Diabetes clinic

Apart from being away from home and in a hospital cell or library dungeon during the day and an isolation unit during the evening and night, it's been a bit less miserable and slightly more interesting recently. I'm getting used to the confinement and disempowerment and all that stuff, and it was curry day for lunch again. Only a week and a bit to go.

I went to a multi-disciplinary meeting of the Palliative Care Team at the local hospice yesterday. It wasn't a very long or interesting meeting, but loads of people were there, including doctors, specialist community and hospital nurses, the chaplain, clinical psychologists, social services, Macmillan nurses and the palliative care and oncology specialist dietitian. What essentially happened was that they talked about all the people needing palliative care who were in hospital, in the hospice, new referrals, and those that had died (the RIP's). The lady I wrote about two weeks ago when I was on the ward was on the RIP list. She had lasted three weeks from her admission to hospital, and she wasn't even aware that she had cancer when she went in.

The diabetes clinic last Friday was really interesting. I have a friend with diabetes so I thought I knew a bit about it, but I certainly had no idea of the complexity of the condition and its treatment and the dietary implications. Rotherham runs a specialist diabetes service that brings together doctors, nurses, dietitians and others who have expertise in the treatment and management of people with diabetes in the same building. Every so often (maybe once a month) they have a clinic specifically for 18-22 year-olds, as this is the time when the responsibility for managing diet, injections and everything else tends to move from parents to children. And there's a lot of responsibility, much more than I had known about before.

They now think that type 1 diabetes is an auto-immune disorder, where the body destroys the pancreatic cells that produce insulin. Insulin is the hormone that allows you to store the food you eat so you can use it for energy later on. Without insulin, all the carbohydrate that is broken down into glucose in your intestines goes into the blood, but doesn't get stored, and goes straight out in the urine. Before insulin was synthesised and purified, life expectancy was short following diagnosis because people essentially starved - no matter how much they ate, it all came out in the urine. The essence of treatment of diabetes is to replicate the insulin levels of someone who still has intact control of their blood sugar.

In most of us, a rising blood sugar level triggers secretion of insulin. After we eat, blood sugar levels rise as the food is digested, broken down and transferred into the bloodstream. Insulin allows the liver and other cells around the body to convert the sugar into fat. When blood sugar levels fall and we need energy, glucagon (also secreted by the pancreas) stimulates the liver to convert fat into glucose, off it goes into the blood and around the body to where it's needed. Nothing is wrong with glucagon homeostasis in most people with diabetes. They just need the right amount of insulin at the right time. Too little and the glucose isn't stored (and in the long term, too much glucose in the blood has other nasty effects); too much and the blood glucose level drops, the brain is starved of fuel and goes haywire - a hypoglycaemic attack, or 'hypo'. Interestingly, someone with untreated diabetes can't have a hypo, there's always too much sugar in their blood.

We only had two patients turn up at the clinic (and I was there ALL DAY.) Both of them were candidates for a new insulin regime. I hadn't appreciated just how many types of insulin there are, the differences being how long it takes before they act and how long they last. Previously, both the lads had been on a regime where they took intermediate acting insulin twice a day, which meant that no matter what, they had to make sure they ate enough at regular intervals to avoid a hypo. The insulin was in charge, they had to follow its direction.

The new regime involves a background dose of long-acting insulin, injected once a day, and then shots of quick-onset short-acting insulin, injected whenever needed, usually when having food or drink. Insulin has to be injected because it needs to get into the blood, but it is one of the hormones in the body that is a simple protein, like others we eat as food. If it were taken orally, it would be digested in the stomach and gut and wouldn't reach the bloodstream intact.

The disadvantage of this 'basal-bolus' regime is that it involves many more injections - two with the old regime, at least four with the new, and possibly more. The advantage is that the person is back in charge - they control the insulin rather than the other way round. They can eat what and when they please, as long as they calculate and administer the right amount of insulin. They can miss a meal, have a kebab, exercise as they please, and have a carbohydrate-free meal should they wish, all of which were difficult to manage before. There's a transition period even for this new regime while the patient works out how to manage the system, but once it's in place, it seems to work a treat. One of the patients who's been on the new system for five months whooped and punched the air when he got the results of the HbA1c blood test that indicates how good his blood glucose control has been over the last 3 months. He was pretty happy.

Anyway, I learned a lot about diabetes in that hour or so, and was also impressed by the maturity and self-possession of these two young men. I'm sure I didn't take anything like as much responsibility for my life and future health when I was their age. I'd tell you about it if my parents weren't listening.

I learned lots more than this - what happens when you're ill, the effects of alcohol, adjusting for exercise, 'carbohydrate counting', pregnancy and ante-natal care, when to take yourself to A&E, and the courses available for people to help them manage their condition. I heard about the results of a survey of clinicians, who were asked what the treatment for a hypo is. Only 20% knew what to do (short answer: administer glucose). The day didn't even touch on type 2 diabetes, the sort that is closely linked to overweight and obesity.

On Tuesday I went out to watch how the enteral feed regimes were reviewed for three patients in a nursing home. Yesterday I spent some of the morning with a Speech and Language Therapist (SALT) assessing dysphagia on the wards - that's anything to do with swallowing. There's remarkably little collaboration between dysphagia specialists and dietitians in the hospital. It seems entirely possible for the SALT to impose a 'nil by mouth' regime because of some swallowing malfunction, and for a referral to be made to a dietitian only when the patient has lost two stone after a fortnight on nothing but intravenous fluid. But perhaps I'm wrong and there are infallible mechanisms to ensure that nobody forgets that people need food in order to recover from whatever it is they're in hospital for.

Today I shadowed a dietitian in a brand new clinic for people with respiratory problems, common in this area where people worked in mining and steel and smoked forty a day in their time off. I learned a lot about how to use a dietetic consultation to build rapport and trust rather than to acquire useful information and provide dietetic advice. Very useful indeed, probably the best lesson I've learned in my time here so far.