Vaccinating is exhausting

Coronavirus Vaccination Clinic 2 (the Portakabin), March 2021

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

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

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

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

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

Reception in the Portakabin clinic

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

Proximity alarms being charged

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

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

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.

I work a bit harder for a change

My life recently is contained neatly in just five categories: LTRP, Badminton, Garden, Buddhism, and Work. I don't think there's much else gone on in the past week except eating and sleeping. Note that Music and Running do not feature - Music starts again in September, but Running may never make a further appearance. Holidays, Camping and Travel are imminent though - I'm looking forward to several trips coming up soon.

LTRP

I met the kitchen man Ylf again, hopefully for the last time. I have selected and specified everything I can think of - plinths (I do love that word), units, doors, handles, worktops, 'upstand' (where the worktop extends a little way up the wall), 1 hob, 2 ovens, 2 sinks, 2 taps, 2 draining board arrangements, 1 dishwasher. I'm keeping my current fridge/freezer and washing machine. Ylf has provided a floor plan, a final quotation, and some computer-generated pictures of how it might look.

Meanwhile I have approved Ulf's chosen LVT (Luxury Vinyl Tile) supplier and he has partly broken down his quotation for me. We will have to talk more because (a) his quote for the flooring was supposed to be cheaper than the alternative Karndean but it isn't, (b) Ylf not Ulf needs to be responsible for the whole kitchen installation because Ulf doesn't have a fitter for my preferred worktop, and (c) I still don't have an overall comprehensive picture of what Ulf will be doing and how much it will cost. However, at this stage I can probably construct this for him, which is what I may do to save time.

As you can imagine, every other aspect of the LTRP is on hold until the kitchen project is done, except for trying to sell various unwanted white goods and the terracotta wine rack with capacity for thirty bottles that has never held more than about five. I'm not even thinking about what could be done next, although when the stairs are replaced (part of Ulf's quote) perhaps it will be time to consider the upstairs hall... so maybe I am thinking about what could be done next.

Badminton

Always evolving, my Monday club now only has three female members. I'm there for the full two hours every week without fail, and another lady regularly comes but for only one hour because she has childcare issues. The third lady turns up once in a while and swears that this time she will keep coming every week, then we don't see her again for months. So I spend a lot of time playing with the boys, which is fine, but it would be nice to have more women.

I tried to arrange a summer barbeque for the club. When will I learn? They all encourage me by saying what a good idea it is and won't it be fun, so I set a date and time and place and construct a welcoming and enthusiastic email, and just three people respond to say they can come, one of whom is bringing a child. So we abandon the BBQ and I book an Indian restaurant which turns out to be unsuitable for the mother/child combo and has to be un-booked, and we go to Pizza Express. At the last minute we did get three more, so there were eight of us in the end. It lashed down with rain throughout, so a good thing we didn't stick with the BBQ idea. And I so rarely get to eat pizza.

Garden

Nasty, thorny, back-breaking, stupid garden. I don't even spend much time sitting in it, not even back when the weather was good. Day 1: I hacked it back by at least a third and left all the debris on the lawn and paving. Day 2: I filled ten bags with non-thorny stuff (wisteria, forsythia, sage, spotted leaf plant whose name escapes me, other one with the scented white flowers), left the rest where it was. Day 3: took ten bags to the tip, returned and filled them again with the remaining thorny stuff (rose, berberis, pyracantha, holly, hawthorn) and more non-thorny stuff, took another ten bags to the tip. Another couple of bags still waiting, and the lawn needs mowing.

When the indoor LTRP is done I'm coming for you, garden. You'd better watch out.

During Day 3 a head popped up over the wall from my neighbour's garden. It is a gardener, who reports that he visits twice a year to hack back my neighbour's plants in much the same way as I hack back my own, except she has a much smaller space with much less in the way of thorns. I invited him to come and attack her overhanging shrubs from my side of the wall, which he did, and I now have his contact details. If this flirtation proceeds to full engagement then he may join the ranks of my named tradesmen, and I may never again have forearms that look as though I have been fighting with cats.

Buddhism

My Thursday badminton club doesn't play over the summer, and the Buddhist Centre in Birmingham has a Thursday night event. So at the beginning of the summer I thought I'd go there on Thursdays, except that I kept finding lots of good reasons not to. My local Tuesday Buddhist group doesn't happen in August either, but eventually I made it to Birmingham last Thursday. Conveniently, they were holding a Bake Off activity so there was a lot of cake, followed by a talk about how baking might complement Buddhist practice which didn't do much for me. But I enjoyed the cake a lot, and met some more new people who were also very pleasant and welcoming. I might even go again on another Thursday.

Work

There is a Health and Well-Being event scheduled for mid-September and aimed at staff at my hospital site, and the Dietitian who used to work in Public Health and 'cardiac prevention' has moved on to Weight Management. So I've been called upon to create the Healthy Eating stand, together with the two part-time ward Dietitians. (Almost immediately, and for reasons that are not connected with the Health and Well-Being event, one of them resigned.) I have made a few phone calls to a couple of organisations and with luck I'll receive a poster or two and some leaflets about fat, fibre, salt etc. in time for the event. It will not be an impressive display, and hopefully someone more competent will be appointed soon so I won't have to do it again.

I've also agreed to do an ante-natal clinic which is my least favourite clinic in the world, and I'm covering another clinic to help out the team because our Team Leader has gone, and I nearly covered another two clinics because of staff unavailability but I wasn't needed in the end. Look at me, volunteering for extra stuff. Maybe I am starting to work a bit harder than before. And my very least favourite patient of all time has decided that I can help him if he sees me on a regular basis, which is sufficient punishment for all my previous sins.

Birthday treats

In the last blog post I left you with my soggy tent at the end of Famfest. There was more to come in my birthday week because on Friday I headed down to London for further events, staying with Lola II and Mr M as usual. There was a concert in Islington and a picnic in Regents Park. Or, as I discovered, The Regent's Park.

On Saturday I slept very late while Lola II did exercise at the swimming pool, then we had brunch at a fancy brunch spot, did the shopping for the picnic, ate some more and went to the concert. The Indigo Girls are from the South of the USA, and are a duo singing what I suppose I'd call Folk Rock. Here's the one that always makes me cry. I was a little overwrought. Got something in my eye.



They are MUCH older now than when these videos were produced. But so am I. Here's the one they do before the encore (I have no idea what the visuals in the video are all about. Ignore them and just listen):



And the closing number, which had the whole venue singing at full pelt:



I could listen to them forever. And sometimes I have to, given Lola II's propensity to sing whatever's in her mind at all times. On our camping holiday during the walk around the reservoir she started to sing the sound of the squeaky gate. She does cashpoints and pelican crossings too. Unbelievable.

It was my birthday on Sunday, but I knew that work loomed on Monday and I'd need to wake up a lot earlier so my plan was to set my alarm for 8 a.m. Lola II and Mr M seemed a little put out by this, but I thought nothing of it until about five to eight when they arrived in my bedroom to sing Happy Birthday, a ritual not performed for me for at least 20 years. No wonder they were a little disappointed out at my choice of an early start.

I was presented with splendid and practical gifts - a road map, because we had experienced together the uselessness of satnav in the lanes of Devon. A mug painted by Lola II to represent the 'jazzy drop' fake chocolate sprinkled with hundreds and thousands that we enjoyed 30 years ago. A plastic toothbrush cover for travel protection in the washbag, from Mr M I think. Half a bar of chocolate left over from the hazelnut, plum and chocolate birthday cake that Lola II baked the day before. And jars of homemade (by Mr M) plum jam and grape jam. I couldn't have asked for better presents.

On Sunday I'd arranged for a group of friends to meet in The Regent's Park, near the bandstand in case it rained, but it didn't and everyone came and we had a lovely picnic. I found out some fascinating insider political facts by grilling my friend who works at the Home Office unmercifully about Teresa May, Amber Rudd, Boris, Brexit, the last general election, the next general election and anything else I could think of. I don't see him very often and I have to say he delivered quality information. There was also a brief conversation about another skiing holiday. Yay!!

My birthday was also celebrated at work on Monday where we routinely give each other a card and a cake and some flowers. On returning home my sleep patterns have reverted to regular insomnia again, so on my usual day off on Tuesday I was determined to sort out some of the LTRP issues that have been on my mind. It took three hours to get to the bottom of my options for hob, dishwasher, ovens and taps, and another hour to consider floors and other matters relating to the overall project.

I went out for a walk in Kenilworth with my ex-team leader, on the same day as the interviews for her replacement. Her job was in the midst of a team which is entirely dysfunctional and everyone in it is trying to find work elsewhere. None of the applicants was appointed, not that it makes much difference to me as I wasn't really being managed before either. The reason given to one internal candidate was that she lacked management experience, which makes me believe I may well have been successful if I'd applied for the job. But although I have management experience I know that I am not a good manager, and I am trying to make my life less complicated and coast down the slope towards retirement. I get entirely enough responsibility and leeway for service improvement in my current job, and the extra money would not make up for the stress and unpleasantness of the team leader post.

Kenilworth Castle, August 2017

Tired (again)

Somewhere in Rugby, May 2015

Usually I make a start on writing something vaguely interesting at the weekend, and finish it off ready to publish on a Tuesday. This week that hasn't happened, so I am putting this out without benefit of deep consideration or self-editing. I am tired.

This is my last month of full-time work. From October I am reverting to either 27 or 30 hours a week (I don't yet know which it will be - either way, not more than 4 days) and I am looking forward to it immensely. They are certainly getting value for money out of me this final month. An extra clinic has started, we are still short of one Dietitian who has left and a replacement not yet recruited, one of the remaining Dietitians is on holiday, but a new service is due to start shortly after she gets back and needs a load of preparation, which I'm not sure is being done. Two of the Diabetes Nurses are now off sick and another is about to have an operation on her foot that will keep her at home for six weeks.

On top of all that, a couple of weeks ago I committed the most heinous crime that it is possible to commit - I didn't turn up for a clinic which I was supposed to be covering. I got confused with where I was supposed to be and whose clinic I was standing in for. Luckily there were only three patients and apparently they didn't get too angry, although they were entitled to be cross because their previous appointments had been moved to this new date at short notice because one of the remaining Dietitians not previously off sick had been put out of action with a bad back, due to being made to work in a room with a coffee table instead of a desk (thankfully she's back at work now). I felt bad about missing that clinic for days. Actually, I still feel bad about it. I hope the feeling will wear off soon.

It's all been a bit much, and now that my age has exceeded the half-century I am starting to appreciate that I am no longer a bright young thing who can just pack as much as I like into my days. Playing badminton makes me much more tired than it ever did before - not that I'm about to stop playing, but I used to start early and finish late at club nights and now I'm much more inclined to start late and finish early. I am significantly tired the day after any vigorous activity, where in the past I wasn't. Of course as well as the badminton I'm doing the running that leads up to the event in November, so that makes for extra tiredness. Perhaps I'm overdoing things.

[Nostalgia note: When I was a child, my grandmother used to say that I was always overdoing things. "Do not overdo," is one of the few phrases I remember her saying, along with "Speak more slowly," the numbers in German and a rhyme that started "Hoppe hoppe Reiter" which I still remember word for word.]

This has turned into a bit of a whine - it's interesting what manifests itself when I sit with a blank screen and write whatever comes into my head. Things are fine. I am essentially fit and healthy and most of my complaining is about activity that I have chosen to do of my own free will and could stop at any time - in fact, I have missed a badminton opportunity tonight. I have completed some significant and difficult tasks and am optimistic that I will manage a few more by the end of the year. Work is essentially fine too, although there are and always will be annoyances and inefficiencies and personalities and conflict, as well as satisfaction and success and achievement and progress.

Outside work I've already mentioned badminton and running - there are also films on DVD, the usual reading in print and audio, food shopping and cooking, watching the one TV programme of the year that I like (The Great British Bake Off), cleaning the house, a massage, and welcoming Lola II and Mr M for the annual Leamington Food and Drink Festival. As usual I made sure I examined every stall in the arena over the two days of the Festival, and this year purchased three packs of sausages, a sachet of curry paste, a mushroom and garlic vegetarian Scotch Egg, three different cheese scones, a chocolate and cherry brownie, a Thai curry with cashew nuts and rice, and a pastrami and cheese toasted sandwich. I have already eaten all of them except one pack of sausages, but not necessarily in that order.

My ongoing plan for this evening is to go to sleep quite soon. I'm looking forward to recovering at the weekend before starting my penultimate week of full time work.

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.

Seize the moment to blog

Garden rose, June 2015

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

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

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

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

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

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

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

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

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

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.

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!

Dietetics and more

Sissinghurst, June 2012

Events move apace in the Dietetic department, while I blog about inconsequential matters like my reading habits and creatures made from meat and pasta. There has been laughter! tears! patients! clinics! and a few interesting developments.

Wards

We have swapped wards again. If you have been following the saga since the beginning, I started with the stroke and elderly wards, followed on with respiratory and urology wards, and now have cardiac rehabilitation and neurology. Next rotation, I may get the orthopaedic and labour wards. Admissions at the start were for reasons of 'general deterioration', then it became 'shortness of breath', and now 'chest pain' or 'headache'. Or I get patients transferred over from Critical Care or the stroke ward. But in the end, patients are just patients and the dietetic treatments they receive are pretty similar, whichever ward they're in. A combination of artificial feeding, nutritional support and frustration.

Neurology and neurosurgery are slightly more gruesome than any of my previous wards. Head injuries and intracranial bleeds are not pretty, and often affect personality as well as physiology. There are loads of new and very obscure abbreviations both in neurology and cardiology, and sometimes even the nurses are a bit vague about what they stand for (I don't tend to bother the doctors with my questions). Strangely enough, I have found the doctors' handwriting is an order of magnitude worse in neuro notes. But the cardiac wards win the prize for the most badly kept folders, to the extent that sometimes it isn't possible to find what the doctors have written over the past days or weeks, or you have to look in three different places to get the full story.

Complaint

I have been involved in a complaint about treatment received by a patient a few months ago, and had to revisit the notes I took at the time and at the decisions I made and documented. It wasn't too bad, although there's always something to learn. In future, I intend to pay a bit more attention to making sure everything is done as it should be when a patient is discharged home.

Staffing

You may (or may not) remember that there are three of us 'junior' Dietitians, all on partly or wholly temporary contracts. We are occupying posts that belong to three other Dietitians who have been filling posts left unoccupied by three further Dietitians who are on maternity leave (it's actually not quite as simple as this). Until those latter three decide what they would like to do, and until a plan is agreed by The Authorities, none of us knows what the future holds. There's a further 'senior' Dietitian who is on a temporary contract, filling in for yet another Dietitian on maternity leave, who is my team leader. This temporary stand-in has now found another job and will be moving on in just three weeks' time, leaving a very short term vacancy at quite a senior level.

It is all very complicated, and I may not have explained it very well in the above paragraph, but the immediate upshot is that we will be short of bodies at the coalface very soon, and the Dietetic Manager is taking steps to try and make sure that we will all be able to cope. For a dreadful minute or two, I thought this meant that I would lose my clinic, but a swift reorganisation has restored it to me, albeit on a different day, and I am very relieved. There will still be extra work to do, but I think we will cope.

Job application

I have applied for yet another job, and heard today that I have been offered an interview. Just for a change it is not in the middle of a holiday, although it could have been - Mr A and I and all the family are going away for a week very soon. In the past, this might have disrupted the flow of this blog, but nowadays it will hardly be noticed. The interview is for a job that I would very much like to have, but it is quite a long way away and would involve a significant amount of commuting.

Other news

I have been to London to meet up with children I went to school with (who are now adults with children of their own) and our former clarinet teacher and her husband, who do not seem to have aged in the slightest. Then onwards to Lola II's and Mr M's house where we always intend to do things like go for a walk but end up just mucking around. I can't even remember what we did in the end, but I'm sure it was lovely. Oh yes, we went out for Japanese food, for the first time in ages.

What do points mean?

Yes, I have won another prize from a blog, through the medium of my favourite joke. To see it, you will have to visit this page and look in the comments. I received a bag of Jordans Superfruity Granola, and three Jordans Absolute Nut bars, which arrived last week. I have tried one of the bars (delicious! but 260 calories per bar), but we haven't opened the Granola yet. I'm sure it will be jolly tasty.

CAE and CPD

Henry the Harris Hawk, May 2012

Well, we have swapped wards, on the first day following the three-day week. During that previous week I worked all three full days, colleague #1 worked two days, and colleague #2 worked one and a half which included an outpatient clinic (and therefore she was not available for ward work for half a day). I handed over my patients all up to date and tidy, and received wards in return that contained all sorts of loose ends (and the wards in question have not stopped referring patients since Monday).

Then two specific things happened. Firstly, a Clinical Adverse Event (CAE) was recorded about a patient on one of my (new) wards who had not been seen despite having been referred and then chased. Secondly, it became clear that the referrals continued to come in at a rate of two new patients for every one I was able to actually see. Add the fact that my outpatient clinic on Tuesday was the biggest ever (full clinic, no gaps, ten patients! Only one DNA!) so there was much letter-writing to be done, and I had a day's professional development course all day Thursday when I wouldn't be able to see any patients at all.

At this point, I had to ask for help from our new clinical manager, who is covering for maternity leave and has been in post for less than a month. I have to say that she took the load of referrals away from me in a matter of minutes, and I was able to go for my CPD with a clear conscience. I did make the small mistake of looking in the referrals book before I went off on the course, and the relentless stream of new patients didn't seem to be diminishing at all. Of course the nature of referrals is that they do not necessarily come in at an ideal rate, sometimes too many and sometimes too few, but I know which I prefer.

By the way, I am not in the least concerned about the CAE. When I did go to see the patient, he was not in a particularly bad state, and I wouldn't have prioritised him over many of the other patients needing nutrition support. He had been looked after as I would have wished, offered snacks and supplements, and his intake (mostly) recorded along with his weight and other details that form the evidence base for my intervention. As this is a ward that is wholly unfamiliar to me, I can make no judgement about why the CAE was raised and by whom, but I hold no grudges - presumably someone thought that the poor nutritional state of a patient was important enough to complain about, and that is generally a good thing. I can't take it personally, given that nobody on the ward knows who I am yet.

The course I went on for a day was part of something called 'Preceptorship', which is supposed to provide a framework for supported ongoing learning within the first year post-qualification. The organised forums are mostly aimed at nurses, with a couple of session suitable for other healthcare professionals. This one was mostly about patient safety and brief behavioural interventions, and was much more relevant than I was expecting it to be, especially the session about Motivational Interviewing. This is an evidence-based technique for promoting behaviour change, which turns out to be the part of the job of a Dietitian that I like the best, although I'd never have guessed it before I started. I actually like weight management! Up until very recently indeed, I was claiming that this was an area of Dietetics that really didn't interest me.

I have also spent a short time with a Specialist Diabetes Dietitian, planning how I might gain an insight into what they do. This is for the enhancement of my CV, my professional development portfolio (which at the moment is rather in the nature of a virtual portfolio until I get round to actually writing things down and filing them) and for brandishing at a future job interview to show how interested in diabetes I am. Among the wealth of practice-related matters that I gleaned from this session, I also took away the abiding impression that all the Dietitians currently in the Diabetes service are young, committed, and unlikely to move away to leave any room for me in the near future. There are also many impediments to expanding the service, so it may be some time before any vacancies appear. The last Dietitian recruited into the Diabetes team had remained at my current level for seven years before the opportunity arose for her to move upwards. But you never know.

[I have also looked into volunteering at Diabetes UK weekend events, and the only thing currently putting me off applying is the need to express enthusiasm about working with and/or supporting children. Being a truthful person, I have yet to contrive a convincing response for this area of the form.]

The good news was that thanks to my manager I was able to leave at the end of Friday with most of the new referrals seen, although there are still a few that are having to wait until Monday. As for the type of interventions I'm seeing on the new wards, that will have to wait for a future blog post.

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.

Reducing the workload

Wisley, August 2011

My workload reached the point last week where one of my colleagues (who only has an outpatient clinic every two weeks) offered to help out, and I accepted gratefully, handing over six patients who really needed reviewing. That relieved the immediate pressure, but we had another discussion and agreed that I would hand over my three outlying wards to the other two Band 5 Dietitians. Since then, I have felt so much better that I actually told someone that I'm enjoying my job now.

I have felt slightly guilty about this transfer of work - maybe I'm just not doing as well as the others, maybe I'm too slow? But then I think - there's a new Dietitian starting in May who's only going to be looking after one of my wards as a full time job. While she will be able to address aspects of care that I don't have time for (e.g. why aren't patients routinely weighed once as week as protocols dictate?) I have four other wards to look after. Or I did have, and my colleagues insist that they are able to manage with the extra workload, which actually only came to two or three patients each. My main wards each have between about ten and twenty patients on my caseload, on average.

Then there was the Nutrition Nurse, who asked me why I hadn't applied for the more senior job when it came up. Nutrition Nurses are part of a team that make the strategic decisions about nutrition - whether a feeding tube should be surgically inserted, for example, or whether IV feeding is appropriate - and also do some hands-on nursing relating to the tubes. They are in charge of making sure there is no infection at the tube site, and no other complications with the tube components, and will pass nasogastric tubes if the nurses can't manage it, and help to unblock tubes in appropriate ways, and are responsible for a specific type of tube called a nasal bridle. I also discovered recently that they also assist with the endoscopic and surgical  insertion of gastrostomy tubes (feeding tubes into the stomach).

The main problem with nasogastric tubes is that they are designed to be temporary - easy to insert, but also easy to remove. Patients routinely cough them out, or pull them out, because who wants a tube going up your nose and down your throat, especially if you can't understand where you are or why you are there? I expect that some patients have specific and ethical objections to being fed, but often we can't ascertain whether this is case, if communication has been seriously disrupted by a stroke. So decisions are made by the Nutrition Team according to their assessment of the patient's best interests. If a patient repeatedly pulls out an NG tube, one of the options is the nasal bridle.

This is an NG tube that is not just passed up the nose and down the throat and fixed in place with tape, but a 'bridle' is also inserted behind the nasal septum. This just means that the tube can't be pulled out easily, and pulling on the tube may become painful, preventing all but the most determined patients from removing it.

Getting back to my Nutrition Nurse, I told her that I wouldn't have been given the more senior job because I've only been working as a Dietitian for two months. She was gratifyingly amazed, which made me feel great: someone who doesn't know anything about me other than my interaction with the patients thinks I'm doing a good job. My Dietitian supervisors and managers don't actually see as much of my day to day work as the Nutrition Nurses. So that was a very good day at work.

When the new Dietitian starts in May I will hand over the largest chunk of my work, and responsibility for all the other wards will be re-allocated between us three junior Dietitians. So the workload will be even more manageable, and I may have a little bit more time for thinking and planning, which hardly happens at all at the moment. I'm looking forward to it, and actually enjoying my job in the meantime, now that the workload is more manageable.