What I've been reading

The Boy Who Could See Demons
by Carolyn Jess-Cooke

"Alex Broccoli is ten years old, likes onions on toast, and can balance on the back legs of his chair for fourteen minutes. His best friend is a 9000-year-old demon called Ruen. When his depressive mother attempts suicide yet again, Alex meets child psychiatrist Anya."

This book was number six of my 12 Books of Christmas, and the first one I've read that was both a good book and didn't have any sex in it. It kept me reading - I finished it when I should have been in bed - but reflecting afterwards, I found a lot of inconsistency. The demons were both real (because they revealed knowledge that the boy could not have had) and not real (because they were a feature of the boy's illness), and I don't like it when the author just leaves paradoxes lying there, no matter how gripping the story.

Gulp
by Mary Roach

"Eating is the most pleasurable, gross, necessary, unspeakable biological process we humans undertake. But very few of us realise what strange wet miracles of science operate inside us after every meal - let alone have pondered the results of the research."

The sort of book that I like: interesting facts about the digestive system, told in an amusing and irreverent way. Nothing earth-shattering or particularly unexpected, but enough to keep me well entertained with a few  proper laughs thrown in. I'm going to look out for her other books, especially the one about space travel.

Katherine
by Anya Seton

narrated by Diana Bishop

"Katherine comes to the court of Edward III at the age of 15. The naïve convent-educated orphan of a penniless knight is dazzled by the jousts and the entertainments of court. Katherine is beautiful, and she turns the head of the King's favourite son John of Gaunt. But he is married, and she is soon to be betrothed."

I knew very little about this book except that it's on one of my reading lists. Another reason I chose it was because it's very long, and my audio book subscription is not keeping up with the length of journeys that I now undertake. But it was definitely worth it: a beautifully written story, read perfectly, and paced to perfection. Lots of period detail that I'm prepared to believe is well-researched, and very satisfying all round. Best book of the year so far (although that's not saying much, I've had some dodgy selections recently!)

When You Are Engulfed in Flames
by David Sedaris

narrated by David Sedaris

"Sedaris proceeds from bizarre conundrums of daily life - the etiquette of having a lozenge fall from your mouth into the lap of a fellow passenger or how to soundproof your windows with LP covers against neurotic songbirds - to the most deeply resonant human truths."

I bought and read this book a year ago - for some reason I didn't include it on the blog back then - and enjoyed it so much that I felt moved to read it again. It's a series of short stories read by the author, who has a dry American humour and a very characteristic style. Sister D once gave me one of his books more than 10 years ago, and I disliked it a great deal - I wonder why? At the time, I remember thinking that his writing was cruel, but it doesn't seem that way now. Anyway, I'm re-reading it because I ran out of audio book subscription with more than 10 days to go before the next monthly credit, and I have pretty much decided to increase my subscription to two books a month while I'm spending so much time in the car.

Carbohydrate reference tables

Leamington Spa, March 2013

People with diabetes who take insulin can do so in a number of different ways. The most common regimens are either a twice-daily injection, a fixed basal-bolus schedule of four injections, or basal-bolus with 'carb-counting'.

The twice-daily injection is 'mixed' insulin, where a proportion of the shot is long-acting and the rest is short-acting insulin. The amount is fixed, so with this regimen it is important to eat regular amounts at regular times, because if you skip a meal or a snack or don't consume enough carbohydrate, you can experience low blood glucose - a 'hypo'.

The fixed basal-bolus regimen consists of a daily shot of long-acting insulin, and three fixed injections of rapid acting insulin, one with each main meal. This is a little bit more flexible than using the mixed insulin, because you can tweak it a little by adding in or omitting some extra rapid-acting insulin as a 'correction' to pre-meal blood glucose levels that are too high or too low. It is still necessary to eat regular and consistent amounts of carbohydrate.

'Carbohydrate counting' is the most flexible option, where you still need the once- or twice-daily long-acting insulin, but you match the rapid-acting insulin to the amount of carbohydrate you eat. It allows you to skip meals, eat extra meals, eat early or late, and eat as much or as little carbohydrate as you want, but in return you have to do some work. In order to match carbs and insulin, you have to estimate how much carbohydrate is in your food, convert that to units of insulin, sometimes add in or take away a correction dose, and that's what you inject.

Estimating carbohydrate content of food can be done in a few ways. Food labels are the best estimate, as long as the food has a label and you can work out how much of it you ate. A whole margarita pizza is 337g and the label says it contains 29.1g carbohydrate per 100g, and you ate about a third of it with salad - call it 30g carbs. But if you cooked six handfuls of raw macaroni and added tomato and cheese and shared it with your partner who ate a bit more than half and there's some left over, and the macaroni packet says there's 73g of carbohydrate per 100g raw macaroni and the tin of tomatoes is 400g at 3g carbs per 100g, and then you had a medium apple, then how much carbohydrate did you have?

There are now pictorial guides and smartphone apps that will help you to estimate visually how much carbohydrate is in various foods, but they cost money, and many people don't have smartphones either. So we give patients carbohydrate reference tables that we have compiled ourselves.

For historical reasons, our hospital has two different carb reference booklets. Neither is particularly comprehensive, and I have some major concerns about their inconsistency. I don't much like either of them, so when it was suggested that I take over the project to bring them together in a single updated version, I thought that would be a great idea.

I have spent a lot of time on four different supermarket websites. They are great; nowadays you can find out all sorts of nutritional information without actually having to pick up a packet of food and look at the label. I am discovering some interesting things - for example, the carbohydrate content of sliced bread is a common starting point, and it's easy to remember that a thick slice is about 20g carbohydrate, a medium slice is about 15g and a thin slice is 10g. What I discovered in my 'research' is that supermarkets no longer offer thin sliced bread. Who knew!

I've also been using the pictorial guides, and the Bible for nutritional information: McCance and Widdowson's The Composition of Foods (Sixth Edition) which contains not only the carbohydrate content but a million other details of the nutritional composition of almost anything edible that you can think of. I must be about a third of the way through the job of revising the tables, and there are some interesting questions that I'll take to the team for a decision. For example, I think we've already decided that, unlike previous tables, we won't be rounding the figures to the nearest 5g. But how many different breakfast cereals should be included, given that cereals always have labels with nutritional information? Should we bother to include any cereals at all?

It's an interesting exercise, it's useful for me to focus on carb content of all sorts of foods, and a handy task to have when patients don't turn up for their appointments. I'm looking forward to having an agreed final version that we can all trust.

Low calorie sweeteners

Asamkirche, Munich, March 2013

We often recommend to people with diabetes that they limit their intake of sugar, but that artificial sweeteners can be used in their place. In fact, I discovered following a bit of research that there are more categories of sweeteners than I had thought, including fruit sugar (fructose), nutritive and non-nutritive sweeteners. And that the advice to avoid sugar may not actually be valid. I haven't yet got the complete picture and I certainly need to do more investigation to understand the claim (by Diabetes UK) that, if the same total amount of carbohydrate is consumed, then "sugar does not raise blood glucose levels any higher than starch."

Fructose is only slightly slower to be converted into blood glucose compared with sucrose, but usually comes neatly packaged inside fruit which has many obvious benefits. Granulated and refined fructose, however, is comparable with sucrose. Nutritive sweeteners are polyols (sugar alcohols), including sorbitol, maltitol, xylitol, isomalt and mannitol. They contain fewer calories than sugar and are better in terms of dental health, but are generally not absorbed consistently from the gut into the bloodstream. This has two consequences: firstly, it is more difficult to estimate their effect on blood glucose and therefore to administer the correct dose of insulin. Secondly, as they are not fully absorbed, then they pass on through the gut causing flatulence and producing a laxative effect.

These nutritive sweeteners are often used in 'diabetic' products, which is why we generally advise people to steer clear of those. As an aside, Diabetes UK is now calling for an end to food labelling as 'Suitable for Diabetics,' saying that it is misleading, since a report from the European Commission in 2008 states that there is no role or benefit from the use of diabetic foods, and specifically:

• There are no grounds for developing specific compositional requirements for foods intended for people with diabetes;
• People with diabetes should be able to meet their dietary needs by appropriate selection from everyday foods; so
• There are no grounds for especially formulated foods for people with diabetes to manage their condition.

But I digress.

There are now five different chemicals that are commonly found in artificial (non-nutritive) sweeteners: aspartame, sucralose, acesulfame K, saccharin and stevia. In the supermarket aisles, you will find Canderel, Splenda, Sweetex, Hermesetas, Sweet & Low and Truvia as well as Silver Spoon, Tate & Lyle and supermarket own brands. There are tablets and granulated sweeteners, types designed for baking, and 'half-and-half' sugar if the transition to sweetener is a step too far. It should be possible to find something palatable.

Sometimes there is suspicion: wasn't there a report about rats getting cancer? Are sweeteners really a suitable replacement for sugar? The European Food Safety Authority (EFSA) has been tasked with reviewing all food additives for safety by 2020.  They were asked to review aspartame as a priority; their report was published in January 2013 and can be found in full on the EFSA website (ref 2013-EN-399). The following highlights are quoted directly from that report.

• Aspartame is classified as additive E 951. 
• The molecular shape of aspartame stimulates our taste bud receptors in a similar way to sugar, so we perceive the taste as sweet, but in fact the molecule is broken down to aspartic acid, phenylalanine and methanol in the stomach and gut before absorption. So the actual aspartame molecule does not reach the bloodstream (oral bioavailability is zero).
• No significant acute or subchronic toxicity has been observed in animal models even at the highest doses of aspartame which could reasonably be administered. 
• Epidemiological studies have not identified any association between brain tumour incidence and use of aspartame.
• It is suitable for pregnant women.

So aspartame was found to be safe. And, presumably in response to some other hypothesis, the EFSA review also states that "intervention studies have consistently failed to demonstrate that low calorie sweeteners promote weight gain."

Safe as it is, an Acceptable Daily Intake (ADI) still has to be specified. This has been set at 40 mg per kg body weight per day, which for a person weighing 70 kg (11 stone or 154 pounds) would equate to 140 level teaspoons of sugar. This daily amount would be equivalent to 12 x 330ml cans (4 litres) of diet soft drink containing the maximum permitted amount of aspartame, or 36 or more cans (12 litres) at the usual concentration in diet soft drinks on sale.

Of course, there is one significant proviso - people with the inherited metabolic disorder phenylketonuria need to restrict their intake of phenylalanine, so they should definitely avoid aspartame and aspartame-containing products. The rest of us can do as we wish.

Sources:

Low calorie sweeteners: Their safety, role in the diet and route to the supermarket shelf, Complete Nutrition Vol. 13 No. 1, Feb/Mar 2013

Review of data on the food additive aspartame, EFSA, 8 Jan 2013 (2013-EN-399)

EFSA FAQ on aspartame: http://www.efsa.europa.eu/en/faqs/faqaspartame.htm

Position Statement on Sweeteners, Diabetes UK, July 2007
Position Statement on 'Diabetic Foods', Diabetes UK, March 2013

A morning in clinic

Sissinghurst, June 2012

I have a patient booked at 9am. When I looked forward over the clinic list yesterday, he needs an interpreter. I am still new to these hospital systems, is one booked? I asked office admin to check. Office admin called back a bit later, asking "Which language?" The records say ‘patient attended with interpreter’ but don’t say what language. A bit of detective work and deduction and I come up with a theory, but this morning, office admin regret to tell me they couldn't arrange an interpreter. Plan B: do as much as possible with drawing and hand gestures and make a new appointment, with interpreter.

I am expecting a busy morning. The nurse in charge says hello, and tells me that one of her colleagues was exhibiting symptoms of diabetes, they persuaded her to check her blood glucose, it turned out to be higher than it should be. A diabetes consultant happened to be in the clinic at the time, he agreed to see her, and now he's writing to her GP. Her blood glucose this morning was too high again, so it's looking likely that she has diabetes. I offered to talk to her after clinic about her diet.

RSB drops in to say hello. He’s officially off work on holiday today, but has some work to do towards a diploma and is more likely to get it done if he’s sitting in an office rather than at home. He admires my new purchase – a door wedge, Robert Dyas, £1.69 (I won’t bore you with the annoyance of small crowded rooms with spring-loaded doors propped open with bins and chairs). I resolve to treat him to a doorstop of his own. He offers to help with a difficult patient later on, and for the interpreter patient he suggests Language Line, which is a service where the interpreter is on the phone to both the therapist and the patient.

The nurse in charge says the receptionists have all the Language Line instructions and equipment. The receptionists fish it out of a drawer and say it’s fairly straightforward to set up, they will come and help when the patient arrives. They also mention that the difficult patient has rearranged his appointment – this is good, the slot with the interpreter was only 30 minutes which would be tough to manage, and now there will be less pressure. I reminisce about clinics at my previous job, where 30 mins would have been luxurious – most consultations had to start winding up at 10 mins. Now I can have a roomy 60 minutes if I need it.

I call up to RSB to let him know he won’t be needed for the difficult patient. The patient needing the interpreter is now 15 mins late – looks like he’s not coming. This is a huge relief, although I always feel slightly guilty about feeling glad when someone doesn’t come. Now I only have two more patients to see this morning, plus the possible new diabetic colleague. I talk to reception about re-booking the interpreter patient, and they are surprised he hasn’t come, because they have seen him a number of times before and say that he always attends his appointments. We look a bit harder at the systems, and it looks as though his appointment was changed from two days ago. If the change was made very recently and he was sent a letter with the new appointment rather than being contacted by phone, the letter would probably not have arrived in time.

Next patient – looks like another DNA. I dig a bit deeper, and it looks as though three out of the four patients this morning were switched from two days ago (the fourth is the difficult patient, who we already know won’t be coming). I am now not expecting a busy morning. I ask office admin when the appointments were changed. It was back in January, so that’s not it. I now have time to talk to my nursing colleague about what would be best to eat, and then the last patient does actually turn up - one out of four.

P.S. RSB was delighted with his door wedge.

Pumping insulin

October 2012

In the early days of insulin-treated diabetes, people with Type 1 diabetes used to draw up insulin from a vial and inject using a hypodermic syringe. Nowadays, most people use 'pen' devices. These have a pre-filled insulin cartridge, a way of 'dialling' the number of units of insulin you want to inject, and a very tiny thin needle, which can be as little as 4 mm long. [Note: the linked website made me chuckle with its description of one of the insulin pens as "designed for people who don't like needles and children."]

However, today's blog is about one of the newer developments in insulin delivery, the insulin pump. This consists of an insulin reservoir containing rapid-acting insulin that provides continuous subcutaneous insulin infusion, 24 hours a day, via a cannula inserted into the skin. Most insulin pumps have a tube between the reservoir and the cannula, but there are tubeless types as well. The cannula can stay in place for two to three days. You can safely disconnect for about an hour, for showering, sports, trying on clothes etc.

For those of us who don't have Type 1 diabetes, our insulin level is adjusted minute by minute in response to all sorts of hormonal signals, such as levels of adrenaline, cortisol and growth hormones as well as the amount of blood-borne glucose. To imitate the insulin-secreting action of the normal pancreas, people on multiple daily injections (MDI) inject two types of insulin: long-acting once or twice a day, which is designed to release slowly into the circulation over a period of around 24 hours, and quick-acting insulin that lasts about 4 hours, injected at mealtimes to deal with the glucose entering the circulation from the carbohydrates that are eaten.

Like the human pancreas, an insulin pump only has one type of insulin, but two separate ways that it is delivered. There is a background or 'basal' rate that delivers the constant low-level drip of insulin day and night. At mealtimes, the pump user still has to decide how much 'bolus' insulin to give and at what rate - the pump doesn't remove the need to test blood glucose and calculate the carbohydrate content of food, and the injected insulin still doesn't act as quickly as insulin secreted by the pancreas directly into the blood circulation. But there are advantages to having more control over the amount of insulin going in.

For example, the basal rate can be adjusted on an hourly basis, and some pump manufacturers set up their pumps with a variable basal rate to match the general circadian pattern found in most people. A pump can also be of great benefit when exercising or drinking alcohol, because both of these activities tend to lower blood glucose, and it can be frustrating to have to take extra carbohydrate in order to avoid a hypo, especially if you're trying to lose weight. With a pump, a temporary lower basal rate can be set. [Note: exercise with diabetes is a fascinating physiological puzzle that I've been trying to figure out for the past few weeks, and I'm sure a blog post will appear on that subject very soon.] If you're on a once-daily injection of background insulin, then you can only adjust the background rate over a period of days.

There's lots of flexibility with the bolus insulin too (which could almost be done with MDI if you were prepared to give several extra injections). Many people find particular foods take ages to digest, especially if there is a lot of fat mixed with the carbohydrate (pizza is a typical example). If they inject just before or just after the meal, the rapid-acting insulin deals with the first surge of glucose but then its period of action is over before the food is fully digested, and their blood glucose level drifts upwards. With a pump, you can program the meal bolus to be delivered either in multiple bursts (just after the meal and then 30/60 minutes after or whatever) or at a constant rate over a period of time. This also works for really long meals, like a posh dinner with big gaps between courses, or for buffets and parties where you might be grazing over a long period of time.

Other advantages with the pump: it can help you with the sums, so you can be more accurate with your insulin dosage. For example, if you have calculated that your meal contains 48 grammes of carbohydrate and your ratio is 1.8 units of insulin per 10 grammes of carbs, the pump can do the calculation without blinking and deliver fractions of a unit (8.64 units in this case). On MDI, everything would be rounded off because we don't hold 1.8 times tables in our heads, and most pens can only deliver whole units of insulin (50 g carbs at 2 units/10g = 10 units of insulin). The ratio of insulin to carbs may change through a day (many people are more insulin resistant in the morning) and that can be programmed in to the pump software. And if you tell it your blood glucose reading, it can also suggest a correction dose, which can even take account of 'insulin on board', i.e. any insulin previously injected that may still be having an effect.

Of course there are disadvantages, not least the cost of the pump, which is available on the NHS only for those who meet the funding criteria. There's the inconvenience of wearing the pump at all times, which can place limits on clothing: at the beach, or on special occasions (e.g. with a party dress). The most worrying to me, based on what I've seen of patient care for diabetes in hospital, is that with a pump you have no long-acting insulin on board, and if your pump is disconnected for any reason your blood glucose level will start to rise after just an hour or two. If this happens at home, perhaps because of a blocked tube or kinked cannula, you should spot it and be able to deal with it. In hospital, the general awareness of diabetes is fairly minimal, and knowledge of insulin pumps is non-existent. There might be a risk of not being given insulin because it is assumed that you will have some level of background insulin on board, and that could have serious consequences.

Where I work, there are special clinics for pump patients, and I attended one of the monthly education sessions where pumpers can drop in to catch up on particular aspects of treatment. My colleague RSB is covering the pump clinic at the moment, so I don't yet have much contact with this group of patients, except for Mr M, who is a pump user, and who is always happy to enhance my knowledge of the issues.

[Update: Mr M informs me that contrary to my assumption, the first wearable insulin infusion pump was invented by Dean Kamen in 1970, while the first insulin injection pen device was introduced and marketed by Novo Nordisk in 1985. Thank you, Mr M!]

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.