Recent events

Les Deux Alpes, March 2014

Having caught up with events from a month or two ago, it's time to return to the more recent past. A quick summary:

• I went to the Food and Drink Festival
• Two tradesmen have provided quotes
• Domestic appliances continue to cause trouble
• The hall is showing signs of water leakage at gutter level
• My mobile phone had a fit in the night
• The Tuesday community diabetes clinics are interesting
• I attended a presentation given by a colleague
• I attended a public meeting and had to do some facilitation
• The second patient education course that I'm delivering has started
• I had to prepare for an upcoming course
• I had a 'trial lesson' in a glider.

The Royal Leamington Spa Food and Drink Festival was lovely, the weather was fine and warm and reports in the paper suggest there were 25,000 visitors. I can believe it; there were certainly crowds. I bought some lime pickle and chose a South African lamb curry for lunch on Saturday, and Caribbean jerk chicken with rice and peas on Sunday.

Tradesman report: The fourth carpenter I contacted actually came to see the airing cupboard, and has even followed up with a quote. I would ideally like to get a second opinion, which means finding a fifth carpenter. I am not optimistic, but I have another two phone numbers. The electrician has provided a quote for replacing the fuse box; the oven is working well on its fan setting after its repair, but the grill has now stopped working - I will do some research before calling in a repairman this time. And there is staining on the newly painted hall walls that suggest the guttering or leading might be leaking - this is a job for Alf. Lots to do in the house, as always. I won't even mention the garden, it is too distressing.

We had a disturbed night when, for no apparent reason, my mobile phone started to reboot itself over and over again at about 3 a.m. The battery is built in and can't be removed, so I took the phone downstairs and attempted to put the SIM card into a different phone. What with being half asleep I managed to lose the SIM completely, leaving me phoneless. Then there was the faff of having to find an alternative method of setting the morning alarm, and finding a way to take the phone into a shop to sort it out. It turns out that EE had made a mess of an automatic software update, so I met several other people in the shop with the same problem. It's fine now, and only cost a few hours sleep and a trip into town.

The main work news concerns the reason that I have now been employed on Tuesdays - the Clinical Commissioning Group in the area, which is responsible for making sure that all health services are available as necessary, has stumped up some money in order to try and address the backlog of patients waiting for their structured education on Type 2 Diabetes (called DESMOND). I will be trained to deliver this training next week, and have received the pack which requires me to observe a course before I do the training myself. There are none in the area to observe in the time available, so they have sent me three DVDs to watch, and some academic papers to read as well as some written homework.

My Tuesdays are now planned out until December, with community clinics to cover for a colleague who is on holiday and then to allow her to do some home visits, and then four DESMOND courses have been scheduled. The community clinics are very similar to my hospital ones, but there are a few different options around the edges for referral to local activity programmes and weight management groups. The biggest challenges were getting me physical access to the building, and electronic access to the computer systems. I still don't have a code to allow me to print, but when I do I will have access to the biggest fanciest printer/copier in the world.

My colleague's presentation was about the lower carbohydrate diets that we are facilitating for people with diabetes who want to lose weight, and she was very good. The public meeting was the first of two where Diabetes UK and the Clinical Commissioning Group have invited people with diabetes to respond to proposals for change to their services. There are various eminent personages who introduce themselves, then facilitated groups to provide the attendees' views about what they like and don't like about diabetes services, and then a panel of experts to answer specific questions. This time I was asked to facilitate the discussion on one table; next time I am on the panel of experts. It will be daunting. The first question to the panel this time was about the quality of hospital food, and there are no easy answers to that one.

The second course for people with Type 1 Diabetes has gone quite well. The team is very relaxed about my contribution, but I feel that I need a bit more rigour in my approach. This may be achieved by going on the DESMOND course - I have watched the DVDs, all six hours of them, and done my homework too. I believe that I will need to do lesson plans, and peer review, and will have to prove that I am competent before being let loose on real people. I'm hoping to follow the same process to improve my delivery of the the Type 1 education, but we'll see.

You'll have to wait for the account of my flight in the glider, and it may be a while. Next week is packed with extra-curricular events including the trip to London for the DESMOND training.

Consultations: doing and observing

Sissinghurst, June 2012

There have been complaints. Actually, there has been one complaint. All right, it wasn't even a complaint, it was a phone call, and there was a visit too, in both of which the absence of new blog material had been noted with some concern. Mild concern. Actually, probably no concern at all, and it was nice to have a chat, and I'm glad that the cat has returned and is getting on with the other three, and everyone is doing well. And that the bees are all right at the moment, and the sheep, and the new mowing machine that doubles as a device to take out your enemies at the knees.

Latest employment news: I have been offered an interview for the job that is nearer, but with the interview still a week away at the time of writing (although maybe not at the time of publishing) I have had to seek advice from my elders and betters about what to do about the first job, the one that I have been offered subject to Criminal Records clearance and references. The advice I was given was "put your head down and keep quiet until they give you something in writing." So that is what I am doing, and they haven't given me anything in writing or even contacted me by phone or email, even though it has been weeks and I'm sure that references and CRB checks are all done. I haven't handed my notice in for my current job, so I won't be starting any new job until mid-January at least.

The interview for the newer job requires me to deliver a presentation on the challenges and opportunities of working in a multi-disciplinary diabetes team in the community. As luck would have it, I had previously arranged to spend some time this week with an experienced Dietitian working in a multi-disciplinary diabetes team in the community, so I was hoping to get her to write my presentation for me. She is much too experienced to let me get away with that one, but she did give me a few ideas that I can incorporate into the work of fiction that will be my presentation. It only needs to be ten minutes long, and I can probably keep up the pretence of knowing what I'm talking about for that length of time.

I had planned to spend the morning in the community diabetes clinic observing the Dietitian and the Specialist Nurse and anyone else who would stand still long enough for me to observe them. I did do quite a bit of observing, but just to prove that things are the same the world over, all the patients booked into the clinic turned up and the Dietitian and Nurse ran out of time, which resulted in me being asked to do a dietetic consultation with one of the patients. It was fine. I like clinics. I was hoping to go out and see some home visits in the afternoon, but there weren't any.

Watching the experienced Dietitian do her consultations was wonderful. It should be compulsory, every year or so, to sit in with someone who knows what they are doing. Managing the flow of the conversation is like directing the flow of water through sand. It is liable to change course abruptly in random directions, and the Dietitian's job is to keep diverting the stream back towards the proper destination, damming unwanted breaches of the riverbank, and eventually ensuring that the conversation and all of its tributaries reach a constructive conclusion, joining the greater body of the evidence-based ocean.

What I particularly noted was that it isn't always necessary to address everything that the patient brings to the appointment. In fact, it isn't even necessary to acknowledge some of it, and when the patient is in fact a little bit 'mental' (a technical term), then it's a very useful tactic to acknowledge only those aspects of the conversation that are relevant to the matter in hand, i.e. diabetes in this case. And I should really think a little bit more before I answer questions, but I'm not sure how I will remember to do this without a big sign in the clinic room saying 'WAIT - THINK' and it might be a bit obvious, not to say off-putting to the patient.

My own clinic has been changed, and I'm on a different day now, so I'm doing follow-up appointments for patients who were originally seen (maybe several times) by a different Dietitian. It is interesting to see how other people do things, and I've been able to report back to her about a couple of patients who have achieved really good outcomes following her advice, and have asked me to thank her. There is no difference in the mix of conditions in this clinic though - mostly IBS and obesity, with a few malnourished individuals thrown in for good measure. I even had to use an interpreter. I have also supervised a student doing consultations in an outpatient clinic, and am encouraged by a) recognising many of the mistakes the student made as being things that I did as a student, and b) being confident that I don't do them any more. At least, not often. I hope.

Last week the Diabetes UK local group had their last talk before Christmas, from a Dietitian. I missed it. I meant to go, but somehow had 'forgotten' to put the date in my diary. I think this was a successful attempt by my subconscious to prevent me from going, in order to avoid unpleasantness, and it meant that I went to badminton instead and had a good time.

Discharge

Pump Room Gardens, May 2012

Today is Friday, the last of my pointless days off, without which I would have felt cheated, but after which there is always twice as much work to do. So yesterday was my last full day in the week, trying at least to see every patient who hadn't been seen the previous week. Yes, I'm struggling to review longstanding patients once a fortnight now.

While I was thus engaged, every colleague in the hospital was conspiring against me. A patient is going home with a tube feed, and both colleagues in the Dietetics office who help out in this situation were on holiday. Another patient may be going home on a puree diet, and will need information and advice on how to achieve this at home. A doctor has specifically requested a Dietitian to see a patient with interesting blood results as soon as possible. A previously tube-fed patient is now able to eat, so the tube feed has to be adjusted or discontinued. A Ward Manager wanted to talk to me in her office about a specific patient, and I had a lecture to attend at lunchtime and my first clinical supervision after lunch.

Patients leaving my wards are almost as much work as patients who stay there. I am still trying to grasp all the different options and processes that need to be followed. If they are eating and drinking well when they go home I can put their Dietetic Record Card in a plastic basket in the office and relax (this is rare). There is a different basket for 'RIP' cards. If a patient is transferred to a different hospital, we have to contact the dietitians there and let them know what the situation is, especially if the patient is being tube-fed, and sometimes send the Record Card over as well (depending on whether the hospital is in our region or not).

If a patient goes home but is not likely to eat and drink enough, there are a number of options. I can write to the GP asking for supplements to be prescribed for a period of time and leave it up to the GP to review the situation, or send the patient an outpatient appointment with a Dietitian (there is a different basket for the Record Card if this is the case). If the patient is going to a nursing home, I can be fairly confident that their nutritional status will be monitored, but I can pass the Record Card to our Community Dietitian if there are any worries. She also looks after every patient who is sent home with a feeding tube, whether it is being used or not. Even if not used, the tube needs to be looked after, and eventually removed.

If a tube is being used for feeding into the stomach, there are many administrative and practical steps that must be taken before discharge. The patient needs to be sent home with enough supplies to ensure they are fed until further supplies are delivered. This means bags of feed (between 7 and 14 kg altogether), a pump, a stand, tubes to connect the feeding tube and the feed, syringes for flushing the tube with water, and sometimes a water container have to be physically taken to the ward in time for the discharge. There is a form that gives the patient and/or their carers instructions on how much feed to give at what rate over a specific period of time and how much additional water is needed. They need to sign a form to consent to their address details being given to the company that will be delivering the feed. The Dietitian has to register the patient with this company and provide all the same details and more, and then print a letter to the GP asking for the feed prescription to be arranged. Then all this is handed over with the Record Card to the Community Dietitian. Sometimes the ward forgets to mention that someone is due to be discharged on a feed imminently, so everything else has to stop until it is all sorted out.

More difficult is if the patient needs a modified texture diet, especially if they are elderly. Constructing a nutritionally adequate diet when everything has to be blended to a smooth lump-free puree is not straightforward, especially if the patient doesn't have a blender or liquidiser. If fluids also need to be thickened, then the choice of supplements is limited too. Chances are that the patient will lose weight, become dehydrated, and/or eat or drink something that goes down the wrong way and they end up with a chest infection or worse. There is a commercial company that will deliver pureed ready meals, a bit like Meals on Wheels, which can help a great deal, as long as the patient can afford it. It is likely that the patient will be on supplements long-term, and even need to be seen occasionally in outpatients.

There are different baskets for Record Cards of clinic outpatients who are going to come back for a further appointment, outpatients who have been discharged, and outpatients who didn't attend their appointments. There is another basket of Record Cards for upcoming outpatient clinics. There are probably more baskets that I'm not even aware of yet, perhaps for newly referred patients, and for IV feeders at home (Home Parenteral Nutrition).The Dietetic admin staff who manage all these baskets (and much more) are universally helpful, patient and good-natured, and don't seem to mind me asking the same questions multiple times. In fact, all the Dietetic staff seem friendly and supportive (have I mentioned that before? Probably). Tonight we have arranged a departmental outing in a local Indian restaurant, and despite my nervousness about large social groups, I think it will be fun.