicemail message was cut off. An exciting prospect - perhaps this would be enough to make up a full time job together with the one day I've been offered by the other employer?

I had to wait until Monday to get more details. It took nearly a whole day of phoning and leaving a message, followed by not being able to answer the phone when it rang, then leaving another message, then being with a patient again when the return call came through, and so on throughout the day. Eventually we managed to find a time when both of us could speak, and of course the extra hours turned out to be on the same day as I had been offered for the one-day job.

Pros: four days with one employer is better than three with one and one with another, and it would cut out all the travel. Cons: the one day job would be doing education for people with Type 2 diabetes which is something a bit different that I'd actually like to do; I've said I'll take the one day job and don't like to mess people around; the extra hours tacked on to the 20-hour job would have to be taken on trust because that offer can't be put in writing. Watch this space.

I have been given the extension to the deadline for my Masters module that I asked for, and spent the whole of last weekend working on it. Really and truly, the whole weekend, except for a couple of hours watching La Vie En Rose, a biopic of the life of Edith Piaf, and a trip to the shops for provisions. I was able to do this due to the absence of Mr A, who is on a Bulgarian Biking Bonanza for a week. He returns very soon, and I await the thrilling tales of excitement and adventure. As far as I know, he hasn't broken anything, but I doubt that he would mention it if he had - he would just return home in plaster as a lovely surprise.

There is more to do for the stupid Masters module, which is taking up a disproportionate amount of leisure time, to the extent that I have decided to use work time to do it as well. Studying as a full time student was wonderful; combining it with a full time job is not so much fun. Just a couple more weeks of pain and it will be over - I do wonder whether I can be bothered to put myself through this for all the other modules necessary for the degree, but I imagine when the memory of this module has faded I shall miss the learning experience.

I am doing a fair bit of learning through everyday work, because I always want to make sure I'm on top of the game. A chance remark by one of the nurses set me thinking about the effect of caffeine on control of blood sugars in diabetes, and I chanced upon a recent paper which investigated just that. In case you're interested, it concludes that caffeine is bad for blood glucose control in Type 2 diabetes, and probably also in Type 1 and gestational diabetes. I'm not sure whether the paper is freely available because I accessed it through my university account, but if you're interested then look for "Whitehead N. & White H. (2013) Systematic review of randomised controlled trials of the effects of caffeine or caffeinated drinks on blood glucose concentrations and insulin sensitivity in people with diabetes mellitus. J Hum Nutr Diet." Or ask me, and I'll email it to you.

Speaking of gestational diabetes, those ladies keep on coming. I have had to deal with a glut of interpreters recently, some of whom have been truly awful, along with some very difficult patients who have been struggling both to understand what is being asked of them and to put it into practice. But some good news to finish with: at the end of today's clinic there was a lovely smiley lady whose interpreter hadn't arrived, but whose blood sugar record was near perfect and who indicated (with the help of family present) that she actually felt much better having made the recommended changes to her diet. That hardly ever happens, but so nice when it does!

Ante-natal clinics

Dorset, July 2013

Time passes and there is always something blogworthy going on. This week it has mostly been pregnant women - my team leader is on holiday, and my colleague RSB is facilitating a week's worth of patient empowerment (calling it 'structured education' doesn't do justice to the cult that is DAFNE - Dosing Adjustment For Normal Eating. More about that another time perhaps). So it fell to me this week to support the multi-disciplinary ante-natal clinics in both hospitals within the NHS Trust where I work. I have had my fill of pregnant women this week, what with the Royal obsession to add to the mix.

In each hospital, the ante-natal diabetes multi-disciplinary team (MDT) is allocated a room that is much too small, and the poor patients are channelled through various procedures - scans, samples, tests - before they start the proper waiting. When a clinic room is free, a patient occupies it, and various members of the team visit them until everyone who needs to see them has done so and the patients moves on to wherever else they may have to go, freeing up the room for the next victim. The team office, waiting rooms and clinic rooms are all much too hot - the radiator in one of the team offices was actually pumping out heat, with no means of switching it off on the hottest day in 30 years.

In the hospital where I normally work, the ante-natal department has just been remodelled, and the team office has been created from a room that used to be a cupboard, without any ventilation at all and with a very unpleasant lingering smell. The room is long and thin, with space for about six people all standing in a line (there is no room for a chair except at the far end where there is a computer). The MDT consists of obstetrics and gynaecology doctors, diabetes doctors, Diabetes Specialist Midwives, Nurses and Dietitians, a Healthcare Assistant and various students within all these specialities. In other words, more than six people. The other hospital has a team office that is a more convenient shape, but with little more space - except it does have a window, which even opens.

I am very new to the ante-natal clinic, having observed a couple of times and taken part just once or twice. I don't know much about what goes on during a pregnancy, what tests or scans are required and when, and I don't really understand how the patient journey is conducted, either in general throughout a pregnancy, or on a specific clinic visit. The patients' files are filled with impenetrable graphs and printouts filed in seemingly random order, and there may be several pregnancies-worth of notes in a file. I noticed that there were a couple of heavy duty electric torches in the team office, the sort that you take out of the boot of the car on a snowy night to find out what the noise in the back garden is. I was going to enquire what they were for, but then thought about what sort of clinic this was, and decided against it.

I'm not sure how the different teams operating in the ante-natal clinic fit together - reception staff, then nurses and midwives managing the routine tests, then the fetal scanning team, and then our team at the end of the line. What I do know is that in the two days of ante-natal clinics I saw more patients than in my last two weeks of clinics put together - something like 22 of them - and most of them had to wait longer than in any other of my clinics, more than an hour in some cases. The majority have Gestational Diabetes, but there were a few with Type 1 and Type 2 Diabetes. It was tiring but satisfying to be occupied so intensely, rather than sitting in a general clinic room wondering how long to wait before assuming that the scheduled patient is definitely not coming.

There are some who need interpreters - Turkish and Arabic on this occasion - and I find this quite interesting, especially Arabic. Combining my knowledge of Hebrew with my recent study session on Ramadan, I was entertaining myself by trying to anticipate some of the words used. It turns out that words for 'onion' and 'carrot' are very similar in Hebrew and Arabic, but the Arabic for 'meat' sounds like the Hebrew for 'bread'. I had met the Arabic interpreter before. She told me that she teaches Arabic at evening classes at a nearby school, and I am tempted to sign up (if my employment contract is extended).

Four more Gestational Diabetes patients are booked in for Friday afternoon, my least favourite time of the week by a long way. Two patients are booked at 1.30 p.m., who are seen by myself and a Diabetes Specialist Midwife (we swap after half an hour), and two more arrive at 2.30 p.m. In theory we are all done and dusted by 3.30 p.m., enabling me to go home at my scheduled time of 4 p.m. In practice, I'm lucky to be out of there by 4.30 p.m., and often it is later. This is on a Friday afternoon, remember, and I then have to set off down the motorway for the journey home. We are all agreed that this is unsatisfactory, but so far there has been no alternative proposal for various legitimate reasons including a key member of staff being away, and lack of clinic space and time.

I will be taking over the Dietitian role in one of the two ante-natal clinic on a regular basis starting in September, so will be making more of an effort to understand how things are done and how I fit into the team. If we can streamline the workflow a little better, it will not only improve the patient experience, but ours too.

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.