Bonding

I have been spending time bonding* with my landlady. I don't think I could have found a more congenial place to stay, the main reasons being that a) she doesn't watch TV, b) she reads books, and c) she likes films. She is not bothered when I retreat to my room to work, and is currently engaging with the occupants of the house next door, to try and tackle the night-time noise that wakes me up in the small hours and forces me to use earplugs for the remainder of the night.

I continue to stuff information into my head for later regurgitation. A rep and a nurse who work for the company that has the contract for tube feeds and nutritional supplements came to see us in the department, and demonstrated how to use the pumps that squirt the feed through the tubes, along with the different types of tubes and the feeds that they offer. It took a surprisingly long time to go through it all.

Then I was off to another hospital (my third in three weeks) where there was work to do on the ward with a new patient just admitted with a naso-gastric tube. Back to the second hospital on Thursday, and I did the full range of dietetic activities involved with a new patient: using the computer system to look at biochemistry results, extracting information from medical notes, the care plan and the end-of-bed charts, talking to the nursing staff, talking to the patient, documenting everything in the care plan, dietetic record and drug chart, handing over the plan to the nursing staff and recording the intervention on a different computer system.

It all went very well, but took much too long, so my focus over the next week or two is time-keeping. It's not surprising that things take a long time, not just because I'm still new at this game, but also because going to a new setting or ward means I have to spend ages just trying to understand where the information I want is kept. Another reason to look forward to going back to somewhere I've been before.

Onwards and upwards to Friday, when I really came unstuck, and my ego took a beating. The long and short of it was that I'd received so much positive feedback and encouragement that I believed I was doing well, and essentially forgot that while I have some experience of hospital wards and cancer and renal dietetics, I'm still a beginner at weight loss. The first consultation at the GP clinic was worse than the second, but neither went particularly well. My feedback on this session was a little bruising (but nevertheless justified), and then there was the regular Reflection meeting (which I never enjoy) and then some further feedback from someone else asking me to go away and do the task again.

So I was very glad when the week ended and I went home and Landlady came home and we shared horror stories about our respective days and went to the pub for some supper and a drink. A welcome end to not a very nice week.

* bonding = sharing strong drink

Consultations, dreams and hospital food

It's going well up here in GNT, although people still keep asking if I'm enjoying myself. Would they expect me to be enjoying myself during an exam? I'm constantly under supervision, being tested and assessed and asked to do difficult and sometimes challenging things that I've never done before while someone watches like a hawk, making notes about my performance, and then tells me what they think of me. Of course I'm not enjoying myself, but it's a means to an end. Get through this and the final exams, and perhaps I can get a job which I will enjoy, and a salary which I will enjoy even more. Until then, I'm just doing my best to get along.

One thing I do enjoy is my badminton on Monday nights. Another thing is the lack of responsibility because of living in someone else's house. And a couple of times, for a brief moment, I have felt pleased with something I have achieved. I have been seeing patients as well as watching other dietitians: three obese patients wanting to lose weight, two patients on mental health wards because of the effects of alcohol, and a patient who has made significant changes to improve her diet after a stroke. I am less apprehensive and more confident every time I manage to get through a consultation without juddering to a tongue-tied halt.

It's still very wearing, though, doing something different every half day. That makes 10 sessions a week for two and a bit weeks, and the only thing repeated so far has been Reflection with the Dietetic Manager on Friday afternoons, where we mull over what has happened over the past week. Everything else has been with a different dietitian and/or a different clinic and/or a different ward or hospital, every half day, for two and a bit weeks. I find it excessively tiring not knowing what on earth is going to happen next, and yet being continuously assessed. I need a bit of consistency before I can relax, so I've been pretty tense for those two and bit weeks. I can't stop thinking about how utterly unbearable it would be had I not found this house to live in.

I had a dream the other night, very vivid, partly because I was mid-dream when my alarm went off and woke me up. I was at a party, which I was in some way responsible for hosting, but it was underwater and everyone was in scuba gear. I mentioned it in passing to colleagues this afternoon, who started to muse about what it might represent, and we decided that it is how I am coping with the placement - I am in an unfamiliar and dangerous environment, perhaps feeling out of my depth, protecting myself with a metaphorical wetsuit.

Enough self-analysis, if not self-pity. Everything is fine, my face has not been chewed off by dogs, and I have even been invited to another badminton club, which unfortunately meets on Tuesdays. I might try and get there next week, but tonight I have been doing homework, including watching this television programme about hospital food. I thought it lacked balance, but sympathised - my B placement hospital used cook-chill methods and 'regenerated' (i.e. heated up) the food on the ward, and it did come out looking pretty awful. The difference was that in the programme the meals were assembled and chilled off-site and then shipped in, while on B placement the meals were cooked from scratch in the hospital kitchen and chilled on-site. Other than the single day in the catering department, I haven't yet had any exposure to the patients' food here.

Onwards and upwards then, with two more new environments and activities to tackle tomorrow. It could be worse, though. It could be a whole lot worse.

Farmers' Market

Home for the weekend: I was talking to a friend earlier, who likened my experience to being at boarding school. Luckily, I'm as happy in GNT as I am at home, which makes an enormous difference - I don't dread the thought of returning on Sunday night at all. In fact, next weekend I'm planning to stay in GNT and do some sightseeing, since Mr A will be away.

So, the second half of last week included attending the GNT Farmers' Market, a coeliac clinic, a departmental meeting lasting a whole day, a GP clinic, and the regular Friday afternoon Reflection session. I did two follow up coeliac consultations, so now I feel much more confident about my own abilities. The supervising dietitians have all been supportive and encouraging, so that's good too.

Attending the Farmers' Market is an interesting idea, intended to promote healthy eating and the weight management interventions offered by the department. There are really very few stalls in the Farmers' Market, but once a month we have two Food Educators (a grade below Dietitians) who offer samples of food, recipes to take away, and try to encourage people to sign up to a group or individual course of weight management.

It was absolutely freezing, but I kept moving in order to keep warm. There was soup and two types of cake on offer to start with - one cake baked without any added fat, to demonstrate how it could be done. A bit later we cooked a stir fry and a corned beef hash, and encouraged people to taste all the samples and take away copies of the recipes. It was very popular, not least because of the free food, and a large number of those dropping by were previous participants in the weight management courses, wanting to pick up new recipes and chat. I wondered about the cost effectiveness of the time, ingredients and equipment, but the stall is paid for by the body that commissions and pays for services, and this monthly event is part of the Dietetic department's contract for weight management services in the town.

The coeliac clinic was much like ones I'd seen previously, but with more time: a whole hour for new patients, and 30 minutes for a follow up appointment. With the long-term coeliac patients being much more experienced than me, it wasn't hard to carry out a follow-up consultation. They knew what they were doing, and there wouldn't have been much that could be done if they were aware of the risks but chose not to follow a gluten-free diet.

The departmental meeting was interesting in parts, including a good description of all our weight management options including surgery, and some statistics on outcomes. There was also a session on Information Governance, reinforcing the message that I will be in deep trouble if I write anything here about any real patients. There was early warning of severe financial restrictions, including the possibility of redundancies, and vocational matters were covered in sessions about Job Plans (the totally unrealistic ratio expected between clinical and non-clinical work) and Practice Supervision. It was a long day, in a week of five long days.

The GP clinic was the first I had seen since A placement nearly three years ago, so the dietitian kindly let me observe this time, ready to have a go next time - as my timetable stands, I'll be coming to this clinic each week, with the aim of running it myself by the end of the placement. In fact, all the conditions presenting were those I hadn't done before and am a bit shaky on - high cholesterol/heart health and obesity/weight reduction. It's not that difficult, just unfamiliar, so I'll be taking one or two consultations next week, and will have to get busy collecting all the relevant leaflets so I'm ready to go.

Home and away

It's that blog-time again, as I struggle to commit my thoughts to bits and bytes, but it's a random stream of consciousness tonight.

I have spent some considerable time trying to work out how to get the car MOT'd when the car and I are in GNT during the week, and my garage of choice is in Leamington and doesn't open at weekends. I could try and find a reliable garage up here and beg for time to drop the car off and pick it up again and hope that it passes the MOT so it doesn't need work doing to it. I could leave the car for Mr A in Leamington and travel to GNT by train, using buses and/or taxis while I'm here (or even bring a bicycle). I could hire a car, or perhaps borrow one! None of these options is entirely satisfactory. What adds to the bother is that for the next three weeks, I have been scheduled to travel to various different community hospitals and GP clinics virtually every day.

I'm sure this problem will be resolved in due course. Meanwhile, I had a lovely weekend at home, with Mr A doing lots of the cooking, leaving me to have a proper rest. Coming back to GNT on Sunday night wasn't too bad, and I've spent my time so far this week observing a paediatric outpatient clinic (two patients out of five turned up), a multi-disciplinary paediatric diabetes clinic (i.e. patients see the consultant, a specialist nurse and a dietitian), a dialysis unit, and I attended a meeting where dietitians discussed a procedural document about how to manage patients who are having feeding tubes inserted.

I haven't actually led a patient consultation yet, or even talked to a patient, because none of the clinics and wards I've been in has been suitable. This is making me increasingly nervous, but with any luck I'll be able to lead on a patient consultation tomorrow. The longer I go without having to demonstrate my abilities, the more difficult it is to build up confidence. I'm sure I'll be OK, I just need to get started.

On the social side, home life with Landlady and two cats has been blissful. We get on like a house on fire, and I think she must be the only person I have ever met other than Mr A who likes to read a book in preference to watching television. I don't think the TV has been switched on in all the time I've been here, except when we watched a DVD last week. She goes to bed even earlier than I do, and apart from an unfortunate couple of days without hot water when the boiler broke down, it has been the perfect place to stay.

First week on final placement

I'm home for the weekend, allowed to travel south for good behaviour in my first week on placement in GNT. There are three of us students in the department, and we have spent much of the first week together, meeting a large number of dietitians, and starting to find our way around the hospital.

After this first week we will split up, and we have been allocated to various dietetic services according to our preferences. In my case I will be spending a lot of time outside the hospital, which I didn't do on my last placement, and I will have some time in the diabetes service. The other two students will be on the wards more, and focussing on obesity and intermediate care, which is when someone is well enough to leave hospital but not quite well enough to go home.

So last week we spent a day with the hospital catering service, so that we know how meals are prepared and ordered by patients, and how alternative requirements can be supplied. Patients (and ward staff) can select certain options themselves—renal or texture-modified options, for example—and additional snacks can be ordered for people who need extra calories. Unlike my last placement, this system appears to work, and the additional snacks do find their way to the patients on the wards.

Of course, all the notes and recording systems are different in this hospital, and different wards also operate slightly differently, but there seems a little more consistency in what I have seen so far. I've been able to attend a case conference, where a patient's discharge to a residential home with a tube feed was being organised between the community matron, the district nurse, the social worker, the owner of the home, the ward staff and the dietitian.

On Friday, we were sent into town to see the fresh produce markets, which I think was partly a treat to give us a break at the end of the first week, and partly to emphasise the importance of local knowledge. We had a 'task' to complete, comparing prices in the market with supermarket prices. In general, the prices in the market were about the same or slightly higher than the very cheapest 'value' brands in the supermarket, but the quality was much better in the market. We happened to see a stall in the indoor area selling gluten-free produce, giving us some useful inside information about where someone with coeliac disease might shop. It was also interesting to see that despite the introduction of metric measures ages ago, GNT market shoppers and traders still work mainly in pounds and ounces.

The post-graduate centre at the hospital hosts Friday lunchtime lectures, and just by chance this week's was given by a bariatric surgeon, talking about obesity and surgery options. It was fascinating. Again, my last placement couldn't give me any experience of weight management, but this is a major part of dietetic practice in this hospital, and although this isn't on my training schedule (because I have community and diabetes options instead) I hope to learn a lot more.

A point made in the lecture is that it takes only a very little amount of excess food over a long period of time to lead to obesity, and given the large amount of food available to us all, the question is not why some people become obese, but why many people don't. The body's management of energy intake is very finely balanced through production of hormones and metabolic pathways, and we actually have very little conscious control over it, which is why we can do things like fooling ourselves into thinking we have more food by using a smaller plate. Our unconscious systems also tend to 'defend' the highest weight achieved. No wonder it is difficult to restrict energy intake; my own brain is fighting against me.

There are the three options available for 'treating' a patient's obesity: diet, drugs and surgery. Given that the presenter was a surgeon, it is not surprising that his message was clear: diet and drugs don't work when the outcome you want is not only weight loss, but maintenance of that weight loss. Of course it isn't as clear-cut as that, because there are many other ways to 'treat' obesity, the main one being social measures. For example, smoking is as hazardous to health as obesity, but taxation clearly didn't work and psychological and nicotine-replacement therapies may have helped. What has had the greatest effect, I'm perfectly convinced, is the introduction of the smoking ban in public places. I have no idea what measures might apply to obesity, though. It's a hellishly intractable problem.

More holiday

I have somehow managed to transfer myself and sufficient of my belongings to GNT, and even survived the first three days. So that's a relief. But before writing any more about the placement, I shall finish documenting our holiday, by way of a string of photos, as threatened in the last post.

First, the hotel: a very high class establishment, far better than any I have stayed in before. The only disadvantage was that access was up a very steep driveway, difficult to negotiate with jelly legs at the end of a long day on the slopes. They served delicious afternoon tea consisting of rounds of bread decorated with sausage, cheese and other tasty morsels, together with wonderful cakes of various kinds. Dinners were 5-course feasts: a starter, soup, salad, main course (choice of three), and dessert. I tried two strategies: leaving half of what was served, or skipping dessert, but in the end resistance was futile.

Tartar from ewe's milk cheese on grilled zucchini and yeast pastry stick

Cream soup from parsley roots [parsnip actually] with paprika cream

Salads from buffet

Poached salmon on spinach with pine seeds on saffron sauce and served with rice

Panna cotta in a glass with mint pesto and strawberry ice-cream

I tried snowboarding, I really did. After all the lessons and practice, and one more lesson while we were there, I wasn't getting any better, and it wasn't fun. So after three days I switched back to skis, and wheeee! I felt better straight away. Mr A is made of sterner stuff, plus he really couldn't face the idea of returning to the pain of ski boots on his shins. So he soldiered on, and by the end of the week he was able to make fairly reliable linked turns, interspersed with the occasional face-plant in the snow. His homemade shin protection (toilet paper, cotton wool, elastoplast and gaffer tape) worked pretty well, but his knees have swelled up like melons as usual. He has since been investigating the issue of how to deal with dodgy knees in sporting situations. I would probably try to find a different way to enjoy myself on holiday, but he seems undeterred.

The best evening by far was the barrel-stave racing. Competitors had to tie staves to their feet with straps (no fancy bindings allowed) and slide down a slalom slope including a small jump, assisted only by a long stick which acted as both steering and brake. Some were tremendous, and completed the course without a hitch, including one unbelievable woman of more senior years. Others found it utterly impossible, and either got tangled up in the obstacles, or simply couldn't stand up and ski at all. One youngster started off being supported by two of the course marshals, and ended up with them carrying him over the finishing line, to cheers from the crowd. Another had to be transported down to the finish in the toboggan that carried the staves from the finish back up to the top. For much of the time we were crying with laughter.

For the first three days I was obviously spending time on the easiest slopes, attempting to snowboard with Mr A. When I switched to skis, I could be more adventurous, and spent some time whizzing about with the friends we went with, J&C. There was a lovely descent to a lake that was sunlit for much of the day, the only hitch being that the only way out was a drag lift, rather than a cable car or chairlift. The area we were in was quite small, although there was a much more extensive area accessible with the free Skibus; J&C went there for a day, but reported that it was incredibly busy, and they preferred to come back and finish the holiday in our little area. Of course Mr A was in no position to take advantage of a large number of slopes, and would have struggled more than I did with a drag lift.

Poor J&C had to catch their transfer back to the airport at a time that made it hardly worth them going to bed on the last night, but we had a much more civilised afternoon transfer. We spent the morning of the last day in the 'Alpinarium' museum commemorating the terrible avalanche that cost 31 lives in 1999. There were photos, there was video, and some interesting and strange Art, including a curtain of rocks, a hairy human-yeti creature, and a knitted landscape suspended from the ceiling. There were wooden representations of yearly snowfall, a stuffed marmot, silent film of pioneer mountaineers and skiers (wearing skis not dissimilar to those barrel staves), and a disorientating room with mirrors for walls, floor and ceiling. On the roof of the building was a viewing platform, from which vantage point you could see where the avalanche had taken place, and the defences built to prevent any repeat of the catastrophe.

So that was it. Back to the hotel, coach transfer to the airport, short flight, train back home and a cold but welcoming house for less than 24 hours before I was on the move again, on my way north.

Snow holiday

We're back from our week's holiday in the snow, and I have just uploaded more than 150 photos to my computer, many of which are exceedingly good. and illustrate all there is to know about our week. Some of them will no doubt feature in the pages of my blog over future days or weeks.

There is a photo series that covers the sophisticated toilet-paper-and-gaffer-tape-based adjustments that Mr A made to his shin in order to protect it from abrasion within his snowboard boot, but these are probably not suitable for general viewing. I have also attempted to photograph my bruise, which is massive and covers the whole of my left elbow and some of the upper arm, but while my camera has 'sepia', 'snow', 'night time' and a myriad of other settings, somehow Canon has failed to include a 'bruise' setting.

All the pictures taken of me in some snow-based activity using my own camera are, without exception, terrible. Mostly I have forgotten to use the 'snow' setting, which means everything has a deep blue cast that I need to spend time working out how to correct. There are, however, some pictures of me located in various bars and cafes which have come out better. Taking photos of Mr A is complicated by his ski clothing, which is actually his motorcycle clothing, and therefore has a number of reflective strips that confound any pictures taken with flash - all you see are the reflective strips and a large amount of flare.

Other significant series of photographs include the food we were served at our hotel, which was unbelievably good. I shall miss our afternoon teas and five-course dinners. I also have a large number of pictures taken at the 'barrel-stave racing', where competitors strapped barrel staves to their feet in place of skis, and had to negotiate a short downhill course while everyone clapped, cheered and laughed themselves senseless. There are few things in life more funny than watching people falling over, especially on snow with sticks attached to their feet. Another set of photos is from our visit to the a museum in the resort, which documents and commemorates a serious avalanche that killed 31 people in 1999.

I now have a whole lot of stuff to do in the next six hours, which is all the time I have left before I must set off for GNT and a new life that doesn't include sliding on snow. So I'd better get a move on.