What I've been reading

The Thread
by Victoria Hislop

narrated by Sandra Duncan

"Thessaloniki, 1917. As Dimitri Komninos is born, a fire sweeps through the thriving multicultural city, where Christians, Jews and Moslems live side by side. It is the first of many catastrophic events that will change for ever this city, as war, fear and persecution begin to divide its people."

During the first month of the big commute, the only reading I was doing was in the car - at home I was too tired to concentrate on complicated words. This was good to listen to, superficially a love story, but it also taught me a little bit about the history of Greece since the 1920's.



The Hare with Amber Eyes: A Hidden Inheritance
by Edmund de Waal

"When Edmund de Waal inherited a collection of 264 tiny Japanese wood and ivory carvings, called netsuke, he wanted to know who had touched and held them, and how the collection had managed to survive."

This was a book that I finished reading because I am faintly obsessive and hate to leave a book unfinished. No doubt it is a work of art, like the things it describes, and I could appreciate the quality of the writing, but it wasn't my cup of tea. Sister D gave it to me when she had finished reading it on our trip on the Danube, and when I asked if it was good, she kind of shrugged. I should have known from that reaction.



Appleby at Allington
by Michael Innes

narrated by Gordon Dulieu

"Sir John Appleby dines one evening at Allington Park, the Georgian home of his acquaintance Owain Allington, who is new to the area. The evening comes to an end, but just as Appleby is leaving, they find a dead man, electrocuted in the son et lumiere box that had been installed in the grounds."

An author that was recommended to me by Hugh, a regular reader of this blog (while I am a regular reader of his weekly circular). He is right, it is old school detective fiction in the style of Dorothy L Sayers' Lord Peter Wimsey and Francis Durbridge's Paul Temple, both of which I like. This was just right, although the narration was a bit slow, with some heavy pauses. A proper whodunnit with a satisfactory conclusion, even if not an outstanding work of literature. But as I found with the previous book, literature can be a bit tedious sometimes.



The Wonderful Wizard of Oz
by L. Frank Baum

narrated by B. J. Harrison

"When a tornado crashes through Kansas city, Dorothy and her dog Toto are whisked far away, over the rainbow, to a strange land called Oz. Plucky Dorothy and Toto embark on a magical adventure to search for the Wizard of Oz and along the way encounter the Tin Woodman, the Scarecrow and the Cowardly Lion."

Another freebie from the Classic Tales podcasts, and he didn't do too badly with the narration of this one - no difficult names or foreign words. Surprisingly similar and yet distinctly different from the movie version, Dorothy inherits white shoes rather than ruby slippers, and I'd forgotten the bit where the wizard flies off in a balloon, although Lola II tells me it's in the film. Easy listening, but engaging enough for adult reading.



The Man Who Knew Too Much
by G. K. Chesterton

narrated by B. J. Harrison

"The eight adventures in this classic British mystery trace the activities of Horne Fisher, the man who knew too much, and his trusted friend Harold March. Although Horne's keen mind and powerful deductive gifts make him a natural sleuth, his inquiries have a way of developing moral complications."

Another English author narrated by the American, but not too bad - the mistaken emphasis on the wrong syllable of Westmorland can be forgiven. These are in the style of Father Brown but much more political and less straightforward 'whodunnit'. It was a very useful filler, because I finished the Appleby book before my next monthly audio book credit arrived!

Weekend trips and a holiday

Liverpool Docks, February 2013

Most of the posts for a couple of months have been about work. There has been a great deal of life outside work, as I have hinted a few times. There was a trip down south to see Mr A's family, there was Lola II's and Mr M's film festival, there was a trip to Liverpool to celebrate Lola II's birthday, and there was a whole week on holiday in Berlin and Munich. Last weekend was mercifully empty (except for a tiny little badminton match) and this weekend I can relax again, although there is a plan to meet up with Lola II for nonsense and silliness (and lunch).

Mr A's dad and sister are fine, and his mum is now living in a brand new nursing home that seems very comfortable and modern, with some interesting ideas for its residents, all of whom have dementia. There is a garden with raised beds, there are the activities you might expect such as music and crafts, but there are also different seating areas - some with tables, some with sofas, some quiet, some with a view of the garden, and an interesting representation of an old railway carriage complete with luggage rack and suitcases. Mr A's mum seems as well as can be expected.

The film festival was a treat! There was a big screen, floor lighting, there were trailers, there was ice cream, an usher(ette) with a torch, a projectionist and a very appreciative audience in the three screenings I attended. The trailers were particularly good, and you can see them all in the YouTube Gulloebl channel - I have picked my favourite 'Gulloebl Chinema' trailer to show here. Mr M and Lola II must have spent ages setting it up and filming the trailers, and gave up a whole weekend to various enthusiastic film-goers. I hope they do it again, it was brilliant, although the surprise of the trailers will be hard to repeat. But if anyone can do it, they can!

The trip to Liverpool was good too, although somehow the weekend seemed shorter than it has in previous years. There was a bit of trouble with the hotel room - instead of our usual little guesthouse or B&B, Lola II had got a great deal on a large centrally-located hotel. I arrived first and checked in, but when I got to the room it had a double rather than twin beds. I thought I would phone reception rather than trek back to the desk, but the room phone had been pulled out of the wall. Back at the desk, they gave me another room, but neglected to re-program the keycard, so I couldn't get in. After a third trip to reception, I returned to what was indeed a twin room this time, but there was an odd, unpleasant smell, and when I took my shoes off, I discovered a large wet patch of carpet by the door.

The third room was fine, and reminded us both of Great Aunt Sylvia's flat in Golders Green. What looked like a wi-fi router was up in a corner of the ceiling, so we had fine Internet reception - there was hardly any need to go out. But out we went - down to the docks, dinner in a lovely sushi restaurant, into town for a retro clothes fair, and an art gallery to finish up.

Then my most recent holiday - Berlin and Munich with Mr A. Neither of us had been to Berlin before, and as Mr A described it to a friend, we were looking forward to a week of "good food, markets, and museums about death." Which was pretty much how it turned out. We saw many sights in both cities, rented bikes for a few hours in Berlin and rode around the Tiergarten and along the canal to a large stretch of preserved Wall, interspersed our walking with museums about death, ate sushi, and did indeed visit a couple of outstanding markets.

In Munich the outstanding attraction (apart from the company of the friend we stayed with) was the Deutsches Museum - a museum of science and technology that is both enormous and wonderful, and where we spent six hours and would have stayed longer had the museum not closed. In Berlin, one of the highlights was the Ritter Sport Museum, devoted to the local chocolate, and containing a Tower of Ritter Sport, which amused me a great deal.

No more trips or holidays are planned at the moment, although I'm thinking I might return to Tunbridge Wells for my Solitary Holiday again this year, mostly attracted by the lovely apartment I stayed in last time and the wonderful sushi restaurant. Mr A and I are thinking about a camping trip to France and possibly a trip to South Wales, and he has a scheme to go biking in Bulgaria. But for the moment, while the snow accumulates on the daffodil buds, we sit on the sofa and stay snug and warm.

Counting carbs

October 2012

I am still on my own at work, and it's not going too badly. I like the job more every day, and my steep learning curve continues. I feel privileged to read and hear the accounts that patients share with their doctors,  nurses and other healthcare professionals, even if they are not complimentary. Patients are angry, sad, depressed, anxious, overwhelmed or struggling, and luckily for my state of mind they are occasionally happy, positive, grateful or just demonstrate a very welcome sense of humour. They are always interesting, and sometimes interested.

I am now working with several patients on carbohydrate (carb) counting, which means that the patient estimates the carbohydrate content of everything they eat. I try to start with a brief description of digestion, then ideally find out what the patient tends to eat on a typical day. This allows me to understand their choices a bit better, and tailor the rest of the consultation to suit that person - for example, if the usual diet contains couscous and tofu, I might go about things differently compared with pie and chips.

Carb counting is usually something that adults with diabetes tend to learn after they've been diagnosed for a little while, a few months at least (although there are exceptions). So they ought to know already which foods do and don't contain carbohydrate, although it always pays to check their knowledge at this stage. Even within my short experience, I've found a surprising number of people who have been choosing their insulin dose according to the quantity of food on the plate, rather than considering only the carb-containing foods. For example, a very large cooked breakfast including bacon, eggs, sausage, black pudding, beans, mushrooms and tomatoes with a mug of tea with a splash of milk contains very little carbohydrate, and the amount of fat and fibre in the meal means that no quick-acting insulin needs to be injected.

So we establish appropriate knowledge of carb-containing foods, then move on to quantifying the amount they contain. I can provide different types of written information, and we have food models, pictures of food on plates and packets of food complete with nutritional labels. Then I can refer back to the typical day's diet, so the patient can have a go at estimating the carbs in their typical day. That's the first stage, and sometimes that's all that happens to start with. The patient goes home, and for a period of time just estimates the amount of carbs in their food without changing anything else.

The next stage is to apply this knowledge to insulin dosage. Essentially, to maintain good levels of blood glucose, carbohydrate intake and rapid-acting injected insulin need to be closely matched. This is a simple statement, but it's never that simple. There are different insulins, people react differently to the same food. Other factors impinge - stress, activity, alcohol, hormones, medications, illness, previous dietary intake, dosage of long-acting background insulin, the sex and size of the patient, previous blood glucose readings, injection sites, quality of insulin, quality of injection devices - there are a myriad of possible factors that will mess things up. But to start with, we work with just a few numbers.

At this second stage, having checked whether the patient's carb estimation is reasonably accurate, they might choose to start adjusting insulin dosage. This is done using two ratios: the amount of carbohydrate that is matched to a unit of insulin (or vice versa), and the change in blood glucose level that can be brought about by a unit of insulin. There is also a target range of blood glucose that people aim for, which is chosen individually and may depend upon the time of day - let's say for the sake of argument that it is between 5 and 8 mmol/L. We will further assume that the background insulin is at the right level, although this is an assumption that can rarely be made in the real world.

The patient tests blood glucose before a meal, and estimates the carb content of the meal. If the pre-meal test is within range, then the insulin to carb ratio is used to calculate the amount of rapid-acting insulin to be injected. For example, if the ratio is 1 unit to 10g and the meal contains 50g of carbohydrate, then 5 units of rapid-acting insulin are needed.

If the pre-meal test isn't within range, then a correction can be applied. If the pre-meal test shows blood glucose is high, then extra insulin can be given, and if low then an amount can be deducted. For example, if the pre-meal test is 15.2 mmol/L and the correction dose is 1 unit to 2 mmol/L, then 3 or 4 extra units of insulin will be needed along with the insulin to match the carbohydrate in the meal. If the pre-meal test is 4.3 mmol/L, then one fewer unit of insulin might be given - 4 instead of 5 units for a meal containing 50g of carbohydrate.

In an ideal world, this would result in a relatively steady blood glucose level that may rise immediately after a meal, but would return to within the target range by the time the next meal is due - no higher, and no lower. A higher blood glucose may make the patient feel ill, and increases the risk of diabetic ketoacidosis and long-term complications. A blood glucose below 4 mmol/L may make the patient feel ill, and needs immediate treatment to mitigate the risk of hypoglycaemic coma and, in the worse case scenario, death.

Together with a specialist nurse, this week for the first time I helped a patient to start carb counting. The nurse prescribed the insulin, but I suggested the ratio and correction dose. Ever since that consultation I have been worrying that my advice was flawed, to the extent that I have been trying to contact the patient to check that all is well. So far, I haven't managed to get in touch, and all I can hope is that if anything had gone wrong, the patient would have contacted us.

I am on my own

Bridge to Esztergom, October 2012

It's been... HOW long? Anyone would imagine that I didn't love writing these posts. I really do, but I haven't even managed to get to badminton this week, so it must be serious. And last week we were on holiday, in Berlin and Munich. Maybe there will be a post about that, but I somehow doubt it.

My colleague, RSB, was away last week, and will still be away this coming week. So I returned from a week's holiday to a proper caseload, with real patients to see in real clinics, and no safety net. There are plenty of people to help out if I needed help, but they are at the end of a telephone. And it was fine.

I'm starting to relax with the job now, a little more confident in my ability to deal with whatever walks in the door. I've got used to asking before anything else in a consultation: "What is it that you want to talk about?" and finding that it isn't at all what I expected. There have been two patients with eating disorders, several others who have cried, and some who haven't. The most satisfying have been where the patient has said "I didn't know that" after I've told them something, and that's happened twice. Because I'm pretty new at this game, and some of them have had diabetes for all their lives, I feel very glad if I manage to pass on some of my acquired knowledge.

I have been working on a document that is called "All About Diabetes". It is both for reference, and a learning tool, so that I can be sure that I not only know about everything I need to, but can also explain it when I need to. My first Gestational Diabetes clinic was on Friday, so now I am pondering about how I can cut down the amount of time it takes to do all the necessary explaining to a woman who is more than 26 weeks pregnant and has been told earlier the same day that she has diabetes. I need to cut it down because I ought to be spending about half an hour with each patient, and on Friday there were only three patients and I was an hour and a half late home. Although it didn't help that the last patient was an hour late.

So this is what I need to cover:

• What diabetes is
• The patient's normal diet
• Which foods contribute to blood glucose, and which don't
• Which foods should be avoided altogether and why
• Any questions

It doesn't sound much, but the 'Any questions' section can go on for a long time. And the patient may have a partner or family member there who also has questions, and their first language may not be English, and the mum-to-be may be in floods of tears as well. I've worked with all of these already, and that's probably why I'm feeling at the moment like I can manage whatever is thrown at me. I'm sure there will be days when it is clear that I can't.

There are other aspects to the job outside the consultations with patients. I have now been to a meeting involving all dietitians within the Trust, and discovered that there are absolutely loads of them, and also learned more than I currently need to know about intestinal failure. I am still getting to grips with the admin, and the computer systems, and finding my way around the hospital and between sites - at the end of one day I wasn't paying attention to which staircase I went down, and managed to get so lost that I couldn't find my way out of the building. I have also managed to arrange a large service and MOT for the car, which felt like quite an achievement. But I haven't managed to go to badminton, so there is still room for improvement.

I start to find out how much I don't know

Sissinghurst, June 2012

It is a nightmare. I Have No Time At All. This evening (the second one I have spent at home since last Thursday) I have managed to contact a friend whom we will be visiting next week, ordered some Euros for that visit, and 'helped' Mr A sort out parking at the airport by generally answering either "I don't know" or "I can't remember" whenever he asked me a question. The only answer I got right was "Terminal 5". I have about 20 emails that need attention, I need to help dad upgrade his computer, most of my savings accounts and utilities are now uneconomical and need switching, and I'm nearly a week behind with blog reading, let alone writing.

I am crazy tired, and it is my own fault. I continue to try and play badminton twice a week for two hours, and this eliminates two evenings from the week. I am challenged by simple tasks like arranging a service and MOT for the car, because I need to drive the car to work, so will have to arrange everything in a city I don't know at all, at a garage that allows me to drop the car off and pick it up without impinging on the working day. The job makes me late home quite a lot, although this ought to change in April when the schedule of clinics will change, and I will have my own clinics with my name on and everything.

Work is interesting and stressful and difficult but full of promise. I have been keeping a list of 'things to write about on the blog' that I thought I would get round to, but (see paragraphs above) I may as well summarise now because that's as much as I can manage.

Things I have learned about diabetes: all about different sorts of insulins, rules for days when you are sick if you use an insulin pump, how to manage exercise and alcohol if you take insulin, how to manage someone who has just been diagnosed with Gestational Diabetes and keeps bursting into tears, what carbohydrate counting really involves.

Things I have been taught that are not about diabetes: how to use at least four different computer systems, how to apply for study leave, where to find at least 100 policies and procedures, what the Very Low Calorie Diet is for, how to wash my hands and not contaminate food.

I would like to write much more about most of these things, except for handwashing and food safety.

One of the most annoying things at the moment is needing to remember at least five different combinations of user names and passwords. I am told that all of the passwords have to be changed regularly, and don't allow you to just change a number e.g. password01 to password02. This policy does not improve security; all it does is force you to write your user names and passwords down. As long as I can remember the password that gets me access to the document with my passwords in it, I should be OK.

All the most annoying things so far involve administrative systems. The induction process has been shocking. My scheduled day for induction is two months after starting my nine month contract, and seems to be a series of presentations about the Values and Vision of the Trust - the mandatory training I was expecting will be at a future date that I won't be told about until induction day. Just as I think I've done everything administrative that needs to be done, I find out about more - I have to email evidence of mandatory training to a random email address. Food Safety and CPR training is arranged by someone who works in Catering. I have to complete a document for my Personal Development Review that I didn't know about on a date I haven't been notified about. I have to book any annual leave at least six weeks in advance, using a form I haven't been given yet, without knowing how many days I'm entitled to. Today I found out that a filing cabinet drawer in the main office contains copies of referral letters for me - nobody had thought to mention it before. And don't get me started about Tracking... I may muster the strength to write about Tracking another time. And clinic procedures: what to do if a patient doesn't attend, or changes their appointment, or does attend, or I am asked to see them by someone else, or I want them to be seen by someone else.

There are some very good aspects of this job, though. Professional development seems to be built into the job, rather than an expensive luxury available only to the lucky few who have to pay for it themselves. This means that I am already booked onto a postgraduate module about diabetes taking place over four days at the university, and there seems to be little resistance to other opportunities that come my way. I have already learned a great deal about diabetes, and have reached the uncomfortable stage of being much more aware of how much I don't know, but I do occasionally have flashes of insight allowing me to feel good about some of the things I do know.

There is so much to write about work that it has almost squeezed out any mention of the fun that has been happening at weekends. Lola II and Mr M staged a film festival, and Lola II and I went to Liverpool for the weekend, and there was much hilarity at both these events. I would love to write blog posts full of amusing anecdotes and illustrated by YouTube clips and photos, but perhaps Lola II will volunteer to document these occasions on my behalf. She is pretty busy most of the time as well.

What I've been reading

Kiss the Dead
by Laurell K. Hamilton

"My name is Anita Blake and I am a vampire hunter and necromancer, as well as a US Marshal. So when a fifteen-year-old girl is abducted by vampires, it's up to me to find her. And when I do, I'm faced with something I've never seen before: a terrifyingly ordinary group of people - kids, grandparents, soccer moms - all recently turned and willing to die to avoid serving their vampire master."

Fourth of my 12 Books of Christmas. It's like nothing I've ever read before. My literary education has clearly been incomplete, because I had no idea there was a well-developed body of vampire literature for adults. I would never have chosen to buy or borrow this type of book, and probably wouldn't read another, given the choice. It started well, and I thought the story and the world that the author had constructed to hold it were interesting. But the story petered out in favour of the explicit sex scenes - I would have preferred the emphasis to be the other way round.

It happened in Venice
by Molly Hopkins

"He cheated, but only once! Evie Dexter has promised to forgive and forget her fiancé Rob - and her efforts to absolve his sins are paying off: in the past ten days she's only called him a two-timing love rat eleven times. Thank goodness her flourishing career as a tour guide takes her to fashionable Dublin, in-vogue Marrakech and cool Amsterdam. So when Evie's offered a luxury visit to the sensual city of Venice she jumps at the chance."

Number five out of 12 books of Christmas, and this one really strays into 'chick lit', which I loathe. It wasn't as bad as it could have been because she writes quite well, but characters were somewhat two-dimensional, the plot was predictable, and (this is becoming a theme) there was too much sex in it - the only book out of the five so far not to have too much sex in it was the self-published one, and that was awful in most other respects. Here, the men are all rich, powerful and attractive, the women are irresponsible, ditzy, self-obsessed and caring only for clothes, make-up, alcohol, spending money and sex. Is it my age? Or was I always like this?

Mort
by Terry Pratchett

narrated by Nigel Planer

"Although the scythe isn't pre-eminent among the weapons of war, anyone who has been on the wrong end of, say, a peasants' revolt will know that in skilled hands it is fearsome. For Mort however, it is about to become one of the tools of his trade. As Death's apprentice he'll have free board, use of the company horse, and being dead isn't compulsory."

Back to the lovely audio books now that I can spend about three hours a day on uninterrupted listening pleasure. And pleasure it is - I'm so glad that I finally managed to penetrate the world of Terry Pratchett, although it still reminds me of Douglas Adams, which is a compliment to both writers. Witty, clever, beautifully crafted, and this book didn't take much time to get started, which is an improvement on the other books of his that I've read. And a happy ending. I couldn't wish for more.

The Naked Sun
by Isaac Asimov

narrated by William Dufris

"The victim had been so reclusive that he appeared to his associates only through holographic projection. Yet someone had gotten close enough to bludgeon him to death while his robots looked on. Now Baley and Olivaw are faced with two clear impossibilities: either the Solarian was killed by one of his robots, unthinkable under the Laws of Robotics, or he was killed by the woman who loved him so much that she never came into his presence."

I know I read this as a child, because I read lots of science fiction back then and remembered the setup for the crime, although I didn't remember the solution. It was published in the 1950's, but you wouldn't know it. There was some interesting comment on the evolution of societies where physical presence is taboo, and another where exposure to the open air has become impossible for its citizens to endure. A good read.

The Devotion of Suspect X
by Keigo Higashino

"Yasuko lives a quiet life, working in a Tokyo bento shop, a good mother to her only child. But when her ex-husband appears at her door without warning one day, her comfortable world is shattered. When Detective Kusanagi of the Tokyo Police tries to piece together the events of that day, he finds himself confronted by the most puzzling, mysterious circumstances he has ever investigated."

Oh. My. Goodness.This is an amazing book, the best I have read for a very long time indeed. I gave it to Mr A for Christmas, along with another that I'm still waiting for him to finish and pass on. I chose it without knowing anything about it, just because I know he has enjoyed Japanese crime fiction in the past. Unusually, it starts with a full description of the crime, and then the police get involved trying to find the perpetrator, but you (the reader) already know who the perpetrator is. So that's not the mystery; in fact, I didn't really work out what the mystery was until very nearly the end of the book. It's really good.

More meetings and pump clinic

Bridge over the Danube, October 2012

It's becoming increasingly difficult to know what I have and haven't written about, especially now that there is so much going on. I have related different stories to family and friends starting and stopping at different points in the saga of getting to grips with a new job and all that entails, and I can't exactly remember what I've put in this blog. It's tedious to keep reading back over previous entries, and I don't have a great deal of time to do it, so I'm just hoping I'm not repeating myself too much.

Last week was a good week, I observed lots of things and didn't get too tired. This was probably because events prevented me from playing badminton: a social event organised for new starters, a Diabetes UK meeting, and a planned dinner with previous dietetic colleagues that ended up not happening. This week I have already played badminton three times, and now I am very tired.

The large and important departmental meeting about convergence of the hospital diabetes services from two sites to one was more interesting than I was expecting. There was general consensus about the principles of a re-modelled service, which was the point at which I made my getaway. Those who remained endured another two hours, and those I spoke to next day seem to agree that I departed at the perfect time, because no further progress whatever was made.

The local Diabetes UK meeting was its normal unfriendly event - would it kill any of them just to say hello? The subject was Driving and Diabetes, and the talk was given by someone from Diabetes UK. It was mostly about the change of law in 2011, the circumstances in which the DVLA can take away your driving licence, and what you can do to get it back. I left before the raffle.

My colleague RSB has been working hard to devise a timetable to allow us to cover all clinics in an equitable manner. I'm not entirely sure why this has been so difficult to do. At the moment, my only disappointment is that it looks as though I will be covering an ante-natal clinic on a Friday afternoon, which means seeing all those women who are newly diagnosed with gestational diabetes. Given the nature of the condition, it is possible that there will be any number of patients from 'none' to 'all' of the clinic list, and may make my Friday afternoons run rather late.

As well as this clinic, I will be doing general adult clinics. These will mostly contain patients with Type 1 diabetes, because the newly formed Clinical Commissioning Group (which replaces the Primary Care Trust) has demanded that Type 2 patients are discharged into the care of their GPs in the community. RSB will take care of the pump clinic and patients using continuous glucose monitoring, the main ante-natal clinic and the young persons' clinic. Given time and more experience and I may well need to cover these when he is away. But not yet.

I observed a pump clinic this week. Attendance is optional, but it is for patients who use an insulin pump instead of multiple injections to control their blood glucose, and runs for two hours once a month, covering a different topic each time. An insulin pump delivers insulin subcutaneously via a metal or plastic cannula that remains in place for 2-3 days at a time, and has a number of advantages: no need for separate injections, a little bit more discreet, and potentially greater accuracy in insulin dosage and delivery, ideally leading to better control and fewer instances of unwanted high or low blood glucose levels.

For example, secretion of insulin in someone without diabetes consists of a continuous background trickle that may vary according to levels of stress or hormones or time of day, plus increased bursts to match the surges of blood glucose following digestion of carbohydrate foods. For someone with insulin-dependent diabetes who doesn't have a pump, the background insulin is supplied by a once- or twice-daily injection of a medium- or long-acting basal insulin, and the post-prandial insulin is injected as a bolus of short- or rapid-acting insulin, ideally shortly before eating. The background dose can't be changed easily, as it is released slowly over many hours. Although the action profile of the basal insulin is relatively flat, there is a period of maximum effect, and if not matched precisely to carbohydrate intake this peak can be at an inconvenient time (e.g. during the night) and cause hypoglycaemia.

With a pump, both background (basal) and bolus insulin is rapid-acting insulin delivered from the same reservoir in the pump. The pump rep who also attended the clinic answered lots of my questions, and also described the research they have done to map the requirement for background insulin through the day, which can be set up on their pumps. This means that a circadian profile of a trickle of insulin varying hour by hour can be delivered to mimic the 'normal' insulin profile for any individual, to try and minimise nocturnal hypoglycaemia. A step forward indeed.

A few steps forward

Brixham, August 2012

Into week two I go, forging ahead with getting more of the policies under my belt (Arson Prevention Policy, anyone?) and still observing other people at work rather than doing any proper work myself. I spend a happy couple of hours walking around the hospital with floor plans, discovering a deserted Cyber Cafe, the ID office, the car parking and security office, and registering with the medical library. I can nearly find my way to most of the important places now.

My parking pass arrives, and mystifies me by being entirely paper with a small hologram, and no accompanying explanation. Given that the car parks are 'pay to exit' with barriers, I can't understand how it would work. I pay a visit to the car parking and security office, which I now know how to find, and they explain that some of the car parks would now accept my swipe cards, while others operated by numberplate recognition. Having made sure to clean my numberplate, I am recognised successfully this morning.

I have decided to call my Room-Share Buddy 'RSB', which can equally represent 'Really Supportive Bloke'. He is proving a delight to work with, and although I am not moving forward towards independent working as fast as I would like, he is reassuring about my progress. We have discussed which clinics I will cover, and agreed a start date of 11 March, when I will be on my own. It is unfortunate that this date is my first day back after a week's holiday that I have planned with Mr A, and is the start of two weeks when RSB won't be around. So I really will be on my own, except for the DSNs, who I'm sure will help if I need it.

On Friday, by coincidence, RSB was scheduled to deliver a talk to Dietitians from the main department, so I joined the merry throng. We were split into three groups and given tasks to complete: one group was looking at medications for Type 2 diabetes, I was in the group categorising different types of insulin, and the third group was sorting out various hypo treatments. We made a dog's dinner of the insulins, highlighting again that I still have much to learn. I have found a checklist designed to ensure that different types of patients are given all the information they need, but it will prove useful for me to indicate how much I don't know.

I attended another CPD session led by the specialist obesity Dietitian, all about obesity in pregnancy - how much weight a pregnant woman might gain, healthy eating advice in pregnancy and whether weight loss should be encouraged for obese women who get pregnant. It was very interesting although not very relevant, as I won't be covering the ante-natal diabetes clinic unless I am called upon due to unforeseen circumstances. More relevant was a session delivered by a rep from one of the companies that sell insulin - more on this in another post, I think, along with a report on the 'structured education' that I have been attending, aimed at people with Type 1 diabetes and delivered one day a week for four weeks.

I had a long discussion with a very congenial chap from IT, and we took about a quarter of an hour to find suitable times for training on three essential systems, after which I still had to move my Occupational Health appointment (again) and send apologies for a meeting that I can no longer attend. I'm sure that computer systems will feature again on these pages before long. I have many strong opinions already about the state of the IT to which I have so far been given access.

Part of the difficulty of scheduling the IT training is the number of meetings that have been deemed appropriate for me to attend. Being part of two separate teams (Diabetes and Dietetics) doubles the number of team meetings, and the Diabetes team seems to have a lot of other meetings, including education and updates from reps aimed mainly at the medical team, and sponsored by pharmaceutical companies. I've been to two of these, but they were rather dry and focused on the presentation of lots of clinical data to support the prescription of their products, and the speakers were soundly heckled by the doctors, seemingly as a form of sport. It does mean a free lunch one day a week (although of course there is no such thing as a free lunch).

We have a large and important Diabetes meeting tomorrow, which all ranks and grades and specialties are required to attend, and which will 'debate' the future convergence of the Diabetes service, potentially onto one site rather than over the current two sites where it is presently located. I am not looking forward to this meeting one bit - it will be highly political, I won't know any of the background and locations and services and personnel, and while I would prefer the future location to be Hospital A because that is easier for me to get to, I have no relevant arguments to support this in terms of quality of service outcomes. The meeting is also scheduled to end more than an hour after the end of my work day, so I will be trying quite hard to sit near the door and leave as inconspicuously as possible.

Specialist Diabetes Dietitian

Sissinghurst, June 2012

Are your fingernails bitten to the quick? Is your breath bated? At last, I have more than two minutes to sit down and waste time on this blog, rather than running about like a mad thing. I have to admit that I didn't help myself by agreeing (having my arm twisted) to play in a badminton match on Tuesday, so that I didn't have more than ten minutes at home and awake and not in the shower between Sunday night and Wednesday evening on my first week in a new job.

So the new job started bright and early on Monday morning, when I reported for duty at Hospital B. The new employer is an NHS Trust which was formed from the amalgamation of two Trusts several years ago, and contains two large hospitals which I shall call Hospital A and Hospital B. My main place of work is Hospital A, but my direct line manager and her manager are both based at Hospital B, which is why I started there.

The first few days and weeks of a new job are always difficult, confusing, alternately crazy busy and tediously dull. Because you don't know anyone, are perpetually lost both literally and figuratively, constantly depending on other people for instruction/direction/advice/signatures on forms, there is very little that can be done independently. What I can do independently is deathly, and consists of reading about a million policies. And when I say 'reading', I mean 'skimming in the most cursory way imaginable'.

So far, then, subjects of particular interest are, in no particular order: commuting, parking, hospital navigation, and administrative paperwork.

The drive to and from work is taking a very long time indeed. Hospital A is nearer than Hospital B, but parking is more challenging, so I have been advised to try the (free of charge) Park and Ride service, which adds about 20 minutes to the journey time (including the bus trip to the hospital). Sometimes I have to travel between hospitals, which takes about 45 minutes on the (free of charge) shuttle bus, but may mean finishing the day at the wrong hospital, in which case it takes up to an hour to get back to the Park and Ride car park, followed by that long commute home. So I have applied for an on-site parking permit, which is reasonably priced but doesn't actually guarantee a parking place.

Hospital B is where I had my interview, and is an old site comprising buildings from ancient times that might have been workhouses, through to modern convention centres, with every era in between represented, and plenty of traditional lino-floored corridors. For just a moment one day, I caught an evocative whiff of that 'old hospital' smell of disinfectant and floor polish, transporting me back to the time when dad once took sister D and me to spend the day in Westminster Hospital while he worked there. The site containing Hospital B is huge, and the Diabetes department is in a separate building at the opposite end of the site from the main Dietetics department where the rest of the Dietitians live. It is probably a ten minute walk between the two.

In contrast, Hospital A is a purpose-built concrete monstrosity. I had to go there a few times for courses as a student, and found it confusing then, but now that I am expected to work there I am finding it almost impossible to navigate. Coming from my previous situation in a modern hospital with a completely logical layout and consistent ward numbering, this is a rabbit warren that makes no sense at all and has me utterly lost as soon as I turn a corner. I have learned just two routes so far: from the front entrance and from the nearest bus stop to the department, and even these are fairly flaky. If I go anywhere else, I have to be accompanied, like an idiot child or a convicted felon.

I am based in the Diabetes department, which is a different area from where the other Dietitians live. I share a room with the Dietitian who got the full time permanent job that I applied for, which is only fair as he had already been working there on the temporary contract that I now have. Our room is only just big enough for two, has no windows, and opens onto one of the main corridors. All around are corridors containing doors to rooms housing Diabetes consultants, registrars, their secretaries, Diabetes Specialist Nurses (hereafter abbreviated to DSNs), and the office containing two admin staff, a load of files and the kitchen/eating area. I have been introduced to a LOT of people.

I'm starting to see the end of the administrative paperwork phase. Apart from the contract and the payroll information, which I am obviously very keen on, there have been forms for the parking permit, the ID badge which doubles as a swipe card for getting through security doors, annual leave authorisation, occupational health forms, local induction, Trust policies and procedures, and - my favourite - my competency has been assessed and verified by signature of my line manager in the use of weighing scales and stadiometers (height measuring devices). Trust induction has been delayed, however, because there is no space for me to attend in February and the dates haven't been fixed for March. Let's hope I'm not involved in a cardiac arrest or have to lift anything heavy in the meantime, because I'm sure I wouldn't know what to do.

So far, so good. People are friendly, I can even remember some of their names, the other three diabetes Dietitians are lovely, and my room-share buddy (I'll have to think of a way to refer to him) even baked some delicious cookies and brought them to a meeting. I haven't even mentioned the job itself, but I'm looking forward to getting on with it with great relish.

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.