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 After a lull when students were withdrawn, they're back with a vengeance - we have four, but they can't all be accommodated in the dietetic office over at the main hospital.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.

Catching up

February 2020

Since my last post I've been off skiing for a week in France, and then come back to a punishing schedule of having to go to work for three days, two evenings of Buddhist activity, meeting up with Lola II for a day trip to Oxford, a replacement filling in a back tooth, and a weekend with sister D.

The skiing was with lovely friends and we all had a good time even though we lost out on one day because of bad weather. I travelled over on the Eurostar overnight ski train which means I had two nights of no sleep but a full eight days of skiing. The return trip coincided with Storm Ciara and trains back home from London were terribly disrupted. Instead of a straightforward 2 hours to Leamington it took more than 4 hours and the last leg was from Coventry on a bus, which I had to direct to the station because there was a closed road and a diversion, presumably due to fallen debris.

A recent casualty of the rain has been my front door, which has been performing its annual trick of swelling in the wet weather. It had got so bad before I went away that in order to secure the house I had to force it shut from the inside and then leave the house through the garage. I had a go at shaving it down when I got back but in the end gave in and called the trusty Ilf, who came round the same day and sorted it out. I'm seriously considering getting an alternative and less temperamental front door.

At work I'm finding it quite difficult to fit in everything that I'm required to do in under two days a week, and going away for a week makes it even more difficult. However, I have discovered that one of my Diabetes Dietitian colleagues has been asked to stand in for our Team Leader, which is a welcome development as she is pretty much doing that job anyway and is very competent and nice to work with. Advertising and appointing officially to the post has been delayed because the factors that led to the resignation of the previous two incumbents are still in place, but this may be changing over the next six months as three key members of staff are leaving. The other Diabetes Dietitian who has been off sick for about seven months shows no sign of returning to work, so we are still short of two people.

One of the extra jobs that we are all supposed to do is to supervise student Dietitians on their placements with us. Being part time and not based on the main site I have got away with not doing as much supervising as some others, but I found my name on a list of such people who were being asked to do a bit more. So I stepped up and volunteered to supervise a Peer Assisted Learning activity about biochemistry, i.e. the results of blood tests and how they impact on a Dietitian's role.

I had to go over to the main hospital where the four students were waiting. Their task was to find out all the reference ranges for lots of different factors - electrolytes, liver enzymes, blood components and much more - and then consider two ward-based case studies. The difficulty for me was that I hardly ever have to review biochemistry results except for those connected with diabetes, and the case studies were nothing to do with diabetes. So I'd already had to spend some time with one of the other Dietitians to go through the case studies and make sure I knew the answers myself. But it was fine, I'm one step ahead of them and they believe I know more than they do so that's all it takes.

What else? A big meeting at work that went quite well. A lovely day in Oxford with Lola II, even though the restaurant we wanted to have lunch at was closed and the film we wanted to see was sold out. The weekend with Sister D was good too, even though the weather was not. A proposed walk with the Buddhists coincided with Storm Dennis so nobody turned up except the regular team, and we swiftly retreated to a cafe out of the rain and wind. We held an impromptu team meeting and got quite a bit done in the hour we spent in the cafe.

I still don't feel like I've quite caught up with everything that needs to be done since being away for a week, but I need to remember that catching up with everything that needs to be done isn't always necessary. A surprising number of things can actually wait until I get round to them. All aboard the next week's rollercoaster!

More padding

Adhisthana, June 2018

I still haven't managed to get round to writing about the Spanish holiday, so here are some more odds and ends that aren't all that exciting.

Saturday

Music group was on Saturday, and it rained a lot. When I got back home the kitchen roof light was leaking again, so I was on to Ulf in a flash. Doors and Windows Ulf came round on Tuesday while I was in (and while the sun was obstinately shining in a cloudless sky). I was going to impersonate a rainstorm with the hosepipe but discovered that the adaptor to connect the tap to the hose was missing, so we had to resort to a watering can. DaW Ulf failed to find where the water could be getting in, but agreed with me that I couldn't just resign myself to putting out buckets every time it rains, nor could he drop everything and come on over. I plan to get the hosepipe working and do the rain impersonation thing, then take photos or video if I manage to get it leaking again.

Sunday

I finally managed to gather two out of the three of us who are planning a trip to the Christmas Markets in Munich (you may remember last year we went to Dusseldorf), and we booked flights and hotel. Then we went to a comedy gig from German Comedy Ambassador Henning Wehn. The most notable thing about that day was that I served a vegetarian stew that had such an explosive effect on my gastrointestinal tract that I had to apologise to my friend in case she was suffering the same consequences (she said she'd had worse).

Monday

I had a Dietetics final year student with me all day on Monday, on her third and last placement. I was so traumatised by my placements when I was doing my degree that I'm almost useless as a supervisor, as there is no way I will pass any criticism or test the students at all. Unfortunately there was almost nothing going on in my department that day, but we couldn't find anything better anywhere else so I printed out a diabetes tutorial and she was happy to play around with that until the afternoon clinic, when two out of the four scheduled patients didn't turn up. Thankfully the last one was a corker and I went through the A-Z of diabetes with someone who'd had a very poor experience in a nearby hospital, and was very happy with what she received with us. Anyway, the student said she'd enjoyed the day and that's what I was after.

On Monday I also received my flu jab, which was OK at the time but gave me a very tender upper arm for 24 hours. Then in the evening my doubles partner behind me mis-hit a shuttle with tremendous force right into the middle of my back. That night I had trouble finding a comfortable sleeping position.

Tuesday

Apart from the visit from DaW Ulf the most notable event on Tuesday was that while doing a bit of poking about on the Open University website, I came across a free online module all about Greek heroic epic poetry (which is distinct from ordinary epic poetry) focussing specifically on 'The Iliad'. By coincidence I happen to be reading The Iliad at the moment, so I had a look at the module, and it was extremely interesting. Although I did O level Latin at school I don't know a word of Greek, ancient or modern, and this tiny little insight into the rhythms and construction of the first seven lines of the poem as a representative sample of the whole work was absolutely fascinating.

It reminded me slightly of one of the more memorable jokes from Sunday night, when Henning was telling us how his extensive study of English grammar at school taught him to conjugate the verb 'to be' correctly: "I was, you were, he/she was, we were, you were, they were." Now he feels that perhaps he needn't have bothered as common usage suggests: "I was, you was, he/she was, we was, you was, they was."

Wednesday

I realise I've spent quite a lot of time writing this blog post when I could have been writing about the holiday, and I haven't even shared my photos yet. Oh well, I'll get round to it eventually. Probably.

I need to calm down

Peckover House, August 2014

Here is a list of things that I wanted to blog about but which happened too long ago for me to even remember what was involved or what I did:

• Getting final accreditation as a DESMOND educator despite not meeting the assessment criteria for the session on physical activity
• Having tennis elbow and trying to do things to fix it, including not playing badminton for a month and operating the computer mouse with the other hand
• Going to a study day about 'Diabesity' (combination of Type 2 Diabetes and Obesity) and being impressed by just one of the speakers
• Attending a two-day course all about insulin pumps, including the opportunity to wear one for about 18 hours (I even took pictures)
• Camping for one night, then going to a lovely party, then staying for one night in a room in the college where I lived when I was doing university degree #1 in 1983-6
• Writing a letter of complaint to the college about a) breakfast b) parking and c) payment methods listed on the invoice
• Getting a plumber in who took all of 20 minutes to fix the problem at Lola Towers (so not that serious a problem really)
• Meeting some of the Research, Development and Innovation Team at work and getting a bit enthusiastic about projects that I really haven't got time for any more (see below).

As you might have deduced from the last blog post, things have become a bit overwhelming at work and at home. The work situation is exacerbated because of three factors: 1) one of our Dietitians has moved away and it is proving difficult to recruit a replacement, 2) a new service that has been planned for what seems like an eternity has suddenly popped into existence and needs a Dietitian to cover a new clinic, and 3) we have an unusually high number of candidates for our Type 1 structured education so we've had to schedule extra courses. And it's the season for Dietetic students to spend a week in Diabetes, which just adds to the pressure and workload.

My workload fits into half-day chunks, and previously I had on average about three half days during the week for admin, thinking time, planning, projects and generally catching up with stuff. At the moment I'm lucky if I get one half day on Friday afternoon, which is not the best time for doing anything that requires concentration or stamina. Most of my bright ideas will require time and effort to make them happen, so they've all been shelved in favour of the stuff that has to be done to keep the service going, and I'm only just keeping up with that.

I have pretty terrible teeth (bear with me, this is relevant) but I have so far managed to stop any of them falling out through fairly frequent visits to the hygienist. I had one such trip yesterday, and the hygienist commented that she could tell I was under stress because of the state of my gums. She has supplied me with all sorts of desperate measures to try and prevent further deterioration, but the prospect seems bleak. I don't actually know what the next stage would be in terms of treatment, but I'm guessing that extra appointments, cost and discomfort is involved. 

Like I said last time, there are people whose problems make mine seem utterly trivial - on the whole my health is good, I have a good job and an income and a home and really have nothing to complain about. What I really need to do is relax, do what I can do, and stop worrying. And go to bed earlier.

Moving on

My leaving cake, baked by a lovely colleague

My first dietetic job has now come to an end, and a new era is about to start with a specialist diabetes post. It's been almost exactly a year since my first day as a qualified working Dietitian, which has a pleasing feel to it, and I have learned an enormous amount in that year - maybe not as much as I learned during my degree, but still, important stuff. Most of all, my confidence has grown to the point that I now believe in my own abilities, and most importantly can tell the difference between things that I can definitely do and things that I need help with.

The last week at work was surprisingly quiet, which was wonderful. Added to that, it was also the last week for 'my' student, who was doing a tremendous job and took all the pressure off me, because she was just out on the wards seeing patients. She gave me a card and a present when I left, which was lovely. The quiet week made it easy for me to tie up loose ends and finish the job tidily (and on time!) on Thursday. But I had to phone the office on Friday, because I had been thinking about the patients I handed over and realised that I ought to have prescribed a different feed for one of them.

We had a little leaving presentation when I was given a cyclamen, some chocolate, and a voucher towards a new badminton racquet (which was what I asked for). A large number of people turned up at the pub after work for a drink and a curry, and I was hugged by more people than you could shake a stick at, which was many more people than I usually allow to hug me. It was hard to stop them, so I didn't.

What with my new post being temporary, and not quite full time, and a long way away, I can't rule out the possibility that I may have to return to acute dietetics on the wards at some point. But if I never have to offer another nutritional supplement or calculate and write up a regimen for an enteral feed, I won't be too sorry. In the last week, because it was a bit quiet, I stole some of the other Dietitians' diabetes patients and had some interesting conversations on the wards. But I also had to see the usual patients who are being tube-fed, mostly long-term, mostly for neurological reasons, although there were a couple of acute cases who had been through surgery.

We also had a professional development session on treatment of gastrointestinal failure, which can occur due to surgery, malabsorption (sometimes due to bowel being removed), or just a lack of peristalsis called 'ileus' which can also happen if the intestines are mucked about with or following any serious trauma or surgery. These are scenarios when parenteral nutrition (PN) is called for, and nutrition is given intravenously - it is a last resort, because the risks of infection and other complications are much higher if nutrients are supplied this way. In the meeting, we were all in groups and given the task of prescribing a feed. I was with a community Dietitian and a very experienced renal Dietitian, and found that their knowledge of ordinary hospital dietetics was somewhat poorer than my own, which was a surprise.

On another day, while I was on the endocrine ward, I listened in to one of the diabetes doctors explaining to a student some of the mechanisms used for differential diagnosis of diabetes - type 1 and type 2 and the tests that can distinguish them. The blood or plasma concentration of insulin is rarely measured, because it has a very short half-life in the system, so other indicators have to be used, of which the main one is C-peptide. Insulin is synthesised in the pancreas as a larger molecule which is split into two parts on release into the blood stream. Insulin disappears pretty rapidly, but the other component, C-peptide, doesn't, so it can be measured as a surrogate indicator.

If blood glucose is high and C-peptide is low, then it's either early-stage type 1 or late-stage type 2, because insulin-secreting pancreatic beta cells are being killed off, and insulin treatment is probably needed. If blood glucose is high and C-peptide is also high, then it's type 2 because the problem is not lack of insulin, but insulin resistance. There was a lot more to it, but that's just the bit I took away. He was talking pretty fast.

So all in all I feel very pleased with the prospect of moving forward into specialist diabetes dietetics, but also very privileged to have had the opportunity to see how a large teaching hospital functions. There was rarely a day when I wasn't thankful that I was able to walk away and go home, unlike those I'd left behind on the wards. And what wards! They all have particular challenges - my last batch were cardiac, neuro and vascular, and were as varied as any of the others. The vascular patients were particularly challenging; many had necrotic toes where their circulation had failed, gangrene, horrific ulcers, amputations, and the smell! The only worse smell I encountered was a patient who had very advanced cancer.

I have found the NHS to be a magnificent institution, staffed by people the vast majority of whom are genuinely trying to do their job well, and serving even the poorest without distinction. There are any number of reasons why this is sometimes impossible and we fail, but anyone who thinks that nurses, doctors and all the rest are just marking time and looking forward to the comfortable pension is mistaken. Of course, this has been my experience in this one hospital, and may not be the case universally - the recent history of Stafford hospital springs to mind.

My belief is that the culture within any department, profession or organisation is set by example rather than by rules or policies - if the boss picks litter off the floor and puts it in the bin, then others don't think it is beneath them and follow the example. I can compare the department I have just left with the three others that I met as a placement student - some aspects were better, some were worse. But as I may have written before, I don't think I have ever worked with such a supportive and congenial group of people as those I have just left.

The other difference between this set of colleagues and others is that my interests and passions are shared somewhat further than in any previous job. Of course, I still watch far less TV than most of my colleagues, but I can sometimes steer the conversation towards 'best restaurants in Kenilworth' or 'strangest foods we have eaten' without everyone getting bored. My lunch of celeriac gratin with walnuts is regarded as interesting rather than weird. At my leaving do we had interesting conversations about Michael Mosley's 'Fast Diet', nearest Michelin starred restaurants (Mallory Court), fancy restaurants where we have dined, and cake-making from the Hummingbird Bakery cookbook. I even half wished I'd watched the Great British Bake-off on TV, as it sounded like the least awful of this genre of reality shows.

Mr A has offered to treat me to lunch at the local noodle emporium, Wofon, so I need to get ready. More Lola Life to come in the next thrilling instalment - Specialist Diabetes Dietitian.

Catching up

Detail at the top of a column, Melk, October 2012

I have been back from our New Year holiday for more than a week, and have nearly caught up with blog posts waiting to be read, not helped by Stan Madeley who has started up again and has been posting loads of his letters that didn't get replies and so didn't get into his book, 'Second Class Male'. OK, plug over. Podcasts - well, I'm not sure I'll ever catch up, although when I start driving for 10 hours a week there may be some chance.

On Saturday morning I thought I would make a brief list of the few things I really must do this weekend. When I reached the bottom of the page I realised that it would be a busy time. Factors affecting work to be done during the weekend: parental computing woes; last weekend spent constructing a large bookcase and consequent rearrangement of crap in room; unexpected death of 'new' freezer. The last has prompted interesting meal choices - we are eating large amounts of thawed veg, yesterday was fish pie made with all the fish previously frozen (including fish fingers), today and tomorrow will contain vast amounts of meat, with leftovers providing all meals for the next week. Cereal for breakfast is forbidden; let them eat bacon. Not that we're complaining about that one.

Freezer death combined with my disorganisation over the past few months means that at present, neither Mr A nor I can find the receipt for the dead freezer, nor for the washing machine that we also bought recently. We suspect that they are hiding somewhere together, as it is unlikely that we would have thrown them out. Bank card statements will be of little use because both were bought with vouchers redeemed from TV-watching points. On the positive side, roast beef sandwiches for lunch were delicious.

There is little more to say about work that hasn't already been said. We were two Dietitians down last week but we had three nearly-qualified students helping out, and it wasn't too bad. I have just under two more weeks to go before the new job, when I imagine there will be much more to report. My last clinic: only four patients attended, of whom one was entirely fine, which made me feel like I should keep him talking because the journey to and from the hospital plus the pain of parking and then sitting in the waiting area takes a disproportionate amount of time and effort compared with the five minutes of a consultation.

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I wrote the above at the weekend, intending to publish before the week started. But I had a badminton match on Sunday and things were delayed and you know how it is. It's only Tuesday, but there have already been developments. The bad news is that Stan Madeley has given up his blog, through lack of readership. The good news is that the freezer has returned to its operational state, simply by pushing the plug back in. It must have been dislodged slightly by Mr A, whose bike equipment is kept in the cupboard where the electrical socket is. So the additional life-enhancing exercise of Mr A cycling a bit over the past few days has been negated by the enhanced saturated fat-filled intake of meat products. We lost out on some frozen veg and bread, but I think we've managed to consume everything else.

Festive seasoning

Thank you, Judging Covers!

The run-up to Christmas has been in turn stressful, enjoyable, frustrating and, at last, relaxing.

At work, there's been a lot to do, and fewer people than usual to do it. Last week was busy, and I was working with a student, which made it quite difficult to keep track of what had and hadn't been done, and what needed doing next. I was out on Tuesday at a study day (more about this in a future post), then on Thursday my clinic was relatively quiet, allowing me to enjoy a social Christmas lunch in the canteen. It was proposed as a leaving party for me and a colleague who is going on maternity leave, but my departure had become a little uncertain. I do now have a confirmed start date in the new job, towards the end of January, but both my current and future managers were fighting over me for a day or two! It was a little disconcerting, and not at all welcome.

I was at work yesterday (Monday), and was interested to find that nothing special was happening on the wards, although I spotted a tired-looking man in a Santa outfit reading some medical notes, who might have been one of the junior doctors. Otherwise, there were a few nurses wearing antlers or halos, but patients' stories today were so sad that it was difficult to spread any festive cheer, because who would choose to be in hospital over Christmas unless they were so unwell that they were forced to?

I'm told that some years there's very little to do in the hospital on Christmas Eve. That wasn't the case this year - there were more referrals than usual. We blitzed it in the morning, only to find that more had come in by lunchtime. Some were, frankly, taking the mickey, like the patient who just wanted a cooked breakfast, and another referred because they had been transferred from another hospital on supplements and the nurse didn't want them to become 'lost in the system'. An admirable sentiment, but not today. Diabetics struggling with blood sugar control and patients who had lost a bit too much weight had to give way to patients not able to swallow who needed tube feeding or textured diet and thickened fluids.

I am having nearly two weeks off work, so I also need to ensure all the information about my current patients and their priorities is made available to the Dietitians who'll be looking after my caseload while I'm away. I feel lucky that I was only 30 minutes late leaving the hospital after work.

At home, the build-up to Christmas has been steady, with some notable highlights. We thought we would like to spend our TV watching points on a tablet PC, so we went to review the options at the only high street electronics retailer that allows our points to be converted to vouchers. The experience was underwhelming, but never mind, we ordered the vouchers and returned to the shop at the weekend - the last weekend before Christmas. We were prepared for crowds, but there were none - neither were there any shop assistants. When we finally found one, and indicated what we'd like to buy, we were told: "There aren't any. We're sold out."

On the weekend before Christmas? The busiest shopping weekend there's likely to be in the year? Not only were they sold out, they refused to accept our money against an advance order, because this is impossible if there are no products in the warehouse, or some other nonsense. So we took our vouchers home, and thought about it.

A similar high street electronics retailer has recently gone bust. If this large retailer is unable to take our money at this critical time of year, we were very reluctant to hang on to the vouchers, which would turn to dust should the retailer join its close competitor in liquidation. So we considered our options.

Mr A's mother is now in a nursing home, and his dad asked our advice on a basic DVD player that she could have. Our DVD player is a suitable one, so we thought we would give her that one and upgrade our own system - but we had more money in vouchers than the cost of a new and better DVD player.

I've never had a printer of my own, and although I've been able to connect to Mr A's printer some of the time, his setup changes so frequently that mostly I have to go up and ask him to print stuff for me (or print personal things at work). So as well as the DVD player, I now have a lovely all-in-one printer and scanner - and there was some money left for a new toner cartridge for Mr A's printer too.

Unfortunately, now that we've had time to look at installing the new DVD player, our TV is such an ancient model that the all-powerful new DVD player doesn't have the ancient connectors that are needed to connect it up. Mr A has spent some time looking at various options, including buying a new TV, but we're most likely to buy just a SCART-HDMI converter and wait until the ancient TV breaks down before replacing it.

Lastly, I know it's a little vulgar to boast about one's Christmas presents, but... I WON ANOTHER BLOG PRIZE! On one of the book review blogs I read, a prize of 12 books for Christmas was on offer. I thought twice about entering, because despite reading every post on the blog, very few books that they review are ones that I think I might read. But I entered anyway, and not long ago a very large box arrived containing my prize. I put it under the Christmas camera-tree to await the big day, and this morning Mr A and I opened it, only to find that the wonderful people at Judging Covers had wrapped each book individually!

I'm looking forward to a completely different type of reading for a few weeks - much less weighty than my usual selections. And in the New Year I'll be driving far more miles every week, so I might at last start to get through more audio books in the car. Happy holidays to everyone, and lots of good reading for 2013!

Catching up

Leamington Food & Drink Festival, Sept 2012

It really has been a very long time since I last sat down to do some serious blog writing. It's due to a combination of circumstances: weekends filled with duties to perform, weekdays filled with patients and students that I can't write about, and evenings recovering from both of these, plus extras like badminton.

Since last time, then, in brief.

• Work: a meal out with some of my lovely colleagues, which was very slightly gate-crashed by Lola II and Mr M who turned up early for a family event. 
• Family Event - thank you very much to all those who travelled many miles, some of whom returned home with a gift of tiny pathogens from Lola II and have been ill ever since (get well soon, mum and dad). 
• Another trip to the Cotswold Falconry Centre accompanied by a subset of the attendees of the Family Event. 
• The Leamington Food & Drink Festival, which far exceeded expectations, mainly due to the weather, which was glorious for both days. Most memorable was the Chilli Jam Man, whose samples ranged from very hot to almost unbearably hot. Having engaged in conversation with him, I was foolhardy enough to try the offered fresh strawberry filled with his most fiery jam, which actually made my sunglasses steam up on the inside. It really did.
• After coming back from the Food & Drink Festival on Sunday, Mr A and I attacked the garden. We took four full car loads of unwanted vegetation to the tip, much of it viciously thorny. About three quarters of the garden is now in an acceptable state, with only one corner left to deal with.
• Work again: we had another food tasting session, department meetings, wards and clinics as usual. Both our students passed their placements and have left us, and since then I have been inundated with referrals. It would have been a considerable challenge to manage the workload if this many referrals had come in while I was supervising 'my' student. The only real trouble I had was running my clinic together with the student, which didn't go all that well. A patient who arrived late was missed, ended up waiting an hour and then had to leave before being seen. I feel bad about that.

I decided to go to another Diabetes UK local group meeting, the first since I started my current job. The advertised topic for the meeting wasn't all that attractive: a personal account from a blind kidney and pancreas transplant patient, but these things come in handy when you're trying to construct an attractive CV. In the event, the speaker cancelled at short notice, and the alternative activity dreamed up by the group Secretary was to have us chat in small groups about various subjects, and then report back to the meeting on the most interesting or useful bits. This is the sort of thing that makes my heart sink in professional seminars or workshops, but in this case it turned out to be very interesting. At the other meetings of this group I have struggled to make any connections with the other people there, and barely spoken to anyone. This time, I could actually find out a bit about their experiences of diabetes, which is one of the reasons for going to these meetings.

Another work-related thing this week was that my body composition was measured in the Metabolic Unit's newest toy - the Bodpod.

"Air displacement plethysmography is a technique for measuring body composition. Subjects enter a sealed chamber that measures their body volume through the displacement of air in the chamber. Body volume is combined with body weight (mass) in order to determine body density. The technique then estimates the percentage of body fat and lean body mass through known equations (for the density of fat and fat free mass)." (from Wikipedia)

This came about because I have volunteered to be a subject in an academic research study which aims to measure inflammation in subjects given two different types of diet: either two large meals or five small meals in a day. I have been booked for two periods of 24 hours in which I must remain in a sealed chamber large enough for a bed and a table and a toilet, with all sorts of vitals being collected and measured. In preparation for this, I had to sit in the Bodpod for a minute or two dressed in a swimsuit, and the machine calculated that I comprise a whisker above 30% fat, which puts me right at the fattest end of the healthy range for a woman of my age. So that's good, I suppose. My colleagues think I'm a bit crazy for looking forward to being confined in a small room for 24 hours. I remind them that I went on holiday for a week on my own.

I can make no predictions about how soon the next blog post will appear. I have plans for a couple of posts which may turn up quite speedily, and then there will probably be another big gap. All I can say is that I probably miss my blog as much as you do, and I'm doing my best to keep it going.

Not keeping up

Mr M and Lola II's garden, April 2012

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

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

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

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

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

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

Anthropometry

Norfolk, July 2011

I am getting to know my wards now, and I can even remember some of the names of the staff nurses and Health Care Assistants (HCAs) and therapists and doctors. Some of them know who I am, and a very few even know my name. This is good, because it improves the working environment no end, but I do get extra work because patients are referred just because I'm there.

There has also been some work behind the scenes, possibly because I mentioned to the Dietetic Manager that one of my wards was particularly bad at weighing their patients. Admittedly, many patients are too ill, but it is very difficult to make an assessment of whether someone is eating or being fed enough if you cannot tell whether they are gaining or losing weight. As I came onto the ward the other day, I heard the staff nurse was enumerating all the patients in her area and whether their weights had been recorded or not. As a patient was referred to me in another area, the staff nurse hurriedly checked the paperwork and said. "...and there is a weight recorded here..."

Because of the difficulty in weighing very unwell patients, for the first time I have resorted to what is generally referred to as 'Anthropometry'. This essentially means making various other measurements in order to assess nutritional status. The method I chose was the 'Mid Upper Arm Circumference', which is fairly straightforward. Combined with the Tricep Skinfold Thickness measurement, and appropriate use of formulae that include pi, it is possible to work out the relative amounts of muscle and fat in the upper arm, but I didn't bother taking it to that level. There are centile reference ranges for the MUAC depending on the patient's sex and age, but in this case I knew the patient was underweight. I'm just hoping for an increase in the measurement, even though this will mostly mean additional fat reserves rather than development of muscle mass.

[Interesting note: a friend who is blind once commented about someone's weight gain or loss, and I asked him how he knew. He reminded me that when he is being guided, he holds the guide's upper arm, and I had to acknowledge that this would be a good marker for body weight, especially combined with the height of the upper arm being held!]

I am now partly responsible for the 'Consolidation' period for a B placement student, which is three weeks long. My own B placement went pretty well, and was not so long ago that I have forgotten how it felt. I feel sorry for this student, who is not having such a good time, but I am not sure how to help her without adding to her stress levels, which are pretty high most of the time. I have also been given another student's case study to review because the case in question was one of my patients. I have taken a brief look, and have not been impressed, so that may constitute a fair amount of work.

Things take longer with a student who cannot be left to get on with seeing patients and report back when she has finished. One of my colleagues has also given back two of the wards that I gave her, so my workload is a little bit greater too. The week before last I managed to squeeze in half a day in the office, tidying up and doing a little bit of research to find things like the evidence for the health benefits of losing 5% or 10% of your body weight (if you are overweight). There has been no more spare time since then.

We have done a little bit of CPD as a group, including the training session where I learned all about FODMAPs, and a fairly depressing discussion about the ethics of feeding, palliative care, end of life and the role that we might play within the multidisciplinary team. I have even gone on to use that information on the ward, questioning what the purpose of inserting a feeding tube is for a patient who is not eating well but has no physical barrier to eating.

Before long the new stroke Dietitian will start, and there will be a general reallocation of workload again, and I will probably lose my two biggest wards and move on to something new. It will be a shame to leave the people I've started to get to know on the wards, and a challenge to get to know new people, but I'm enjoying the work more now and am looking forward to such challenges.

Student

New Forest view, Feb 2012

The workload was so nearly under control the day before my long weekend.

I spent the morning on one of my wards and managed to review and discharge a handful of patients, a student Occupational Therapist had asked if she could shadow me at some point next week, a Speech and Language Therapist had just reviewed one of my patients and approved his return to solid food taken orally at last, and one of my favourite doctors was telling me his life story.

It was all going so well, and then a student turned up.

We'd had a departmental meeting the day before, my first. I've done my share of meetings, and this job seems to have far fewer than any job I've had before. We talked about which diet sheets need updating, the financial state of the NHS Trust in which we work, the policies around allowing people time off for courses and professional development, an update to the Bible of Hospital Dietetics (not its real name), and Students. We have three students in the department at the moment, all on their B placement, and the discussion was about their training plan, learning outcomes and how they are getting on. Among many other tasks, each student needs to write up a case study, which involves finding a patient who agrees to be the subject, and then researching their medical and dietetic treatment before presenting the results in written and oral form.

I should have kept my mouth shut, which I succeeded in doing for the best part of the meeting, but I feel enormous sympathy for the students, based on my own less than happy experiences. I may have mentioned that I had a whole load of patients with NG feeds on my wards, none of whom seemed to be going home, and some of whom might be good for case studies. It was this moment of loose talk that started the chain of events that led to the student turning up on my ward.

Normally a new dietitian has 3 months' grace before being expected to supervise a student - after all, I have only been there a month, and my confidence in my own abilities and knowledge is growing from a fairly slow start. Being observed by someone else and having to answer questions and justify my own practice is a little daunting so early in my career. And my workload is so nearly out of control all the time, and working with a student doesn't half slow you down.

Anyway, there she was, asking about the possible case study, and there I was, with a whole load of work. I remembered how wonderful my own B placement supervisor had been, and how she had made me feel as though I had her full attention and support for however long it took, and I tried to do the same. So now I am potentially supervising this case study, although I will try to see whether someone else with more experience could possibly do it instead.

Training continues

Walk in the New Forest, Feb 2012

The job is so much better than my student clinical placements; I am hugely relieved. My dietetic colleagues are universally pleasant and helpful, and I am starting to become familiar with some of the staff on 'my' wards.

Most of the Dietitians don't wear uniforms, which is a shame, because I found the tunic pockets really useful. Some of the renal Dietitians wear a uniform, but it is a purple polo shirt and has no useful pockets. Uniforms that other professionals wear are really helpful in identification of the various species. Nurses are various shades of blue depending on seniority and specialism, Healthcare Assistants are burgundy, Ward Hostesses (the food service staff) are black, Physiotherapists are white with blue trim, Occupational Therapists are white with green trim. The most striking are the Speech and Language Therapists who wear bright crimson shirts, as vivid a red as you can imagine. It is a scary colour, and I can't imagine why they chose it. Doctors don't wear white coats any more (infection risk) but sometimes wear stethoscopes and harried expressions, and say things like "It's half past two, I've been working since seven thirty this morning and I haven't yet had a break." We all defer to the Doctors. They are the omnipotent rulers of the wards.

My patients are mostly uncommunicative. On the stroke ward they are usually either unconscious or have lost the ability to speak, understand speech or express themselves (dysphasia/aphasia). On the elderly ward they are often asleep, dysphasic, have dementia, or all three. One day I was delighted to be able to speak to two patients; by the time I visited the ward again one had already been discharged. I get the feeling that if they can talk, then the nurses can sort them out without the help of a Dietitian. This is a shame, because I would like to have a bit more interaction with the patients, but there's plenty of time for that once I've mastered this first stage of my professional life. I sat in on an outpatient clinic to see how things worked, and there was plenty of interaction between the patients and the senior Dietitian I was observing which went waaaay beyond the scope of my limited abilities.

There are many computer systems in use, including standard packages like Outlook for email, and specialised ones for clinical results like blood tests, x-rays and scans. I have done some small online training packages in order to be given access to other systems, but I had to attend a proper IT training session for half a day on something called iPM. About ten minutes of it was relevant, but I am now fully trained and authorised to operate the tracking system to request and log receipt of archived patient notes from off-site storage. This is a task that I will definitely, absolutely, never undertake. My second session of iPM training was shorter (it was one-to-one), and only took 40 minutes of which about 5 minutes was relevant, but I can show you the screen that will give you a list of patients that are expected to be treated on a day-care basis on a ward. Again, I will definitely, absolutely never need it again.

I've also had the first part of the training that will help us to supervise the Dietetic students we will be hosting on their placements. The B placement students have actually arrived in the department, but with me being so new I won't have to supervise them until later in their placement. The training was at the University associated with the hospital, and was very interesting. The first day was primarily about setting the scene and understanding the way that placements operate in this 'cluster', which is slightly different from the one where I studied. It was a welcome break from the unremitting pressure of patients on wards, as well as a chance to meet and share experiences with some other new Dietitians who are in a similar position to me. The second day of this training is this week.

In between writing and publishing this, I have had a lovely weekend with Lola II, which is why this post is late. It was actually ready on Saturday, but I was too busy cleaning the house to remember to click 'Publish'...