Nurse Rosenberg

Here we are at the end of February, and I feel pretty good about how the month has gone, despite the physiotherapy exercises having done very little to improve the knee situation. Other things have been very helpful in lifting my mood, including Zooming with at least four different groups of friends, walking with another friend and his dog, and some pretty inspirational online talks.

I have completed my first shift as a Covid-19 vaccinator. It started with me going to the location on the first floor of the hospital where the e-roster system indicated I would be working, to find the door locked and everything inside looking dark. So I returned to the Portakabin in the car park, only to find that locked too, but with someone waiting outside who let me into the secret of access to the first floor ward (knock hard on the door). So I went up there again and managed to get in, only to be told that I was actually going to be working in the Portakabin. A good start.

There were about ten of us working there as vaccinators plus about four doing reception and admin on my shift, which ran from 7.30am to 2pm. Reception and admin are about checking that people are who they say they are and are entitled to receive the vaccine, answering basic questions about the process, enabling them to avoid being charged for parking, supervising them for the 15 minutes they must wait afterwards in case of adverse reaction, and setting a date for the second dose.

There are three different roles for which I needed to be supervised and signed off. One is going through the protocol and ticking the boxes on the paperwork to establish entitlement to the vaccine and any contra-indications to be taken into account - for example, people with clotting and bleeding disorders are not necessarily disqualified but vaccinators need to be aware. The second is the process of diluting the vaccine and drawing it up into syringes for administration, and the third is checking paperwork before sticking the needle in. 

The paperwork role is pretty straightforward, the main skill being remembering to ask all the questions and providing the necessary information - it takes two weeks for the first dose to reach full effect, you can still catch Covid, you need to carry on taking all precautions. Reconstituting the vaccine is fiddly. There are many, many steps - drawing up saline, mixing with the vaccine in a particular way, then getting six doses out of one vial, and timing everything to make sure no doses are wasted. When I did the first part of my training a month ago we were only being asked to get five doses out of a vial, which is obviously much easier. I got the hang of it with a bit of practice.

Sticking needles into arms was obviously the most nerve racking for someone who has always been pleased that being a Dietitian does not require you to touch people at all, and certainly never expected to be performing this role! The supervisor was really good and took things just at the right rate, and my first victim was very calm - in fact, they all were, even the one who said she sometimes went a bit funny with needles. I did get some strange flashbacks later in the evening of needles going into arms, but nothing traumatic.

The most interesting experience came when one of my victims was sitting ready to be injected, and I was running through the information he'd provided on the form. In the place where you state your role in order to ensure that you qualify for our clinic (which is for health service and associated roles only) he had written 'Transport'. When I asked what sort of transport, he said 'Uber'. So I went off to fetch the supervising nurse.

I'd been warned that the taxi drivers of the area had found out how to play the system and were presenting themselves at the clinic despite not being entitled to a vaccine. This chap had got through the reception and the paperwork stage, where I would have thought his entitlement would have been challenged, and nearly got his jab. He was turned away unvaccinated. But it does expose the weakness of a fairly loosely defined protocol operated by well-meaning health workers who are reluctant to deal with conflict. Much easier just to let people get away with it than challenge their entitlement.

This decision was made more difficult because it was not very busy in the clinic that day. We are reaching the end of the wave of first doses, and second doses are about to become available at which point it will turn busy again. We only have a certain allocation of vaccines, so it's important not to give too many first doses otherwise we will run out of second doses - hence the criteria for entitlement. I was lucky to do my first shift when I did, because it would have been much more stressful if lines of people were forming outside and there was pressure to operate quickly. As it was I had time to practise and get things right in my own way. I've now booked a day a week for the next six weeks and two days on the weeks when I'm on leave from my main job.

The latest 'road map' out of lockdown has made me feel slightly better because of having an idea of how long things will take to change, and at the same time makes me feel slightly worse because of having an idea of how long things will take to change. There is a risk of raising hopes and expectations only to be disappointed. So I'm still trying hard to take it a day at a time, finding ways to tame my increasingly wild hair, and taking pleasure in music, in visiting mum and dad, in walking, in Zooming with friends, and in films. It's hard to remember what it was like to play badminton.

Risks Must Be Assessed

Stilt walkers, Munich, December 2019

I've been on holiday again, and when I go away, blog continuity suffers. I'll do my best to remember what happened before my holiday and see how we go. This post is about work, and there ought to be another blog at some point about what happened outside work and on my holiday, which was significant.

There were two students. After a lull when students were withdrawn, they're back with a vengeance - we have four, but they can't all be accommodated in the dietetic office over at the main hospital. In fact the dietetic office at the main hospital has been transformed by the introduction of screens, a one-way traffic system and all sorts of other efforts to allow safe distancing without everyone having to wear masks in the office all of the time. I haven't been there, and I hope not to have to go there (ever), but I read the emails that come round. Anyway, students. I had a different one with me for two Mondays in a row.

What with my patients as always being on the complex end of the spectrum, there is never much opportunity for a student to do much more than observe. Now we've got no patients coming in person for face to face consultations either, so all they can do is listen. We use a telephone with two handsets that's designed to be used for the telephone interpreting service. To make it a bit more interesting I asked the other team members (Doctor, Nurse) if they would mind having the students spend a bit of time listening to their consultations as well as mine, and asked the student to write a piece about multidisciplinary working, or diabetes, or really whatever they like, I don't care (I didn't tell them the last bit). It's hard work, though.

Then along with all this there was a meeting - online, with my new headset and camera - to talk about Structured Education. The Clinical Commissioning Group and DSNs and Dietitians from three NHS Trusts are working together under the leadership of a Dietetic Manager (not from my Trust) to sort out the mess that is our Diabetes Education. Actually, our Trust is not in a mess, in fact the consensus has been to pretty much adopt all of our admin processes, educational materials and methods of delivery, which a) is flattering and b) means I don't have to worry about checking through everything to make sure that I agree with it. Although I'm pretty sure that I wouldn't have done that anyway, not now. I might have done a few years ago.

The meeting took two and a half hours, plus the time afterwards for me to do a few things I'd been volunteered to do, and then we had to arrange a smaller follow up meeting to tidy things up, all of which used up an enormous proportion of my two-day week and put me well behind with the 'talking to patients' work that I like to do. There were a number of other frustrations too, but I did manage to make the point to the Commissioners that it is all very well coming up with amazing ideas for delivering education, but we don't actually have the staff to deliver it (particularly Dietitians and admin). I've made the same point up my management chain and will just leave it there.

Since then I've managed to catch up with most of my clinical work, until today when I made the mistake of opening my mouth instead of keeping it firmly shut. Last week in the multidisciplinary clinic, the doctor was quite keen to talk about bringing some people in to the Centre to be seen in person, and we came up with a possible plan for the following fortnight. My mistake was to mention this to my Team Leader, who thought it would be fine until she mentioned it to her Manager, who said, "What about the Risk Assessment?"

So in order for me to see patients face to face, the risks have to be assessed and there are Procedures That Must Be Documented and Carried Out, I gather mainly around cleaning and PPE. Of course none of these risks has been assessed nor procedures documented or carried out, so I don't know what I'm supposed to do. If we all come down with Covid-19 and sue the Trust somebody will end up in trouble, but it would have been a great deal easier if I'd said nothing and just got on with it. Anyway, I told the DSN in charge that my Manager wants a Risk Assessment and Procedures, there was much rolling of eyes and then thankfully it was the end of my working week and I went home.

For the record, our Trust has two Covid-19 cases at present, both of them in the other hospital, and neither one in Intensive Care. We have to wear face coverings when patients are in the building (which they increasingly are), and add gloves and plastic aprons when patients are in the same room, and use hand sanitiser and/or wash hands a lot, and keep socially distanced from one another. When I finish on Tuesday I wipe down all the surfaces in my room as it's used by other people when I'm not there. There are many official signs up now with 2m markings on the floor and a perspex screen for reception, and some kind of classification of Green and Blue Zones which I confess I don't understand. Luckily the Diabetes Centre is a building in the car park so we don't get mixed up in the zoning and restrictions that are in place within the main hospital building.

So that's work. I'll try not to leave it so long before writing about Not Work.

Still going to work

Adhisthana, July 2019

You may remember that one of my colleagues from work was stuck in India. She was there for two months all told, but finally managed to get a flight home. The plane was full - no social distancing, although everyone wore a face mask - and although health screening questions were asked at the Indian end, there were no checks or restrictions at all at Heathrow.

So we asked the Trust HR and Occupational Health Departments about self-isolation, given that travelling in a plane is notorious for spreading infections at the best of times. They advised that as long as she didn't have symptoms she could come straight back to work. This is surprising, to say the least, but all I could do was to stay as far away from her as possible - she came back on a Tuesday so we only had one day in the building together before I had the rest of the week at home. Her situation is slightly complicated by the fact that we were advised to record Covid-19 in the personnel system as the reason for her absence, which was taken to mean that she had been ill with the virus, and therefore would now be better... Luckily for all of us, she has experienced no symptoms.

In case anyone was wondering, none of us has been tested for virus or antibodies, nor has anyone suggested that we should be. This is reasonable as we have very little contact with the public, with patients visiting the centre only for the procedures that simply can't be done over the phone. We now keep the front door locked and we have a new doorbell and a perspex screen in front of the reception desk. When any stranger enters the building we all put on face masks and after they leave the receptionist wipes down all the surfaces they may have touched. If we have to be in the same room as the visitor we wear plastic aprons and gloves as well as face masks, and we ought to wear goggles or a visor too but those of us with glasses are omitting that inconvenience. So far we are not requiring the visitor to wear a face mask. We all work in separate rooms, and when we come together for lunch we sit 2 metres apart.

I have somehow escaped the order that has taken all Dietitian back to the main hospital to work on plans for the apocalypse. Fortunately the apocalypse has not come to pass, so there are a lot of Dietitians at a loose end - I have no idea how they are occupying themselves. Every fortnight I have a very busy Monday with the multidisciplinary clinic that used to allow people to see me and a nurse and a doctor all at the same visit. As a stopgap measure we are sharing out the telephone calls to patients between me, the doctor and two nurses, and it's working moderately well.

However, all the outpatient clinics for all the Dietetic services including mine have been cancelled except for one clinic for each service. That single clinic is filled with only the most urgent cases, so I have no means of booking follow ups for patients that I want and have time to see. I have resorted to keeping a separate diary - my own offline booking system - to get round the restriction.

On a Monday when I wasn't involved with the multidisciplinary clinic I was asked to do one of the sole bookable clinics for diabetes, and it was quite a challenge especially as I had one patient whose first language was not English. I worked hard that day, and it was just as hard to work out how to record what I had done and make plans to follow up that patient. There was no point putting them back into the general clinic because then it wouldn't be me following up, and it was too complicated to just pass the patient back and forth between different Dietitians. A little while later I got a call from the admin team querying how to record the follow up for the patient - the answer being "You tell me." It would have been perfectly straightforward if they hadn't cancelled all my clinics.

Most of the time, however, we are working less hard than before.

The local community is supporting their front-line workers by providing food, which has led to a situation becoming known in the Diabetes Centre as Pizzagate. Various local suppliers are sending food to the hospital - sandwiches, snacks, chocolate and pizza. These arrive at the management offices for distribution, but there are loud grumblings of inequity - the managers are accused of creaming the best off for themselves before distributing to the wards, and we in the Diabetes Centre receive nothing. I try hard to keep out of these discussions, not least because there is no way I can fit pizza into 1200 kcal/day, but it is getting as bad as back in the days when everyone was moaning about parking all the time.

The (first) peak in Covid-19 cases seems to have passed, and now the word from the top is all about how we re-start services. We are in a good situation at the moment - wards are so empty in our hospital that the opportunity is being taken to redecorate - and we have the chance to think about how we would like to do things differently. With this in mind I volunteered to send out a call to arms to our Diabetes doctors, asking them to contribute to a discussion. Not one has responded to me, but it seems they are thinking about it. I'm not holding my breath.

Nothing at all to report

Paraty, Brazil, April 2019

There's so little to say that it hardly warrants a blog post. I'm fine, working 2 days, idling 5 days, still keeping up the running and the Zoom games and Zoom Buddhism and not feeling much like working in the garden at all. Or getting the stuff down from the loft. At the end of a period of such idleness I should be able to look back and say "but at least I got xx done." Doesn't look like that's going to happen based on the last week's activity. But today, with a supreme effort, I have made a start.

At work, I got a call to say that the Ward Dietitian's Assistant was off sick, so could I liaise with her in case she needs help. She doesn't need help - there are more empty beds in the hospital than at any time anyone can remember - but she is finding that seeing people on the wards takes a lot longer than it used to, what with having to put on all the PPE and take it off again all the time. So she gave me a pile of telephone follow ups for cardiac rehab, which was most interesting. I managed to do five of them, not all that well I suspect, but good enough. It was particularly nice being able to tell someone without diabetes that they could have fruit juice if they liked.

And that's really all there is to report.

Being prepared

Adhsithana, July 2019

A lot seems to happen between each of my two-day working weeks, and going back to work on Monday after nearly two weeks away it felt like I'd been gone for a lot longer. Our Consultant was back to lead his multi-disciplinary clinic with me and the nurses, still by telephone, so we spent the  first part of the day going through the list and deciding who was going to contact which patient.

It felt good to have something constructive to do, because the edicts coming from the Dietetic department (often with the rider NO EXCEPTIONS) still forbade any outpatient clinics, leaving me with no patients and nothing else to do. And at lunchtime the doctor had brought in some games for us to play! He is a big games fan, so he brought three different types, each fun in itself but each with an educational purpose as well. One was about collaboration and communication, another about multi-tasking and working under stress, and the third was about interpreting non-verbal communication. It certainly made a change from the usual inane chatter about what has been on TV and the latest rumours about lockdown.

Occasionally a patient is allowed to come and see one of us in person, in which case we have to get fully togged up in uniform, mask, gloves and apron and everyone else keeps out of the way. Afterwards all the surfaces in the room and door handles in the building are wiped down. At lunchtime we sit as far from one another as possible. We are all still well, and our colleague who was stuck in India is still stuck in India.

On Tuesday I'd had enough of the enforced inactivity, and wrote a slightly terse note to my team leader saying that I was going to be telephoning patients whether she liked it or not, seeing as they still have diabetes, some of them still need a bit of help,  and I had literally nothing else to do. My colleagues still have their clinics, and when they identify someone who would benefit from a dietetic consultation it seemed quite wrong to tell them that I can't do it. Luckily this produced an acknowledgement that this did seem to be an appropriate use of my time, so I've got the green light for doing at least part of my job.

My uniform was delivered to the Ward Dietitian, and the Inpatient team identified that her Dietetic Assistant was off sick so I might actually be needed to support her. So I trotted over to pick up the uniform and find out more. She has no patients either and is as grumpy as me about all the outpatient appointments for cardiac rehab being cancelled. I'll give her a call on Monday to find out whether there's anything there for me to do by then.

With all the criticism I see online about arrangements within the NHS, it seems that the Trust where I work is relatively well prepared. I don't know about Critical Care, but elsewhere there is PPE and we are told that there is still capacity for the predicted surge in cases, and ventilators at the ready. There was a Panorama team at the main hospital who broadcast their documentary on Monday, which seems to support my impression of preparedness. And our photocopy room is full of boxes of donated pots of porridge, Snack-a-Jacks, Dorritos and Easter eggs.

Too much information

Rio de Janeiro Botanical Gardens, April 2019

So we finish another week of 'lockdown'. I'm not finding it difficult or stressful at all, but I seem to be a lucky soul in not getting anxious about things that are out of my control. And even things that are within my control don't bother me that much either. And I'm not exactly locked down, what with having to go out to work two days a week.

At work, I'm getting bombarded with information from all sides that changes almost every day. The Dietetic Department must be one of the most well-organised in the hospital. We have two joint Managers who are excellent, not that I see them more than once a year. From the first sign that arrangements within the hospital would very likely change dramatically over the next weeks and months, the whole department began to change in anticipation.

Face to face consultations stopped first in favour of telephone calls, shortly before all outpatient clinics were stopped. This had two benefits. Firstly there was less for the department to do which was helpful as some staff were already self-isolating,  Secondly, all those whose jobs included outpatient work were suddenly available, and they were put to work in formulating operational procedures in four strands: Critical Care, Non-critical Inpatients, Outpatients, and Community.

Everyone in the department was assigned to one of these teams . Except that I seem to be in two teams: Inpatient and Outpatient.

I had a call at home from one of the Inpatient leads, telling me that I would be required on the wards at the hospital where I work, which is not where all the Covid-19 cases will be. At my hospital we will be taking everybody who doesn't have the virus who has been displaced from the other hospital. I left my post on the wards about seven years ago with grateful thanks, but this is the situation now. It was agreed that I would need an update, so I arranged to go and meet the current ward Dietitian.

In the meantime, I successfully argued that there wasn't much I could do to help, so they might as well allow me to carry on doing my clinics (over the phone) until after Easter. But when I arrived at work on the following Monday, my clinics had been cancelled anyway. This left me with absolutely nothing to do, and then I was told that I was actually going to be in the Outpatient team, maybe as well as the Inpatient team. But there was still nothing for me to do, except for reading all the emails that contained all sorts of policies and procedures and spreadsheets and guidelines and drafts.

At the same time as all this, we were getting frequent updates from the top level Trust management team. The latest was a change in the policy for wearing Personal Protective Equipment (PPE) - a mask would now be required for any type of patient contact, even in outpatients. A few patients are still going to be coming to the Diabetes Centre in person - it isn't possible to start someone on insulin over the phone, for example. In case you were wondering, there's been no sign of uniforms yet. But we are all going to get an Easter Egg, so that's nice.

I spent an hour or two with the ward Dietitian, a young man that I didn't know who was covering for the usual Dietitian's annual leave. He had nothing to do either, so it didn't feel too bad to take up his time reminding me of the calculation for tube feeding, going through the specifications for different nutritional supplements, hospital policy on drug charts, menus, meals and snacks. Nothing significant has changed in the last seven years but a lot of the detail was different, and on the whole, better and more organised.

So I'm supposed to keep an eye on this torrent of emails while I have time off for the visit of a cousin who is now not coming, and after Easter I have no idea what I'll be doing. The Consultant's Diabetes clinic is still going ahead (by telephone) so my preference would be to do my actual job, but who knows if this will be allowed. The Consultant himself has been tested for the virus and found positive, but he has now recovered; there is talk that we might eventually be tested but we are low on the list of priorities so it won't be soon. So far, my immediate colleagues and I all remain well.

Tedious parking issues

Krakow Botanic Garden, July 2016

I'm still spending many spare minutes engaged in eBay trading, and my Canadian buyer is still keeping the boat afloat. Meanwhile other members of the family are busying themselves with other aspects of dad's collected material, with limited success. The past weekend contained a trip to The North West, where the weather was cold but the welcome was warm. Part of the reason behind the trip was to stay with old friends I hadn't seen for more than five years, but on the way there and back I offered to assist with the further clearing and emptying of goods currently stored in basement rooms. Just the threat of my presence was enough to prompt the requisite activity - I hardly had to do anything, and even acquired a certain proportion of said goods, some of which I have passed on to Ilf.

Yes, Ilf has paid another visit, and the upstairs spare room is looking even better with its final coat of paint. Next it will need curtains, a bedside table, the clothes rail that returned with me from The North West, and I'm thinking of sanding and painting a wooden chair that is currently in the garage looking very sad. That will complete the bedroom half of the spare room; I haven't thought too much about the office half yet. I made the follow up trip to the kitchen design shop to talk through some changes, and the plan is nearly finished. I'm still feeling good about the progress of the LTRP.

At work the talk has been of parking for a very long time, and is becoming extremely tedious. The Trust has two hospital sites; the one where I don't work (Hospital A) has insufficient parking for both staff and patients, leading to much stress. When I used to do a clinic there, patients occasionally phoned the reception desk from the car park, and more than once it was to say they were not coming to their appointment simply because there was nowhere to park. The hospital where I do work (Hospital B) has plenty of parking space.

Parking passes used to be allocated to staff at Hospital A on some arcane basis that probably had a lot to do with historical precedent and seniority. When I worked there, I used to park on a nearby housing estate that is 20 minutes' walk away from the hospital site. Since I stopped working there, the housing estate has introduced residents-only parking, so staff would park in the Tesco car park, which is 25 minutes away. Tesco is now limiting its free parking to exclude such visitors, and I really don't know what staff do any more.

It was decided that a fairer system needed to be introduced, so all staff are being invited to re-apply for parking passes which will be awarded on the basis of need, taking account of the requirements of the job role and public transport options. These are not free passes, but they cost less than the daily parking charges that patients pay. They used to be charged at different rates depending on pay grade and hours worked, so part-timers and those on low pay grades paid less. The new system is a flat rate for all from part-time cleaner to Chief Executive.

Throughout the extended period of time when details were slowly being made available to staff, it was never made clear whether these changes would apply at Hospital B, where there is no parking problem. The main grouse in my department was the unfairness of changing from proportional pricing to a flat rate, but parking raises such high emotion that barely a day went by without someone complaining afresh about the unfairness, which usually set someone else off, sometimes on an unrelated course, usually about the changes to the retirement pension entitlement. Parking, pensions, more parking - most lunchtimes descended into dissatisfied whingeing.

At last the day came when we could finally apply for a new pass under the new, 'fairer' guidelines. My goodness, the complaining escalated to unimaginable heights when it was discovered that anyone living nearer than two miles from Hospital B was going to be denied a parking pass on principle. Emails were fired off like cannonades - secure bicycle parking was going to be needed, husbands were going to set up lift sharing services, people couldn't be expected to walk all that way at their age, and what if it snowed? I felt like saying that I would love to work within walking distance of my home and not have to pay for parking or petrol at all.

Things calmed down when one member of staff was informed that there had been a mistake, and the two mile limit was supposed to apply to Hospital A only, given that parking capacity at Hospital B was adequate for all who wanted passes. But the price increase would still apply at Hospital B. And this is where we stand at present, and I hope they will all stop moaning about it soon.

In other news, my aspidistra is flowering!

Work, play, the usual

Krakow Botanical Gardens, July 2016 

Last week was exhausting but I don't quite know why, because I did less than the usual amount - not going to badminton one Thursday for example, spending the whole evening reading and listening to the radio instead. I did go into Birmingham on one of my days off, because I'd gone and bashed the baritone sax somehow and bent one of the lower keys out of place, so I took it to the menders. This also gave me the opportunity to have a lovely day in Birmingham, where I went to the cinema and to my favourite Cafe Soya.

I also spent one day of one weekend at a Buddhist 'retreat', which was actually just four hours in the village hall where we go on regular Tuesday nights. The person who was due to lead wasn't even able to come so it was shorter than planned, mostly meditation, with a bit of help from an online recorded talk. I discovered it's much better to meditate when not falling asleep at the end of a day tramping round Birmingham or chopping down shrubbery in the garden. There wasn't a lot of overt Buddhism, just a bit of a discussion about how we are responsible for our own feelings. To be honest I haven't disagreed with much that Buddhism has to say, it all seems very sensible and I've reached many of the same conclusions through my own reflections. And I still enjoy sitting quietly trying to rest my mind in a room full of like-minded individuals.

At home the LTRP continues with plans for the kitchen upgrade being completed and submitted for planning permission, since there will be extra glass and a wall is being moved. This won't progress any further for a number of weeks, so my next indoor project has to be emptying the loft so that the lighting in the room below can be fixed. I've also been in touch with a damp investigation company because of a couple of patches that need looking into.

My ongoing garden project has taken so, so much time. The lawn is still looking ropey but I've planted a million small bulbs and some baby plants that I enthusiastically bought thinking that the garden could do with some spring and summer colour. The effort of weeding the beds and planting everything was probably worth it, but I'm really tired of having to spend so much time keeping it under control. Astroturf and concrete has never seemed so attractive.

At work a new 'junior' nurse has started, and interviews have taken place to replace the other nurse who is now retired. When we are fully staffed there may be scope to move forward after the long hiatus, and improve services rather than just keeping up with what we can manage. The newly recruited nurse will have to work three months notice, and that will start only after all the formalities of the criminal records check and the formal job offer, so we won't be seeing her actually working with us until well into next year.

Now I have to go and pack because I am having a Holiday. Pip pip!

Outpatients and inpatients: clinics and wards

Groombridge Place, June 2013

The consultant-led clinics have been a bit like a roller coaster for a week or two. One of our regular consultants has been ill, and sometimes another doctor has provided cover, and sometimes the admin staff have had to try and contact everyone to cancel at short notice, and sometimes patients have turned up and been seen or not seen depending on who's available and what's needed.

For one particularly busy pump clinic (where patients with Type 1 Diabetes who are using insulin pumps usually spend much more time with the Diabetes Specialist Nurse than in most clinics), we only had one DSN, and the consultant delegated the clinic to two subordinates, neither of whom was familiar with how to manage a patient using a pump. This meant that the poor DSN had to support the doctors as well as trying to do her own job. The whole thing provided a pretty unsatisfactory experience for the patients - none of whom complained, despite having to wait ages.

The whole scenario was relayed back to the consultant, who overcompensated the following week by bringing three doctors with him. Unfortunately we don't have enough rooms in the building to house all these doctors as well as ourselves, and consequently neither the DSNs nor I were able to see patients and we had to squeeze into rooms occupied by researchers and secretaries. There were also far fewer patients booked into this clinic than the previous week, which meant all these doctors had long gaps between patients. At one point, a patient with a baby and a toddler was dealing with a nappy change in the room I was in, and the only place left for me to sit was in the waiting room.

This is unusual - most of the time the clinics run pretty efficiently and on time, and most times I get to see the people I think I should be seeing. I have taken to advertising the very low carbohydrate lifestyle with a few posters on the wall, and flyers given to the patients that I think might benefit. This has rustled up a few candidates, and I am starting to build towards a group that can meet regularly to share experiences and recipes and generally keep each other motivated. There are plenty of others who don't need or want to follow that diet, and I am still seeing new people all the time. It is always very interesting, even if I sometimes end a consultation thinking that I could have done better. There are plenty where I feel I did well.

And in between all this interesting and rewarding outpatient contact, for the last five weeks I have had to spend a day a week on the wards. I've disliked this type of dietetic work from the start, and now I've come to hate it. I would rather spend hours with a recalcitrant diabetic who has no intention of taking any advice from me or anyone else while ignoring spiralling blood glucose, than 15 minutes trying to get a confused malnourished inpatient to drink a sickly sweet milky supplement because that's all we have to offer. I would rather be resigned to the inevitability of diabetic-related complications than despair at the likelihood of hospital-acquired pneumonia.

I have enormous respect for the nurses and healthcare assistants on the wards, who are frequently doing three or four things at the same time, often unpleasant and involving bodily fluids or orifices or both, and who listen to me with patience and good humour even while I'm telling them what they already know. But despite my regard for ward staff and their dedication to doing the best they can, the institutional setting thwarts most of their best efforts. I heard today about a patient with Type 1 Diabetes - elderly, frail - who kept having hypos while in hospital, so the doctor stopped their insulin. Just stopped it. Two days later, the patient had to be transferred to the main hospital for life-saving treatment in intensive care.

Our health service is amazing - the care that is offered without additional payment in NHS establishments is incredible. But I would do almost anything to avoid having to spend even one night in a hospital ward.

Shopping and running

Just a nice picture from 2004

Good news

The gastroparesis article is finished, the editor seems to like it, and has sent a pro-forma invoice for me to submit. They are going to pay me! Given the amount of time it took, the hourly rate probably works out at less than the minimum wage, and I ought to declare it for tax, but on the whole I think this qualifies as good news. Finishing the writing has freed up my Tuesdays for more interesting things.

I have been on a shopping spree. Nearly all online, of course, but still, it felt like going into the street and throwing money at things that I've wanted to get for a very long time but it was just too much effort to go into shops. Quite ordinary things mostly: a dish drainer tray, oven gloves, electronic kitchen scales, a new kitchen bin. The bin is not ordinary because it is a luxury touch-top item from Brabantia and cost more than all the other purchases put together, but it is a thing of beauty while being utterly functional.

I also bought a new mobile phone, or more accurately, a phone contract that comes with a new mobile phone. It had taken me two years to bump up against the limitations of my first smartphone, but eventually I realised that I should be able to download more than two apps and use the camera without it seizing up. It took a few long sessions on the Internet and a fairly extended discussion in a shop, but my new mobile has changed my views on smartphones, and has excelled in an entirely unexpected field - my running.

I downloaded an app that used the GPS signal to track my location and speed. This was hopeless on the old mobile, but the new one coped very well. I turned the app on at the start of the run and then examined it at the end and it told me all about my route and speed and it was great. Then it emailed me a link to create a Spotify playlist, so I thought that would be fun. I no longer need or want the plinky-plonky music that came with the Couch to 5k podcast, but it's much less boring to run when listening to music.

The revelation came when I managed to put all these things together for my second Parkrun. The phone was robust enough to access and play the music, and I started up the running app alongside it and they both worked together, and I plugged in the earphones and I could listen as I ran. It wasn't even raining. All of a sudden, a few minutes into the run, the music was interrupted for a second and the running app gave me an update on how I was doing - how far and how fast I had run. I'm no newcomer to the power of the Interwebnets, but this was a combination of utility and ease of use that I found astounding.

So my running career has culminated in a time of 35-and-a-bit minutes for 5 km, which I am very pleased with. A friend was also there on Saturday, and speaking to him afterwards I was sure that I wasn't going to do any more runs, because all the way through I'd been thinking how tedious it all was, and how much more fun it is playing badminton. Subsequently, however, I looked back on the event with some pleasure, and now I'm not so sure that I won't do it again. I think our holiday will get in the way, but we'll see.

Lastly in the good news category, I spent the best part of a whole day cleaning the oven. Not good news in itself, but it doesn't half look nice when it's clean. That should last about a week.

Bad news

I mentioned that my ipod died and was revived - well, it has died again. Rather than ending my life, Mr A has generously lent me his, which is so far performing as it should, unlike my laptop. The poor laptop has been groaning and shuddering for a while, taking about 20 minutes to boot up and generally being more sluggish than a snail without a home. Mr A bought me a new hard disk and operating system, and once the gastroparesis article was finished I started installing it. Unfortunately, the new and powerful hard disk seems to overtax the geriatric laptop (born in 2009) so that after about 10 minutes of usage the fan fires up noisily and within a minute or two it shuts down without further ado. That's as far as we've got with the laptop. Mr A is experimenting with my ipod to see if he can keep it alive for a bit longer.

Meanwhile at work, there is bad news masquerading as good news. The Dietetic Manager is juggling her many fecund female staff who seem to come back from maternity leave for all of three minutes before admitting to being pregnant again, and that's not counting the ones whose family members require their immediate attention or are themselves needing some time away from the office. Not to make light of a distressing situation, one of the two hospital Dietitians where I work is unavoidably absent, and the Manager is taking none of my excuses or suggestions, and requires me to spend some time On The Wards.

I have tried to keep this to the minimum that is ethically possible, but I notice that I seem to think patients need a lot less attention than the Dietetic Manager does. I am going to have to see people in hospital beds who need nutrition support, and it is not the area of dietetic practice that interests or attracts me, which strongly suggests I am not going to be very good at it. Let's hope my attitude and out-of-date skill set doesn't land me in trouble. I really don't like ward work.

As a carrot dangling before my eyes, however, the same Dietetic Manager has suggested that more paid work may be available in Diabetes. This has been mentioned before, and timescales are vague, as are the actual content and location of the extra work required. I'm not holding my breath. I've started to enjoy my Tuesdays and I'm not quite so keen as I used to be to rejoin the world of full time work.

Also in the bad news category is the garden. I have done absolutely no work in the garden this year, which has left us with an attractive meadow instead of a lawn, an enormous amount of foliage covering every inch of soil, most of the walls, and causing the 'paved' area to resemble, well, more garden. We are about to go away for a week, and it keeps raining, so the plants may well have staged their bid to take over the house as well by the time we get back. If you look closely, the picture shows the dominance of the ten-foot thistle over the puny efforts of the human race. Although its two colleagues were broken by wind/rain, it has latched itself on to the rose bush and shows no signs of halting its assault on humanity. Luckily, its legs have not yet formed so we may yet be able to conquer it when the time comes.

Lastly in the bad news category, you may have noticed a lack of book reviews (good news for some, I believe). I have picked on the book 'Middlemarch' for leisure reading, and it is proving to be hard going. I've found a few good audio books though, and shall take some less heavy duty reading on holiday next week. I wonder how many I should pack?

Oh yes, our doorbell has stopped working too.

Week two

'My' office

The first day of my second week saw me thrown in well and truly at the deep end. I arrived bright and early, hoping to find time at last to get the room sorted, discover the contents of the filing cabinet, and look for all the official diet sheets or patient information or whatever I could find. Instead, I found a) a note from the main DSN saying she forgot to mention she and the other principal DSN wouldn't be around until lunchtime, b) a list of 23 patients who were due to be seen by the doctor that morning, of whom I could see as many or as few as I chose. I also found a small table had appeared in 'my' room, which was absolutely ideal for sitting with patients.

That was a difficult morning, because I didn't understand what was going on or what was expected of me. I tried to get an explanation from the Support Worker and the DSN working in the clinic, and they did tell me how the doctor worked and what all their roles were, but despite repeatedly asking for suggestions, I didn't get much help with what I was supposed to do. I did the best I could, and at the end I discussed how I'd found it a bit hard going, at which point the DSN said "Well, Dietitian X [one of my colleagues who comes over to participate in a joint renal and diabetes clinic] does it like [this], and it seems to work very well." That's what I wanted to know at the start of the day; I don't know why she didn't tell me then. It's all a very big learning curve.

Then on Wednesday I went to the meeting with four other Dietitians, three working in Diabetes in the big hospital and the community, and one working with obese patients. There are distinct differences in the services offered by this team compared with my previous team - for example, I used to offer support for a Very Low Calorie Diet (using meal replacements like SlimFast) to enable weight loss; this team advocates carbohydrate reduction and has two different programs to support this approach. My carbohydrate reference tables went down very well, but my hypo treatment illustrations provoked some discussion about whether the appropriate treatment should be 10g or 15g fast-acting carbohydrate followed by 15g or 20g slower acting carbohydrate.

The main problem through the meeting was that I had to interrupt them repeatedly to get them to explain all sorts of jargon and references to people, events, places, teams, programs and treatments that I wasn't familiar with. I didn't manage to get the full overview of the service that I was hoping for, but I can easily get back in touch to clarify and get more information at a later date.

I still haven't had time in 'my' office to get the hang of what goes on. I was looking forward to time on Thursday, when it didn't seem that there was anything scheduled. At the end of Wednesday, however, the DSNs mentioned that they wouldn't be around on Thursday because they were attending a study day on Type 2 Diabetes, so of course I asked if it would be suitable for me to attend, which it was. So that was where I went on Thursday.

It was a full day of talks from various doctors, nurses and researcher, but Ben Goldacre's views were thoroughly borne out when it became clear that the sponsor's products were featured heavily. It was useful to me anyway, because my knowledge of Type 2 and its features and treatments is a bit flaky. One of the strongest non-pharmaceutical messages that was delivered was that if you are diagnosed with diabetes and continue to smoke, then your risk of death is so enormously raised that if you understood the probabilities you would be thoroughly shocked. Maybe even shocked enough to stop smoking. I don't remember the numbers, but maybe I'll look them up when I get a spare minute. I have no idea when I will ever get a spare minute again.

I saw patients on Friday, which is my 'short' day, so I was home early. I had foolishly suggested to Mr A that we might go out on Friday night to a gig in which a friend was playing, and he was quite keen. I, however, had come to regret the suggestion and would have paid a considerable sum including body parts to be allowed to stay at home on the sofa. We went out, it was good, we came home very late indeed, and I slowly recovered over the course of the weekend. Then the working week started again...

Getting on with it

National Botanic Garden of Wales, May 2013

I left you at the end of induction, and I have now been in the Diabetes department for a few days. I wasn't expected to start clinics straight away, although I did see a patient on day 2, which was fine. I really need to get the hang of what patient information I can give out, and find out where things are in the building and in the hospital. There is a meeting scheduled with the three other Diabetes Dietitians in the Trust, who are based at the other hospital and in the community, and I am hoping to get a better picture from them of how the service operates.

The hospital where I am working is pretty small. It doesn't have an Emergency Department, maternity, or paediatric intensive care, for example. There is a walk-in centre for 'urgent' cases, but anything needing proper hospitalisation will go to the big hospital where I used to work, so it is unlikely that I will see many newly diagnosed diabetic patients. I have met the two Dietitians who cover the five wards in the hospital, and my manager has suggested that I may need to help out on the wards from time to time. I have made it clear to all involved that while I would be very happy to chip in when times are tough, ward work is something I would very much like to keep to a minimum.

The hospital was first opened at the end of the 19th century, although obviously it has been modified since then. The Diabetes department is in a separate building on the site and was built within the last ten years, so it is pretty modern. I have a whole big room to myself, with adjustable heating and a window! I am quite excited about the things I can do now that I have somewhere to store resources in the same room as seeing patients, although I am not the only one to use the room so I can't make it exclusively my own. The main thing it lacks is a table so that I can draw and write easily during consultations - at the moment the desk faces the window and we can't sit around it.

There are just two Diabetes Specialist Nurses (DSNs) based there, along with a clinical Support Worker and some admin staff. Doctors come and go, and there is a big meeting room where we all have lunch and where courses are held. It is so light and airy compared to the cupboard off the hospital corridor where I spent the past year. The Dietitians I am replacing are long gone, and the room had accumulated a whole lot of stuff, so I have started to sort through the legacy and dispose of old and irrelevant material, keeping some things that look like they might be useful.

Lastly, commuting to and from work takes 30 minutes, but the sort of 30 minutes that is almost a pleasure to drive. It avoids all the bottlenecks, is mostly through countryside with farms and animals, A and B roads but no motorways, and once I've left Leamington there is only one set of traffic lights. I'm almost looking forward to the journey!

Induction number 3

Cardiff, May 2013

I've been enduring a third episode of workplace induction, to celebrate the start of my third year as an employed Dietitian. It has been uninspiring and tedious, but has also highlighted some important differences between the two Trusts that have employed me.

I'm back at NHS Trust #1, and induction has changed considerably in the two years since I last went through it here. It is much better - I did not have to sit through the wholly irrelevant and inappropriate session about how to order and collect blood for transfusion, for example. We had a practical handwashing session including UV lighting to highlight deficits in technique. There is a whole lot of e-learning to support topics like manual handling, infection control and 'Health and Safety Awareness' where previously these were all live presentations.

In terms of IT, I got my Smart card and ID card within the first two days; my email account and network access were working almost immediately, and as an added bonus my email address is the same as it was a year ago. During induction, the emails I failed to delete before leaving were still there, as were 470 emails received in the 12 months since I last used the account. I even received my own email thanking me for my leaving presents. Unfortunately, on Thursday when I tried to log in, the system told me my account had been disabled, and when IT support got it back, all my emails and files had disappeared, together with all the messages I had been sent that week about where and how to retrieve various documents and details of meetings.

We still had to sit through quite a lot of Powerpoint, though. Welcome from the Executive Managers, the fire officer's lecture stating the bleedin' obvious, Information Governance (which mostly means confidentiality and data protection), an introduction to the Library, a slightly too-graphic presentation about Safeguarding Children, and Conflict Resolution. Oh, how bored I am of hearing about Conflict Resolution. It gets a lot of time in the programme, probably because of national guidelines, but has not changed in two years. Of course we must try to provide respect and dignity to colleagues, patients and the public, and must try to prevent and mitigate conflict, but oh! the endless acronyms and six stages of this or that and don't forget how we are allowed to defend ourselves and use reasonable force to prevent a crime, and what exactly is the definition of Assault, and should it be reported as clinical or non-clinical?

The highlight of the induction two years ago was a presentation on Equality and Diversity, which has now sadly been changed to an e-learning module - the only one in which I scored 100%. I have learned a great deal more about the incidence, prevention and treatment of venous thromboembolism than any Dietitian needs to know. The latest defibrillation machine is pretty snazzy, and it can even tell you whether you are doing your chest compressions correctly.

All in all, having three compulsory days at the very beginning of a new job is a comprehensive, timely and efficient method of ensuring that statutory and mandatory training is done, especially compared with NHS Trust #2. In that Trust, despite my best efforts, I didn't manage to complete my induction and mandatory training in the 11 months I worked there. And the relief of having modern computers with up-to-date software again is only slightly dented by the loss of all those emails and files.

Other good news: parking at the hospital was arranged swiftly and effectively, and I have been given extra hours on a permanent basis, making 27 hours a week over 4 days. Still ten and a half hours short of full time, but much nearer, and I think the end result will be very similar to what I was getting paid in the last job, if you take account of not needing so much fuel or accommodation costs.

Commissioning diabetes services

Cotswold Falconry Centre, April 2013

At this very moment, right now this instant, I should be getting on with my admin. After a triumph last weekend when I finally, FINALLY managed to switch energy companies, I thought I would keep up the momentum and finish the deal with sorting all the bits of paper heaped up in an enormous pile.

So far this weekend, I have been obliged to go to two, count 'em, TWO Christmas dinners, as well as having my hair cut and going to the greengrocer and making two cakes. Because I am leaving work and there is only one weekend left before my leaving 'party' and I want to stuff vine leaves next weekend and that takes ages. So cakes must be baked this weekend, but I can't do another one because I have run out of cinnamon, so I have to do my admin. Except for the small matter of blogging.

Christmas dinners: one was on Friday night in a local pub/restaurant with my home badminton club that I haven't played with for six months, and the other was on Saturday night in a posh hotel with the Dietitians from the hospital where I used to work a year ago. On balance I probably liked the second one better, because there was a live band and lots of dancing. But the first was very good too.

Cakes: one spiced with fruit, one lemon drizzle.

My leaving 'party': this is taking place after work in a couple of weeks, when a modest buffet will celebrate two people leaving and one going on maternity leave.

Work is a bit strange because I will be leaving in less than a month, so I have much less patience for all the annoying things that happen on a daily basis. Colleagues are constantly complaining about all sorts of things, some of which are genuinely troublesome, but a lot of which are just giving them the pleasurable sensation of feeling put upon. Nothing much has changed in my world, except that I have at last finished the Carbohydrate Reference Tables and sent them for approval by the Trust communications police via the approved route, and have heard nothing at all for two weeks.

The main complaint at the moment concerns a plan by the Clinical Commissioning Group (CCG) to improve the service given to people with stable Type 1 diabetes who are registered with City GPs. The CCG is the official body now authorised to commission services and spend the NHS's money, and it wishes to discharge these patients from care within the city hospitals to be seen in an 'intermediate' service in the community instead. The advantage to the patients is that clinics should be easier to get to and there will be some evening and weekend appointments. There is no change planned for patients who live further afield in the catchment area served by the Trust. People with Type 2 diabetes under the care of the City CCG have already been discharged in this way, but they are back under the care of their GPs rather than being seen in a specialist diabetes service.

In itself, this plan is a good thing. The difficulty lies with the bitter internecine conflict between staff in the Diabetes service based in the two hospitals within the Trust. I may have written long ago about the attempts being made to bring the two locations together somehow, but we have not only remained as two separate units, but the divisions between the two seem to have increased. All this is helped not at all by feuding Consultants and an extreme lack of nurses that is due to become worse when three nurses reduce their hours and one goes on maternity leave in January. Despite the lack of consensus and the lack of staffing, the CCG continues to press forward with the plan.

Some of the difficulty was brought into the open recently because we offer two completely different types of Structured Education, which NICE says should be offered to people diagnosed with diabetes soon after diagnosis. Quite a lot of information, knowledge and skill is needed to manage diabetes in the best possible way, and there are many courses available, some of which are based on a national curriculum and others developed locally. Suitable courses must be evidence-based, and must demonstrate that participants have better outcomes in their diabetes management after they have been on the course.

The two hospitals in the Trust currently offer different Structured Education packages, one developed locally and one licensed nationally. The CCG wishes to offer just one type of Structured Education in the new service, and it is proving difficult and divisive to decide which one this will be. Emotions are running high, as various people have a deep commitment to one or other of the courses, and not only seem unable to decide which to choose, but also seem unable to settle upon a method by which the choice should be made.

The decision to discharge these patients into the intermediate service has also been made seemingly without adequate consideration of the practicalities. How will appointments be made, and by whom? Who exactly will be seeing the patients, and what level of qualifications should they have? Where will they be seeing the patients? What data will need to be recorded, and where and how will it be kept and made available to people who need to see it? How will patients contact the key doctors, nurses and dietitians? A date has been circulated for when the new service will start, without any reassurance that these questions have been considered.

The more forcefully that the new service is pushed, the more resistance is developing, and where I sit and have my lunch all goodwill has evaporated towards the instigators and supporters of the scheme. It is unusual for a day to go by without someone starting up some sort of complaint about the whole situation, and all and sundry chime in, and my pleasant relaxing lunch break is over.

I am very much looking forward to the new job, and it was very useful chatting at the Dietitians' Christmas do. A colleague asked how many days I would be working, and I was able to turn to the manager (who was sitting next to me) and ask, "How many days a week will I be working?" Her answer was "At least four," so that's a bit clearer now. I'm not exactly sure what I will be doing, but another colleague said that she had trained my predecessor for a renal clinic (kidney damage is one of the complications of poorly-controlled diabetes). I was also told that the Diabetes Dietitians in the Trust who are based in a couple of other locations have regular meetings as a team, so I should be able to draw on the expertise of more experienced colleagues for support and for clinical supervision.

Stop Press: my Carbohydrate Reference Tables have been returned by the official people who approve such publications, and who now want us to get written feedback from five service users before approval will be given. And so it goes on...

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.

Cycling to work

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Last stretch towards the main hospital building.

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

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