Chapter 1.

So here is the thing. I am going to write a book.

For ages people have told me that I should. And for ages I have thanked them for their kind words and thought…yeah, right. Like there aren’t 500,000 other people scrimmaging to get their manuscripts published.

For various reasons which I will not bore you with here, I have been trying to figure out lately ways to re-inject a little passion into my own life as a nurse. I have been feeling this bitter creep of becoming the very kind of nurse I most decry. And I do not like it. Not one bit.

With a little strange serendipity, at the very time I have been searching for some strategy to pull myself out of this sludge, the “you should write a book” thing keeps bumping up against me over and over again.

Yesterday, after all that bumping (and I thank all of you who have encouraged me), I finally had this epiphany and decided to actually listen to the wise counsel.
If others could write and publish, why not me? I think I have something to say.

So. I am going to have a crack at it.
I am going to write a book and then I am going to try to have it published.
I already have a fairly good idea what I will be writing about, but I don’t want to give anything away just yet.

I will definitely keep you posted as it progresses.

As I intend to pour all my creative juices into this project, things might go a little quiet on my social media streams for a bit.
But I will be working hard to craft something I hope you might really, really enjoy.

(Not) the end.

This very confrontational video by Jenn Ackerman portrays the reality of those who live with mental illness at the Kentucky State Reformatory in the US.
Perhaps you might share your own feelings or experiences around the way we treat people with mental illness in our correctional facilities?

Trapped: Mental Illness in America’s Prisons http://www.jennackerman.com/trapped from Jenn Ackerman on Vimeo.

My intention was to make that made the viewer feel what I felt when I was inside the prison. I took a more personal and emotional approach to this project than I ever have. I listened to the inmates and the doctors and set out to take photos of how I felt when I was there. I wanted to show weakness, despair, hostility and vulnerability that I saw when I was there. I left the prison everyday wanting to help these men that have nowhere else to go. There were days that I was extremely scared and others that I left thinking how much someone on the outside missed them. Some days, I had to remind myself that many of these men had done heinous things. There were also days when I was reminded that some of these men have faded into the system with no hope of getting out.

I saw them cry. I saw them hit themselves so hard in the head that they bled. I saw them throw their feces at the officers. I saw a world most people don’t even know exists in America. There were hard days but mostly rewarding ones. For most of these men, they have been outcasts of society and rarely heard. So they had a chance to share their story and have someone listen that actually cared to listen not just focused on treatment or safety.

My intention is to spark calls for reform for the treatment of the mentally ill and the prison system in the US. Since beginning on the project, I have produced a film about the subject and have spoken at numerous prison conferences throughout the country. My work has been used as an educational resource for prisons and law schools and I continue to speak for mentally ill inmates throughout the country. My hope is that the project exposes the injustice, spreads awareness and encourages a needed policy change about imprisoning the mentally ill in the US.
Jen Ackerman

The Thunderbox Papers are a set of short pithy one page information sheets.
The idea is that you stick one on your toilet door for one week and commit to learning the information during each visit.

A Thunderbox refers to an old Australian ‘out-house’ or outside toilet. These toilets were often nothing more than a small drafty wooden shed containing a seat over a deep hole in the ground.
Toilet paper consisted of old pages from newspapers or magazines threaded together with string and hung on a hook.

I will post a Thunderbox Paper here every week or so. Stick it in your toilet at work (or home) and use your business time to review or learn.

HERE IS THIS WEEKS THUNDERBOX PAPER
Veins of the Arm.

Remember: to work you must commit to posting the thunderbox papers on your toilet door (you could even consider posting on the toilet door at work) and taking a moment to read over each time you………well, you know. Business.

The goal is to commit each paper to your long-term memory before the end of the week. So repetition is essential (as is business regularity).
Even if its is just a single blood value or suchlike, print it and stick it.

OK, you have completed your Advanced Life Support (ALS) and Basic Life Support (BLS) education.
Perhaps it was a few months back. Or perhaps you are due for a refresher.

And then your patient arrests. When you least are expecting it.
You immediately experience the arrest response mind donk.

Your brain is  total beige…. and all your knowledge of the ALS algorithm seems to be folded up into an origami flapping bird that is migrating south to your sphincter.

I am going to give you a rough thought-script to simplify the whole thing and get you over any mental donk by moving you to move your nursing team through the things that need to be done.

This is NOT a substitute to the ALS pathway you have been taught, it is just a quick script to cover the first few minutes. By that time there should be plenty of assistance unfolding.

And…I am purposefully skipping over all the intermediate skills and interventions that need to be applied. A knowledge of BLS and ALS pathways is assumed.

Really, you know what to do.
It may have just been a while since you have had to access that part of your brain.
The purpose of this is to give you some solid waypoints, some goals to aim to reach quickly and effectively.

• A = Assemble (yourself and your team).
• B = BLS (yes or no)?
• C = Connect & Charge a defibrillator.
• D = Decide to shock.
• E = Every 2 minutes.

Assemble (yourself and your team).

Assemble yourself!  Take a serious instant to wring the adrenaline out of your brain. ALS is easy.
Assemble your team. Yes, you are going to be checking for Danger and Responsiveness and whatnot, but your first waypoint is to have help at hand.
ALS is a team sport.

BLS (yes or no)?

When you undertake BLS and ALS courses, you are taught to assess airway, breathing, and circulation assessment and intervention respectively.
But the key decision point here is “Do I need to start BLS?”
Keep that in mind and move through your assessment swiftly to get to that point.
Then make the call.

If chest compressions are now in progress check that they are being delivered effectively. This is of great importance. If they are not, correct the technique or replace the person doing them.

Connect & Charge the defibrillator

Your next task is to have the patient connected to the defib.
BLS continues.
Once it arrives, ensure that there is minimum disruption (i.e. nil) to chest compressions whilst the pads are applied.
Once pads are applied, turn the defib on¹.

So again, you will:

• Continue BLS
• Call for a defibrillator.
• Connect the defibrillator.
• Charge the defibrillator.

It is a simple as BLS + Connect and Charge.

Decide to shock:

Now you are at your second decision point. Your first one was BLS yes or no.
The defib is connected and charged.
BLS stops².
The rhythm is assessed.
The decision to shock is made.
I am not going to go through all the rhythms here, but to help narrow the options: if the monitor looks like normal ECG complexes or is a flat line, you are NOT going to shock.

If you are unsure what the rhythm is, ASK the team for help. If you are still unsure, recommence CPR until someone arrives who can identify the rhythm.

The decision:

Do not shock.

• Sinus rhythm (PEA)
• Asystole.

Shock:

• Pulses VT.
• VF.

Once this decision has been executed, BLS recommences immediately.

Every 2 minutes:

BLS now continues for 2 minutes without interruption until the decision to shock is again made. Or until the patient lets you know that they are no longer appreciating CPR.

During this time you need to:

• Obtain and secure IV access.
• Draw up Adrenaline 1mg.
  If you just shocked the patient it will be given after the NEXT shock. If you have not shocked your patient it will be given NOW.
• Maximise the airway and chest compression quality.
  Consider adding airway adjuncts (naso/oropharyngeal).
  Consider preparing to replace the person delivering CPR at the next rhythm check if they are fatigued.

There you have it. You are now well into the resuscitation. The donk has passed.
Hopefully the full team has arrived, is organised and following the cardiac-respiratory arrest algorithm by this stage.
HERE IT IS.

1. if the defibrillator is an AED, at this point you follow the audible instructions given by the unit
2. most ALS courses recommend that everyone EXCEPT the person delivering CPR are stood clear whist the defib is charging

**noosphere:** (NOH-uh-sfeer) The sum of human knowledge, thought, and culture. From the Greek noos (mind) + sphere.
This will be a quasi-weekly summary of contributions to the nursing noosphere that have caught my eye recently. Entertaining, educational, controversial or just worthy of a read. I will point to all these things.

If you have your own post or a suggestion for a worthwhile visit, please email the link to: ian@impactednurse.com.

Injectable Orange:

Fundamentals of Nursing (don’t call it basic): Jessie links to 41 videos covering fundamental (or as I like to call them essential) nursing skills.

Francis report:

The 29 points about nursing: Roger Watson is a professor of nursing in the UK. In this post he provides a 29 point summary of the Francis report and provides his comment on each point.

Sean Dent:

4 quirks of an over-the-hill nurse: Over at Scrubsmag, Sean has just turned 40. He reflects on what exactly it is like to be an ‘over the hill’ nurse.

Philip Darbyshire:

The crisis of care in Healthcare. The ‘Enough is enough manifesto for nursing’: Philip has pretty much had enough.

The LITFL Review:

The LITFL Review 099: My mate Kane, an ED nurse working in Western Australia provides his own weekly summary of the best posts from the critical care noosphere. A weekly check of Kane’s recommendations is a must do for any nurse working in ICU or ED who wants to keep up with the latest educational pearls.

Note to Nurse Day. May 9th 2013.

Why bother sending a note to a nurse?

I mean, come on,  that’s all a bit soft around the edges isn’t it?
After all, I show my appreciation every day to my colleagues…. and the nurses that I really think make a difference already know as much…..
Besides, if I sent a note to one or two nurses, some of the other nurses are bound to get their noses put out of joint no?

And besides the first besides, writing little warm fuzzy notes to people isn’t…..well it just isn’t me.

OK then.

John Kralik is a Superior Court judge, who after a particularly bad year back in 2007  made a new year’s resolution to send 365 thank you notes to all the people who had added something to his life.
His experiences of writing those notes were eventually published as a book: “365 Thank Yous: The Year a Simple Act of Daily Gratitude Changed My Life.”

Here is a transcript of an interview with Mr Kralik on NPR (You can listen to the full interview with him  here.).
Perhaps it might help soften your edges.

HANSEN: Why thank you notes? Why not just say thank you?

Mr. KRALIK: I thought of how my grandfather, whenever you sent him a thank you, he would always send you a silver dollar. And then if you wrote him a thank you for the silver dollar, he’d send you another one. And at the time, I really needed money, maybe that’s why I was thinking of that. I thought, I don’t have anything to lose, let me try sending some thank you notes.

HANSEN: What was the first thank you note you wrote?

Mr. KRALIK: The first one was to my son, who is – you know, at first I thought, of course, since I was not in a great frame of mind I didn’t have anything to be thankful for. But I got some Christmas presents and the best one was from my son. And so I sat down to write him that note and I realized I didn’t have his address. But I wrote him a note to thank him for that present.

And what happened was that when I called him to get his address, he said, gee, I need to stop by and take you to lunch. And he repaid me a loan of thousands of dollars in cash that I had totally forgotten about. And I thought, wow, this thank you note thing really works. You know, maybe I’m onto something here. So, I wrote him another thank you note for repaying the loan and also for taking me out to lunch, both of which, at the time, in the financial condition I was in, were very much appreciated.

HANSEN: And then you began to write notes to other people in your life. You wrote a note later on to the Starbucks guy.

Mr. KRALIK: Well, I went through all my Christmas presents and wrote notes to my coworkers and things got better, to some extent. But then one day I just couldn’t think of anybody to thank. I was very down about the fact that there was a lawsuit against me at the time and wrestling with that. And I spent a sleepless night and then on my way to work, all of the sudden, the Starbucks guy says, John, your usual venti. And I thought – and with a great smile, as he always did – and I thought, you know, this is really kind of a great gift in this day and age of impersonal relationships that someone had cared enough to learn my name and what I drank in the morning.

And I found, to my embarrassment, that I hadn’t taken the time to learn his name. So, I waited by the side there drinking my coffee until somebody else who did know his name said, hi, Scott. And so then I sent him a thank you note. At first he thought it was a complaint letter but he was very happy to get it.

HANSEN: Yeah. Now, a lot of people are confronted with all the gifts they’ve received and are contemplating thank you notes. And sometimes people look at it as kind of a chore. But can you give us some tips for writing some sincere holiday thank you notes?

Mr. KRALIK: Well, I found that sincerity was the best approach. So, you know, I try to write one sincere sentence. I think it was Gertrude Stein said to Hemingway, you know, just write one true sentence about what this person means to you or what their gift meant to you, if it was a very moving gift, and how it changed your viewpoint.

HANSEN: You have a list of things to do when writing a thank you note, a good way to write a thank you note. And I’m impressed by the fact that you say they must be written, they should be handwritten. And the reason is because a piece of you will be in the same room with the person to whom you write.

Mr. KRALIK: I think, yes, that your handwriting reflects your personality and you’re there. I’m often moved by how people have saved my notes. It was very meaningful to them. It’s up on their wall. It’s like part of you that’s there. Things we write in cyberspace are so easily deleted and forgotten and buried by the next 30 emails we receive. But in this day and age, a handwritten note is something that people really feel is special.

HANSEN: Your daughter saved the note that you sent.

Mr. KRALIK: She did and, you know, she reluctantly gave it up for some publicity that had to be done in New York but I brought it back and she placed it in her special place with her special rocks. And, you know, every child has a collection of special things – special pictures, of trips of ours. And she’s got a little cupboard in our house and that’s where it stays. And she was very happy to have it back, and that has always moved me.

HANSEN: Yeah. It’s such a short note that you wrote to her. I mean – (Reading) Thank you for being cheerful and happy when I pick you up in the evening. Sometimes I don’t have a very fun day but when I see you and we talk about things and have fun, I feel better. Thank you for being the best daughter ever.

She was even too young to read cursive so you had to read it to her.

Mr. KRALIK: But it came from my heart. And thank you for reading it because I don’t know if I could have. You know, I had the privilege of doing the audiobook a couple of weeks ago and I didn’t know which parts of the book would be hard to get through but that was the one.

You can help me spread the word by downloading a small poster promoting Note to Nurse day here.

At a recent meeting one of my colleagues proposed we start a dementia activity box for our department.
This, I thought, sounds like a particularly good idea, and might even be extended to include some resources for the aged without dementia.

As a department, we are very good at providing play equipment and distraction activities for our paediatric patients, but the elderly spend far longer in our care and are oftentimes left staring at the ceiling. For ever.

It got me thinking as to what sort of kit we would include in such an activity box. Here are some ideas I came up with for patients with and without dementia (comments welcome):

• iPod with headphones and selection of appropriate era related music.
• Albums of selected historical photos, newspaper and magazine articles.
• Squares of different materials (different colours and textures) that can be folded and stacked as a task.
• Simple puzzles (including jigsaw type and wooden block types)
• A puppy¹.
• Knitting (big wool and wooden needles).
• Set of playing cards (for game of patience etc)
• Aroma therapy massage oil (e.g. Lavender) to give quick massage to hands/feet.
• A large portable clock to assist with orientation to time.
• Paper & crayons/pencils

I’m sure some of you already use resources like this in the aged care setting, or perhaps even in your own emergency department.

So, a call out for suggestions from readers who:

1. Work in units that already have put such a project into practice.
2. Know of any literature that supports this idea or guides as to best content of such a box.
3. Might share your own suggestions as to appropriate distraction/activity items for both aged patients and patients with dementia.

1. kidding

The Thunderbox Papers are a set of short pithy one page information sheets.
The idea is that you stick one on your toilet door for one week and commit to learning the information during each visit.

A Thunderbox refers to an old Australian ‘out-house’ or outside toilet. These toilets were often nothing more than a small drafty wooden shed containing a seat over a deep hole in the ground.
Toilet paper consisted of old pages from newspapers or magazines threaded together with string and hung on a hook.

I will post a Thunderbox Paper here every week or so. Stick it in your toilet at work (or home) and use your business time to review or learn.

HERE IS THIS WEEKS THUNDERBOX PAPER
ECG: recognition of VT.

Remember: to work you must commit to posting the thunderbox papers on your toilet door (you could even consider posting on the toilet door at work) and taking a moment to read over each time you………well, you know. Business.

The goal is to commit each paper to your long-term memory before the end of the week. So repetition is essential (as is business regularity).
Even if its is just a single blood value or suchlike, print it and stick it.

I’m sure your have seen the powerful slogan: Fuck Cancer.

Well, I am going to tell you that our profession has the power to not only fuck cancer, but to fuck cardiovascular disease, fuck chronic respiratory diseases and fuck diabetes.

Between them these four diseases are responsible for 60% of deaths worldwide.
In low and middle-income countries they will kill 90% of their victims before the age of 60, and will inflict an added economic burden on those countries surpassing 7 Trillion dollars by 2025.

Go back and read that again and think about it a little.

As nurses we are immersed in the complex technological, physical, professional and ethical responses that are required to manage the impact (and the collateral damage) that they inflict. This is what we do.
But each of us have the capacity to make far more important contributions.

The fact is, these non-communicable diseases (NCD’s) are largely preventable.
And we have strong evidence-based interventions to do this by addressing four key risk factors:

1. Tobacco use.
2. Harmful use of alcohol.
3. Physical inactivity.
4. Unhealthy diet.

In 2012 the World Health Organisation (WHO) met with other international nursing professional bodies to acknowledge the impact that the 19 million nurses and midwives worldwide can make on NCD’s.

They produced an important document Enhancing nursing and midwifery capacity to contribute to the prevention, treatment and management of noncommunicable diseases, outlining strategies to strengthen nurses and midwives capacity to “help prevent, screen and detect NCD’s and rehabilitate those suffering such diseases”. Go check it.

Importantly, our profession has already make significant impacts in these areas through implementing education and screening programs, driving policy reform and research.

The real power, however, may well rest with each of us at an individual level. With the interactions and teaching moments we share with our patients every day.

We need to think about arming ourselves with the best tools that enable us to provide support, education and encouragement.
We need to think about our own risk factors, so we can model the change we will precept to our patients.
And then,  we need to be pro-active, no, actually we need to do more than that, we need to be aggressive in identifying and engaging the risk factors for NCD’s.

All 19 million of us fucking cancer.

Get hardcore. Commit to using every available opportunity to educate your patients on the risk to their lives (and the impact on their loved ones) of tobacco use, harmful use of alcohol, physical inactivity and an unhealthy diet.

The WHO recommends that risk-reduction interventions should become an essential part of clinical practice at all levels and throughout the patients lifespan.

In part 2 of this post I will tell you how I often fail to use opportunities to address NCD risk factors in my own patients.

I will explore why that is, why it is important that I change my practice and I will throw out a challenge to you.

For the diary of any Emergency Department Nurse Practitioners: The 4th Australian Emergency Nurse Practitioner Conference.
Thursday 9th May (also Note to Nurse Day) and Friday 10th May 2013 in Melbourne.

NursePrac ED has evolved to become a premier conference for ED NP’s, and Extended Care Paramedics with its strong clinical focus.

This years program includes:

• A paediatric management stream.
• Workshops on Ultrasound, Physiotherapy, Suturing and Splinting
• Orthopaedics
• Toxicology
• Burns
• Haematology
• Infectious Diseases.

There will also be free papers showcasing Nurse Practitioner research and case studies.

More information and registration details can be found here.

The early detection and aggressive management of sepsis is vital in reducing morbidity and mortality, and the gold standard in detecting bacteraemia in our patients is the blood culture.

Contamination of blood culture specimens or poor technique may lead to delay in optimum clinical decisions and management with inappropriate or unnecessary antibiotics. Not to mention wasted expenses.

Blood culture bottles contain a soup of nutrients that feed a wide range of bacteria/fungi. Some bottles (including the BD BACTEC Plus media) also contain a resin to neutralise any antibiotics present in the patient’s blood in order to promote organism growth.

When taking blood cultures aseptic non-touch technique should be followed.
Emphasis should be placed on following your hospital blood culture collection policy without taking shortcuts.

Decontamination:

The most common cause of false positive results occurs due to contamination from the patient’s own skin at the collection site.

Solutions that can be used for site decontamination include:

• greater than 0.5% alcohol chlorhexidine (drying time 60 seconds)
• 70% isopropyl alcohol (drying time 0 seconds)
• providone iodine (drying time 2 minutes)

Always allow enough time for antiseptic solution to dry before taking cultures. It is also important to thoroughly clean the tops and necks of culture bottles prior to collection.

There are also commercially available one-step applicators containing combinations such as chlorhexidine gluconate and isopropyl alcohol.

Studies have found alcohol based products show statistically significant improvement in reducing false positives from skin contamination (Dawson 2013).

Technique:

One randomized, study involving 64 interns in an ICU/medical wards found that the routine use of sterile gloves resulted in lower contamination rates.
Sterile or not, it is important to resist the urge to re-palpate the vein after cleaning the site as this increases contamination risk.

Blood specimens obtained after an antibiotic has been administered may contain enough quantities of antibiotic to kill any bacteria collected in the bottle (Halm 2011).
Therefore specimens should be collected prior to antibiotics…. with the important caveat that blood collection must not significantly delay time to antibiotic administration.
If antibiotics have been administered the cultures should be taken just prior to the next dose for this same reason (Dawson 2013)

Volume:

It is very important to obtain the correct volume of blood. The preferred volume for each blood culture bottle is 10mls (However, you should refer to your individual manufacturers recommendation).
So that means a 20mls collection from a single site divided into each bottle.
Under filling may result in an insufficient ‘yield’ of microorganisms.
Overfilling may result in false positive results.

Each blood culture collection should comprise a paired set, each set taken from a different location.
In patients with limited peripheral access both sets can be taken from the same site. However the second specimen should be obtained as if from a separate site with new equipment and re-cleaning of the area etc.

If an infected central line is suspected (eg cellulitis or discharge from the insertion site or extended use of the line), the second set of cultures may be taken from this site. Blood should be drawn from the distal lumen after decontamination as above.

Order of draw:

Which bottle should you fill first?
Actually it depends on the technique used.
The idea is to prevent air being introduced into the ANAEROBIC bottle and altering its environment.

• If a butterfly needle and needle-safety connector device is used the AEROBIC bottle should be filled first as there will likely be air in the tubing.
• If a needle and syringe is used the ANAEROBIC bottle should be filled first as any air is likely to be at the top of the syringe and thus introduced into the second bottle.
• If blood is being collected for other tests at the same time the culture bottles should be filled first to prevent cross contamination from other blood tubes.

Collection of separate samples can be done “back to back”. The common practice of separating collection samples by 15 to 30 minutes does not enhance the yield of bacteria and may increase the time to antibiotic administration. (Halm 2011)

The labelling of the specimen bottles is important.
As well as patient details information should be included describing:

• Source of sample (eg central line, anatomical location).
• Time sample was obtained

—————————————————–
References:

Dawson S. Blood cultures. British Journal Of Hospital Medicine (17508460) April 2012;73(4):C53–5. Accessed March 18, 2013.

Jennifer Denno, Mary Gannon, Practical Steps to Lower Blood Culture Contamination Rates in the Emergency Department, Journal of Emergency Nursing, 10.1016/j.jen.2012.03.006.
(http://www.sciencedirect.com/science/article/pii/S0099176712001109)

Flayhart D. Blood cultures and detection of sepsis… …Tips from the clinical experts. MLO: Medical Laboratory Observer. March 2012;44(3):34 Accessed March 18, 2013.

Halm M, Hickson T, Stein D, Tanner M, VandeGraaf S. BLOOD CULTURES AND CENTRAL CATHETERS: IS THE “EASIEST WAY” BEST PRACTICE?. American Journal Of Critical Care. July 2011;20(4):335–338. Accessed March 18, 2013.

Kim N, Kim M, Oh M, et al. Effect of routine sterile gloving on contamination rates in blood culture: a cluster randomized trial. Annals Of Internal Medicine February 2011;154(3):145–151. Accessed March 18, 2013.

Nurses are renowned for being able to adapt, modify, fix and gerry-rig their clinical environment using whatever equipment or resources are available.
Duct-tape may not hold the universe together, but countless rolls of medical tape pretty much hold the health system together.

So in an exercise to get your mental juices flowing and to demonstrate our combined lateral thinking acumen, I am asking you to consider some uses for the humble cardboard toilet-roll tube in the clinical setting.

1. get out a pad of paper and start brainstorming. If that sounds too much like homework, just sit the pad down beside you whilst you are watching TV tonight, and jot down ideas as they come.
2. think outside of the box. Then think outside that box.
3. you can use a single roll, or multiple configurations.
4. uses for the rolls might be practical (and actually pretty good ideas) or be completely ‘out there’.
5. Stretch your thinking. Aim for at least 10 uses.
   Really creative people will probably have no problems with 50.
6. Once you have finished, pick a few of your best ones and share them with us here.

The Thunderbox Papers are a set of short pithy one page information sheets.
The idea is that you stick one on your toilet door for one week and commit to learning the information during each visit.

A Thunderbox refers to an old Australian ‘out-house’ or outside toilet. These toilets were often nothing more than a small drafty wooden shed containing a seat over a deep hole in the ground.
Toilet paper consisted of old pages from newspapers or magazines threaded together with string and hung on a hook.

I will post a Thunderbox Paper here every week or so. Stick it in your toilet at work (or home) and use your business time to review or learn.

HERE IS THIS WEEKS THUNDERBOX PAPER
Basic Drug Calculations (pt 1).

Remember: to work you must commit to posting the thunderbox papers on your toilet door (you could even consider posting on the toilet door at work) and taking a moment to read over each time you………well, you know. Business.

The goal is to commit each paper to your long-term memory before the end of the week. So repetition is essential (as is business regularity).
Even if its is just a single blood value or suchlike, print it and stick it.

Here is the first flyer to promote Note to Nurse day.
I am asking you help me get the word out. Think of it as a nurse initiated tactical campaign. First, download it here. Then:

1. Print it out and stick it up wherever you think it is needed (In colour if possible).
2. Use your own social media networks such as Facebook and Twitter to get the word out by linking to this page or the pdf poster directly (and here is a short url to do that): http://goo.gl/GKwXp
   OR by talking about it yourself.
3. Send the poster out as an email to anyone you think might be able to help with step 1.
4. Ask them to pass it forward (as in step 2.)

Thanks for your help.

Cure sometimes, treat often, comfort always. – Hippocrates.

Any nurse who works in a critical care area, any nurse who has to deal with a dying patient and the family of a dying patient…..should watch this video.

I would put it in the top 5 educational videos I have seen this year.
But don’t watch it now. This is homework. Watch it tonight when you have time and space to give it your full attention.

Critical Palliative Care is a 25 minute presentation given by Dr Ashley Shreves at this years EMCrit conference.

EMCrit Conference 2013 – Ashley Shreves – Critical Palliative Care from Scott from EMCrit on Vimeo.

PEARLS:

Now you have watched it, here is a short summary of some of the most important points from Dr Shreves presentation:

In the last month of their life many patients will present to the emergency department (US stats up to 50%).
This is not because they want you to save them. It is because dying is HARD.

End of life (the last weeks to days) is a very precious time, and presents a huge opportunity to make a positive (or a negative) impact.

The needs of these patients is tremendous. They are intensive-care patients.

Three things that should NEVER be said to the family of a dying patient:

1. Do you want us to do everything?
2. Do you want us to resuscitate her?
3. I am so sorry there is nothing more we can do.

Instead SAY THIS:

1. What is most important to you (and their family member) right now?
2. Based on what I’m hearing, it sounds like he/she would want to die naturally.
3. We are going to do everything we can to support her/him through this process.
   We are going to maximise her comfort and dignity.
   We are going to minimise any symptoms.
   And we are going to support all of you.

Try to move the patient to an appropriate and private room.
Take them off all the monitoring equipment.
Treat any discomfort with morphine in escalating doses until comfortable.

Drugs.
Dyspnoea is one of the most common and distressing symptoms at the end of life. At the end of life the underlying cause of this is usually irreversible.
But this makes treatment simple:

• Opiates.
• Opiates.
• Opiates.

This is evidence based, effective and does NOT hasten death.
When using opiates: Start low and go slow.

• Morphine 1mg IV. or Hydromorphone 0.2mg IV.
• If not effective double the dose.
• Repeat every 15 min. until patient reports relief or appears more comfortable.

I just have to tell you this story. I swear it is true.

Last evening I was flying home from a Critical Care and Social Media conference in Sydney.

I had settled into my window seat and was flipping through the flight magazine. It was a smaller prop aircraft and everyone was pretty much seated, the last few stragglers flopping into their seats.
I love flying in these smaller planes as they cruise at a much lower altitude and you can enjoy the scenery passing by below. It was just on dusk so it promised to be a beautiful flight.

And then he boarded.
I heard him first. An apologising fluster of luggage and juggled stationary approaching from the rear.
I shall call him Mr Vicks for reasons that will soon be self evident.
Mr Vicks looked a bit like Jude Law, dressed in a light grey suit. I knew with certainty that he would be sitting next to me.

After a brief standing hello, Mr Vicks proceeded to unpack from the two black leather carry-on bags that he had placed in the isle.
Like a set of Russian Dolls, more bags were extracted and were placed on the seat beside me. Then some headphones. And after a considerable rummaging, an iPhone.

All but one of the smaller bags went up into the overhead luggage bin, followed by the larger bags. Headphones into suit jacket pocket. Jacket off, and hung over seat in front.

A cardboard folder that was struggling to contain a thick pile of what I would later peek to see were job applications spilled onto the seat. Mr Vicks leant over me to scoop them up.
Good grief.
The flight attendant moved in and assisted where possible with an icy smile.

Finally Mr Vicks settles into his seat. We taxi out onto the runway. And wait.

Mr Vicks then lifts the remaining leather bag onto his lap. It looks like a small black toiletries bag with a single zip across the top.
From inside he produces a bottle of decongestant nasal spray, clears his throat and squirts two loads into each nostril. After much wet sniffing and coughing he pulls some tissues from his kit and gives a loud extended bubbly blow.

Mr Vicks then holds his work out like an open book before him and inspects it intently. Very intently.

One Mississippi.
Two Mississippi.
Three Mississippi.
Four Mississippi.
Five Mississippi.
Six Mississippi.

He is way too close. And Six Mississippi’s is way too long to stare into your mozzarella laden hanky. I tried not to look.
But it was like….right…there.
Despite my greatest efforts not to, my eyeballs panned to the left. Screeching in their sockets like fingernails on a chalkboard.

Mr Vicks was tilting the wad gently from side to side. Perhaps trying to get the best effect from the overhead light.

Satisfied that all was as it should be, the tissues were stuffed into one of the aircraft sick bags. My eyes flicked forwards, you know, just to make sure I had my own sick bag.

Next. Out of the bag came a Vicks nasal inhaler.
Two big sniffs up each nostril, followed by some deep guttural hypopharyngeal sniffing.
Out with another tissue.
Aaaaand… blow.
Six Mississipi inspection.
Fingernails in my eye sockets.

Inhaler goes back into the bag.
Out comes another different spray. This time it was saline.
No doubt to soften up any last remaining tenacious tendrils of booger that may have resisted being expunged thus far.
Four sprays either side. Big wet inspiratory snort. Sounded like the last dregs of a chocolate milkshake being sucked up a straw.

Recovers the sick bag of tissues from between us and blows.

His pre-flight airway management complete,  Mr Vicks carefully packs away his kit bag and stows it down between his feet.

Turning to me for the first time as if he has just this moment sat down he beams, “Oh, how rude of me…..My Name is David. David Vicks”

And then Mr Vicks extends his hand to me… for a firm, moist,  six Mississippi shake.

I had the good fortune to meet two passionate nurse educators, Jessie Spurr and David Corkill at the Social Media and Critical Care Conference (SMACC) which ran over the last few days in Sydney.

Injectable Orange:

Jessie is a simulation educator and ICU nurse from Queensland who has recently started a nascent but promising blog: injectable orange.
To give you some idea where Jessie is coming from, here is a snip from his first post.

About two years ago, I began a relieving post that involved attending hospital governance meetings in an educator capacity. In the first meeting I attended (hoping to sit quietly and keep my mouth shut), I was bemused to observe the receipt of audit results relating to medication chart compliance and the almost immediate reaction “well it seems we need to do some education.” My mouth was open before my frontal lobe could kick into gear, “really… do we think nurses don’t know how they are meant to sign a drug chart?”
-Education, the solution to everything until everything goes wrong

You can also follow Jessie on Twitter: @JessieSpurr

Think Ask Learn:

David Corkill has 20 years experience nursing in the emergency speciality.
He currently works as an educator and has a passion for providing interactive education solutions that are “clinically relevant and easily accessible for for clinical staff”.
This passion has consolidated into Think Ask Learn, a site that delivers 60 minute educational ‘Webinars’ (live online workshops) consisting of:

• Real-time presentations and recorded presentations
• Audio and visual simultaneous presentation
• Q & A during presentation
• Certificate of attendance offered for professional development points

The current charge for most sessions is $23 AUD and you can see a list of upcoming Webinars here.

David is on Twitter: @thinkasklearn

Having met both these guys, I can attest to their commitment and enthusiasm to improve the quality of clinical education for critical care nurses. As an extra bonus they are both super approachable and engaging.

Lets drop Jessie some encouraging feedback as he tackles the difficult task of getting his blog up and flying.
And check out David’s offerings with respect to your own (or your departments) professional development needs.

Following my post on securing on how to secure an endotracheal tube (ETT) with tape, I a received a comment from Kaye Rolls a Clinical Nurse Consultant at the Intensive Care Coordination & Monitoring Unit.
You can follow Kay on Twitter (@kaye_rolls).

Turns out she is indeed an expert on the art (but perhaps not quite yet science) of ETT security. She is co-author of a set of guidelines published by NSW Health titled: Stabilisation of an Endotracheal Tube for the Adult Intensive Care Patient (pdf)

The 3 methods currently used to stabilise an ETT are:

• Tying the ETT to the patients head using white cotton (Trachy) tape.
• Taping the ETT to the patients face with medical adhesive tape.
• Using a commercial tube holder.

A recent survey of NSW ICUs and High Dependency Units (HDUs) with the capacity to provide short term ventilation was conducted to determine local ETT management practices.
Participants from 41 of the 44 eligible units responded (response rate 93%). The white cotton tape method was the most frequently reported method for stabilising the position of an ETT (78%, n=32) however nine units reported using this method in conjunction with a commercial product and a further seven units reported using this method in conjunction with medical adhesive tape.
Renewing or changing the ETT tapes is a procedure completed frequently by critical care nurses, however, only 41% (n=17) of NSW ICUs/HDUs had a written guideline for this procedure and only nine of these protocols were less than two years old.
Intensive Care WIKI

There is really not much research evidence to support the use of any one method over another, but the guidelines provide some clear principles for specific clinical situations.

As there is so little evidence, these guidelines are based on consensus opinion reached following a meeting of the Intensive Care Collaborative Consensus Development Conference in 2006–07

Here is a summary of the practice recommendations:

• Two clinicians must always be present to change the method of securing the endotracheal tube. One clinician changes the tapes while the other holds the ETT in position.
• Of the two clinicians changing the ETT securement at least one clinician must be an experienced member of the critical care team.
• The method of stabilisation should be consistent within units to promote staff proficiency in safe and effective ET stabilisation.
• The use of adhesive tape/devices should be avoided in patients with impaired facial skin integrity (for example burns, cellulitis).
• The use of adhesive tape/devices should be avoided in patients with extreme diaphoresis
• The use of adhesive tape/devices should be avoided in male patients with beards.
• Endotracheal tube securing methods that may cause venous occlusion should be avoided for patients at risk of raised intracranial pressure
• The ETT securing method should be renewed if the tapes are soiled.
• The ETT securing method should be renewed if the ETT is able to
  migrate/move more than 1 cm.
• When using cotton tape the ETT securing method should be renewed if a clinician is unable to insert two fingers between tape and skin.
• The ETT securing method should be renewed if the ETT position on CXR is incorrect (tip should be 2.5cm above the carina).
• The ETT securing method should be renewed if the method of tube stabilisation is not consistent with Unit practice.
• In the absence of other indications the tube stabilisation method should be renewed at least once every 24 hrs to enable skin and mucosal assessment and to prevent sustained pressure on a single point.
• Assessment of the face should include the condition of the skin of the face, ears and back of neck. In addition the assessment of the oral cavity should be inline with the assessment completed for adequate oral hygiene and includes the mouth, teeth, gums, tongue, mucous membranes, lips and barriers to mouth care.
• The ventilator tubing should be supported by a ventilator arm that keeps the patient’s head in the midline and prevents pressure on the lips.

So, what is it like to have a psychotic episode?
Elyn Saks is a she is a professor of law, psychology and psychiatry who speaks for the rights of mentally ill people, arguing for more autonomy and a restoration of basic human dignity in their care.

In this TED talk, Elyn recounts her first episode of schizophrenia resulting in 5 months involuntary stay in a mental health ward. Reflections on her experience with physical restraints, her initial resistance to medication resulting in recurrent dips into psychosis, and finally her stabilisation, which she credits to three things:

• regular psychotherapy/psychoanalysis and good psychopharmacology.
• Strong family relationships and close friends. Relationships that “have given my life a meaning and a depth.”
• An enormously supportive workplace.

Her message:

There are not schizophrenics, there are people with schizophrenia.

 

There is more than one way to secure an Endo-tracheal Tube (ETT).
These days the safest way will probably involve a commercially available device of which there are quite a few and most intensive care units are probably using one.
But what if your units budget does not stretch to such luxuries? Or what if you just need a temporary way to secure the tube?

Again there are many ways to do this, and everyone has their own particularity from white tape and a simple bow, to brown tape cut into ‘trouser-legs’ and secured around the lips (the brown tape camp will know exactly what I am talking about here).
This systematic review of ETT stabilisation from 2005 found no real difference in any method including the commercial devices with respect to outcomes of ETT displacement, unplanned extubation, facial or lip skin breakdown or ease of mouth care.

Well, this is the way I teach to secure an ETT and I am happy to hear on your own views.

You will need:

• An assistant. Tying the ETT is a two person job. Someone should always be holding the tube whilst you tie it up (and ventilating if necessary!)
• White tape. Also known as ‘trachy tape’.
• Scissors
• Duoderm (thin).
• Strong adhesive tape (Brown tape, Sleek, Blendaderm etc.)

The method:

Cut a length of tape (the length between your outstretched arms is a good guide) and pass behind the patients neck.
Even up the tape on each end.
Tip: if you have ‘Magills’ forceps handy, you can use them to grab one end of the tape and pass it behind the neck. A lot quicker than trying to get your hand under there.

Tie a Granny Knot (or any secure knot) between the patients chin and lower lip.
Some ETT tubes tend to ‘dress’ to the right, some to the left and others sit midline….so you want the knot to sit just below the ETT.

You want the tape around the neck to be firm, but not so tight as to impede venous return or risk pressure areas.
Tip: for bonus points here, you can tie several knots, one on top of the other (say 4) to create a short ‘pole’ of knots. This stops the ETT tube from being pulled down across the lower lip when you tighten everything up.

Now you are going to capture the tube. Tie another Granny knot above the tube taking care not to get the cuff tubing inside the knot.
Again, firm but not so tight as to narrow the lumen of the ETT. That would be bad.

Now you are going to tie two half-hitches around the tube. The rationale for this is to increase the surface area of tape against the ETT so it is less likely to slide through.

To tie the half-hitch:
Take one end of the tape, hold it a few centimeters away from the ETT and with your other hand pass it around the ETT and then back through the loop you have just made.
Be sure to snug it all up nice and firm.

Repeat for the other side.

These two half hitches will tend to slip loose to lock them in with yet another Granny knot.

Now you are going to secure the tape to the centre of the patients forehead.

Note: Only do the following steps if there are no injuries or problems with skin integrity at the site.
Wipe some Tinc-Benz (also known as Tincture of Benzoin or Friars Balsam) on the forehead to increase adhesion.
Every resuscitation room should have a bottle of this stuff handy. It is also great for getting ECG electrodes or Cannula dressings to secure when you have a diaphoretic patient.

Place a small rectangle of duodenum thin or adhesive tape over the Tinc-Benz.
Twirl the remaining end of the tape and pass up beside the nose.  Why twirl it? Just because.
Use another piece of adhesive tape over the one you have placed on the forehead to secure this end of the tape.
Trim any left over.

So that is it. 3-point security with good access for oral suctioning and mouth care.
Once you do a few, it is really pretty quick to get it all secured. You can see that some foam has been placed under the tape at any pressure points.

OK then…feedback?

Well this is what I think.

Your patients name might be John or Judy,
it might be Carl or Candy,
it might even be Mrs Smith-Campbell Hewitt III or Mr Vidovich.

But your patients name is not Sweetie,
nor Honey,
or Hon,
and it is especially not Darl.

These names should be reserved for partners and lovers and desert descriptions.
If you cannot remember your patients name then Sir or Ma’am will substitute until you do. Or if you find that too formal, just don’t call them anything.
Remember: the patients name is perhaps the most important word they will hear during their entire hospital stay.

At least that is what I think.
But perhaps I am just showing my age and some narrow-mindedness here.
What say you.
Do you think using such names is unprofessional, demeaning or disrespectful to the person on the other end of your care?
Or is it simply a term of affection and a harmless way to build a therapeutic relationship with your patients?

Please feel fee to vote and comment……..

The Thunderbox Papers are a set of short pithy one page information sheets.
The idea is that you stick one on your toilet door for one week and commit to learning the information during each visit.

A Thunderbox refers to an old Australian ‘out-house’ or outside toilet. These toilets were often nothing more than a small drafty wooden shed containing a seat over a deep hole in the ground.
Toilet paper consisted of old pages from newspapers or magazines threaded together with string and hung on a hook.

I will post a Thunderbox Paper here every week or so. Stick it in your toilet at work (or home) and use your business time to review or learn.

HERE IS THIS WEEKS THUNDERBOX PAPER
The 4H’s and 4T’s.

Remember: to work you must commit to posting the thunderbox papers on your toilet door (you could even consider posting on the toilet door at work) and taking a moment to read over each time you………well, you know. Business.

The goal is to commit each paper to your long-term memory before the end of the week. So repetition is essential (as is business regularity).
Even if its is just a single blood value or suchlike, print it and stick it.

Australian Emergency Departments all use the Australasian Triage Scale (ATS) to triage every patient presenting through its doors.
Triage can be defined as:

A process of assessment of a patient on arrival to the ED to determine the priority for medical care based on the clinical urgency of the patient’s presenting condition. Triage enables allocation of limited resources to obtain the maximum clinical utility for all patients presenting to the emergency department.’
The triage nurse applies an ATS category in response to the question: “This patient should wait for medical assessment and treatment no longer than….
Australasian College for Emergency Medicine. Policy Document: The Australasian Triage Scale

In Australia, the ATS is essentially a tool to sort patients according to clinical urgency, and studies have confirmed it to be reliable in doing so. At least for Category 1 and 2 presentations with some studies suggesting a bit of a drop in reliability for 3, 4 & 5¹.

Overall, our triage nurses do a pretty good job assigning an accurate score in an environment of high stress and workload. A study by Considine et al. found 61% of triage decisions were “expected triage” with 18% “over-triage” (that is, given a more urgent score) and 21% “under-triage decisions”²

To further improve triage quality and consistency, a national teaching resource has been developed known as the ETEK or Emergency Triage Education Kit. This kit is used in many emergency departments to train up new triage nurses as well as consolidating the knowledge and skills of existing ones.

It might be a good system but is it the RIGHT system?

So. We have a well crafted, effective and specialised tool at our disposal.
My question is this: is it the right tool to best manage the situation before us….right now?

Before you read any further, no, I don’t have an answer for this question. I certainly do not have an alternate solutions.
And my thoughts on it change when I listen to various peoples opinions. But I am skeptical.
But I would love to hear your own views.

Our emergency departments have never been under greater stressors. Access block, overcrowding, meeting National Emergency Access Targets, increasingly complex presentations from an ageing community.
Its bloody tough in here.

In 2009, the National Partnership Agreement on Hospital and Health Workforce Reform committed all the States and Territories in Australia to a performance benchmark that 80% of ED presentations will be seen within clinically recommended triage times.

A report card recently released by the Australian Medical Association has found that in 2011–12 only 66% of emergency department patients classified as urgent were seen within the recommenced 30 minutes.

Now this is for category 3 patients which is bad enough.
I believe the real canary in the coal mine would be seen if we had accurate and un-fudge-itated data on the national performance of our  category 2 patients during times of peak workloads.
These are time critical emergencies that should be seen within 10 minutes of presentation, some data that I have seen on these times (which to my knowledge is not in the public domain, & therefore I will not print here) is pretty grim.

And, again anecdotally, I have even heard of delays in category 1 (emergent) patients accessing definitive care, simply because there are no available beds to treat them in the unit.

The AMA report sumarised:

Health reform, as defined and constructed by governments, has failed to deliver direct improvements in the capacity of public hospitals to meet the clinical demands and performance targets placed on them.

(You can read the entire report as a pdf here: Public hospital report card 2013: an AMA analysis of Australia’s public hospital system).

When the triage system becomes a meaningless question.

Talking to my colleagues in other hospitals, the feeling is that the waiting times in our emergency departments have now become so long that essentially the 5 tier ATS breaks down into a bit of a farce when the pressure is on.

The triage system in itself is still working fine. But within the context of its efficacy in an environment of access block and overcrowding, it is simply does not achieve anything other than capturing data to be used later.

The essential question at the core of our triage system becomes meaningless: “This patient should wait for medical assessment and treatment no longer than….”
30 minutes? Well no. How about 4 hours. Or 5. Or 7.

Basically there is little point sorting according to urgency if there is not an appropriate and timely response to that urgency.

Category 3 patients are waiting so long and build into such large group that they require sub-triaging within this category (we all do it no?). The waiting times may be so long that patients triage categories will change (sometimes several times) before they are seen.

Although officially locked into using the ATS, many emergency departments are now experimenting with other systems such as: ATS 1, 2 and then all other presentations seen in time of arrival.

I would be interested in anyone’s thoughts on the medico-legal implications of this for the triage nurses when, for example they triage someone as a ATS 3 and then place them in the queue behind 7 other category 4’s and 5’s, (unless they are covered by local policy).
There are plenty of other initiatives and workarounds that are being implemented at a local level to try to improve patient flow during peek workloads. Hey, way back in 2007 I even suggested my own tweak to the ATS to meet workload demand, a Dynamic Triage System.

Triage or Bricolage?

Bricolage is a term used to refer to the construction or creation of a work from a diverse range of things that happen to be available, or a work created by such a process.
The term is borrowed from the French word bricolage, from the verb bricoler, the core meaning in French being, “fiddle, tinker” and, by extension, “to make creative and resourceful use of whatever materials are at hand (regardless of their original purpose)”

Perhaps this is a better definition of what our triage nurses are doing.
What say you?

————————————————————————

Reference: http://www.acem.org.au/media/media_releases/2012_-ACEM_Triage_Literature_Review.pdf

1. Gerdtz MF, Collins M, Chu M, Grant A, Tchernomoroff R, Pollard C, Harris J, Wassertheil J: Optimizing triage consistency in Australian emergency departments: The Emergency Triage Education Kit. Emergency Medicine Australasia 2008, 20(3):250–259
2. Considine J, LeVasseur SA, Villanueva E: The Australasian Triage Scale: Examining emergency department nurses’ performance using computer and paper scenarios. Annals of Emergency Medicine 2004, 44(5):516–523.

Every rare once in a way too long while,
fist light is not so bad.
And we can clean, and take stock and prepare our work.
Prepare.

Every once in a while, first light is light.
And quiet is not a dirty word.

It doesn’t happen very often. But when it does,
This is what I see.

On a good day.
  

first light from Ian Miller on Vimeo.

If you cannot see the player above here is the link to the video.

The Thunderbox Papers are a set of short pithy one page information sheets.
The idea is that you stick one on your toilet door for one week and commit to learning the information during each visit.

A Thunderbox refers to an old Australian ‘out-house’ or outside toilet. These toilets were often nothing more than a small drafty wooden shed containing a seat over a deep hole in the ground.
Toilet paper consisted of old pages from newspapers or magazines threaded together with string and hung on a hook.

I will post a Thunderbox Paper here every week or so. Stick it in your toilet at work (or home) and use your business time to review or learn.

HERE IS THIS WEEKS THUNDERBOX PAPER
Adult Cardio-Resp Arrest Algorithm.

Remember: to work you must commit to posting the thunderbox papers on your toilet door (you could even consider posting on the toilet door at work) and taking a moment to read over each time you………well, you know. Business.

The goal is to commit each paper to your long-term memory before the end of the week. So repetition is essential (as is business regularity).
Even if its is just a single blood value or suchlike, print it and stick it.

Do you skip breakfast before a morning shift, or grab a slice of plain toast as it flies out of the toaster to munch on the drive in?

Me, too.

This often results in the mid-morning DONK when your energy falls to zero and you get the fine-motor colly-wobbles.

Well, you know how to fix that don’t you.

Here is my own favourite recipe for Bircher Muesli. A filling and nutritious Nurse Fuel that you can have hot in winter and cold in summer and only takes a few extra minutes to transfer to your tank.

Bircher Muesli was first introduced in hospitals in the 1900’s by a Swiss physician Maximilian Bircher-Benner.
It was based on a meal that the had been served whilst hiking in the Swiss Alps, and he thought it might provide a good source of fresh fruit for his patients.

My own version of Bircher Muesli is stupidly simple to make.
I have listed the ingredients below, but the amount if each is totally up to you.

Ingredients:

• Dry Rolled Oats.
  I use Uncle Toby’s quick oats.
• Low Fat Natural Yogurt.
  You can use one of the popular flavoured yogurts if you prefer but that packs in the calories.
• Milk.
  Full cream or low fat, your call.
• Sultanas.
• Finely chopped apple.
  Green apples are best. Some recipes suggest grating the apple, but I like chunks of food in my muesli (for the extra mouth textures).
• Blueberries.
  An essential ingredient. Unless you have an anaphalactoid reaction to blueberries.
• Banana.
  Don’t use overly ripe or really green ones. You want them to add just a hint of sweetness.
• Almonds. Add other nuts and seeds if you dare.
• Cinnamon.
  Another essential ingredient. Don’t be stingy.

Method:

1. Combine dry ingredients & fruit in a large seal-able bowl.
2. Add yogurt and stir with wooden spoon until desired consistency is achieved. The oats will soak up some of the yogurt as it stands so aim for a little more soggier than you want.
3. Let sit in refrigerator overnight.
4. Serve.
   Top with sliced strawberries, a spoonful of Passion-fruit pulp, and a sprinkle of blueberries for show.
   You will only need a small serving of this as it is really filling.
   Add a little milk and sweeten with a little honey if desired.
5. Follow with some quality toast ( topped with Vegemite of course), a glass of orange juice (or how about trying a glass of tomato juice?) and a steaming hot coffee.
6. 15 minutes.
   You are now well fueled. Go and nurse.

Today we have the release of a report card on the state of the Australian Public Hospital system released by the Australian Medical Association (AMA).

The clear message of this report is that there is no evidence of substantial progress towards achievement of any of the national targets that have been agreed by the Council of Australian Governments (COAG) as part of health reform.

The report highlights that there has been far too much political focus on “backroom issues” such as fighting over funding responsibilities and pricing hospital services and little focus on the systems overall capacity to deliver a quality service.

Some of the more disappointing findings (that are no surprise to many of us) include:

• the number of public hospital beds has been slashed by almost 70 per cent since the mid–1960s.
• in 2010–11, there were only 18.9 hospital beds for every 1,000 people over the age of 65 – a decrease of 1.6 per cent since 2009–10.

This is despite the demand on healthcare of an ageing population and increase in chronic diseases requiring complex care.

• The continuing decline in bed numbers means that public hospitals, particularly the major metropolitan teaching hospitals, are commonly operating at an average bed occupancy rate of 90 per cent or above.
• Official statistics relating to the time patients are waiting for elective surgery are fudged.
  Waiting times are counted from the time a patient sees a specialist and is referred for surgery. NOT from the time a patient is referred by their own doctor to see the specialist. And we all know how long those waiting lists are.
• The report shows that the number of administrative staff (as a % of total hospital staff) has actually increased despite a commitment by governments to deliver healthcare reforms without increasing bureaucracy.

And the percentage of Emergency Department Triage Cat 3 patients (urgent patients that should have treatment commenced within 30 minutes) that are seen within the recommended time:

• New South Wales: 71%
• Victoria: 72%
• Queensland: 63%
• Western Australia: 52%
• South Australia: 70%
• Tasmania: 64%
• Australian Capital Territory (my home): 50%
• Northern Territory: 49%

This is bad.

What is much worse remains un-tracked in this report. The  length of time these category 3 patients are actually waiting before they are seen.

The report concludes:

Health reform, as defined and constructed by governments, has failed to deliver direct improvements in the capacity of public hospitals to meet the clinical demands and performance targets placed on them. This is sobering given the energy and money that has been spent by governments and the health care sector to implement the reforms.

Real health reform for patients, doctors, nurses, and allied health professionals means more resources at the hospital bedside to deliver timely, safe and quality health care [bold mine].

Right now, all I can do is shake my head.

You can download the report to read for yourself: Public Hospital Report Card 2013

Last weekend on a trip up the coast, we stopped for coffee in the township of Braidwood.
Thomas Braidwood Wilson was a surgeon who worked aboard convict ships journeying from England to New South Wales and Tasmania in the early 1800’s. During one of the voyages he managed to transport a hive, thereby introducing the first english honeybees to Australia.

Braidwood is a small town pressed firmly down like a tack into the billowing roll of surrounding hills pretty much at half-way point between where I live and the ocean. As the car drives.
Some 1100 residents currently live here. Originally it supported the local sheep and cattle farming industry, and I guess it still does. But more recently, it seems to have become a draw for artists and craftspeople. And tourists.

There are art and craft shops dotting the street and some neat coffee and eating spots to be discovered.
Waiting for Kelly to buy some bread from the local bakery, I wandered into an antique store for a look see.

I creaked around the old room for a few minutes, amongst the smells of polish and grandparents.
The usual array of tables and chairs and glass cabinets containing neatly arranged fine bone china Beatrix Potter bowls and 1970’s plastic lamps. I quite liked one of the dining tables, but it was snatched away by the sold sticker on one corner.

Working my way around, I passed a slightly open door at the rear of the store. Snooping back a bit, I could see that it led through to a much larger room. The door was obviously meant to be closed, but a vacuum of far more interestingness in here sucked me on past the jam.

Stepping through the doorway I snapped off a quick picture just as the lady owner emerged from a darkened corridor between two large bookcases.

“Can I help you?”
“Er…sorry, I just saw all the stuff in here and wanted to take a picture”
“This stuff? Oh, this is the junk that we haven’t got around to fixing up yet. I have been meaning to have a good clean-out in here for years…….come on in, and have a look around”

The room was dim. Two long skylights transected the roof at either end. They cast broad shafts of light, igniting tiny embers of dust that winked alight for a moment and then died as they swirled on through.

From the high ceiling were suspended a large number of chairs and picture frames, and bits of tables, and….oh, I don’t know, bits of farm machinery? Hanging like junksicles, all swathed in icy neon cobwebs.

Around the walls there were shelves stuffed with old books, and jugs, and boxes of things inside other boxes, and tins with mysterious faded labels. There were plenty of desk lamps, not the plastic kind, but the cool 1960’s architects kind. All metal and spring.

Tables jostled for space, some of their draws opened just enough to see they were jumbled full of mysteries. There were broken wooden toys, and leaning piles of LP records and other things that I cannot remember.

It was an amazing place.
Alas, I did not stay long. I knew Kelly was probably looking for me out in the overexposed main-street I could see through the rippled glass in a high window.

I found her a minute later, looking through the window of another antique store a couple of numbers down the street.
“Kelly, you have got to come check this out.”
We dropped the bread and other stuff off in our car and went back to investigate.
But the door at the back of the shop was closed. Er…..and locked.
Nobody was around except the old dog asleep on an overstuffed couch near the front counter.

So. What has all this to do with anything?
Well, nothing really, its just a story of something that happened to me.

However, it might be a reminder that most of the time we often only see the front room of our patients.
One particular, short experience of them, that we walk around in. Picking up things, evaluating, comparing, labelling, judging. We think we have seen it all.

But there are always more rooms out back.
And sometimes these rooms are far larger and far more full of surprise and discovery and value than we expect.

Maybe you will be invited through the door and maybe you will find it locked.
That is up to the owner.

Just appreciate that they are there.

Compassion fatigue ….is a condition characterised by a gradual lessening of compassion over time. …. It was first diagnosed in nurses in the 1950s. Sufferers can exhibit several symptoms including hopelessness, a decrease in experiences of pleasure, constant stress and anxiety, and a pervasive negative attitude. This can have detrimental effects on individuals, both professionally and personally, including a decrease in productivity, the inability to focus, and the development of new feelings of incompetency and self doubt.

– Wikipedia.

Night duty. Personally, I hate, hate, hate, hate it.
But I have the greatest respect for those nurses who either do a lot of it. Or chose to make it their life.

A study to be published in the Journal of Advanced Nursing looks at the experiences of nurses working the night shift at three regional hospitals in Australia.

Data was collected via questionnaires, interviews and diary entries over a six month period in 2010 and was augmented by a series of semi structured interviews.
Of the 14 study participants, 10 were on permanent night duty and all were female.

The results of the study found a very strong cohesive team amongst the night shift. But it also fond evidence of the night shift crew operating somewhat as a silo (or separated unit) from the rest of the shifts. And there were several themes around this:

Staff felt that they had to deal with a poorer working environment that their daytime colleagues, particularly around distribution of workload and staffing.
They also felt that they were required to work with much less resources and “sub-optimal” leader ship support from department managers.
They expressed feelings that the night shift nurses appeared to be considered of lesser value or ‘lower status’ than other shifts.

There was also a sense of disconnectedness from the organization that might stem from the organization not trying to involve night nurses in hospital activities and processes or from the night-shift nurses actively choosing not to become involved. The disinterest in governance issues could be ambivalence or direction of energies to departmental concerns.

Other concerns included access to professional development and educational opportunities.

With respect to the personal impact of working the night shift, participants felt that it had a major impact on their lives. Health, sleep and fatigue were a common theme along with expressions of feeling socially isolated.
Although some participants felt the choice to work night shift afforded them a unique opportunity to have a more flexible lifestyle.

The study also produced a set of recommendations to drive a positive change around the issues raised.

• Managers review current policy and develop new policy and practices as required.
• Managers consider how to build on the teamwork, co-operation, and collegiality practised by night staff.
• Managers consider strategies to improve communication and co-operation related to the night-shift role, responsibilities, and position
• Managers explore professional development needs of night nurses and develop strategies comparable to non-night-shift nursing staff to meet these needs
• Managers recognize that while night staff work with minimal supervision, they still need and desire leadership. Managers examine leadership options for night staff.
• Managers overtly recognize the contribution of night-shift nurses.
• Replication of this study in different geographical areas and facility settings.

The authors go on to conclude:

It is important that the key areas of interpersonal relationships, effective leadership, work environment, clinical competencies, and recognition of the critical role of night nurses be taken on board by managers to inform decisions that have an impact on night staff. This knowledge will assist ward staff, managers, and clinical educators to improve the work environment and potentially maintain a sustainable and effective workforce in regional hospitals. While management has a key role, non-night-shift co-workers must also rethink their approach towards their night-shift colleagues. Just as managers and non-night-shift nurses have a role in change, so do the night-shift nurses themselves, who must accept responsibility for implementing change through co-operation with management and peers.

Although this study had a relatively limited number of participants and was also limited to a small geographical area and particular type of rural healthcare setting, it provides some thought generating reading of any night shift worker.

If you are a regular night shift worker you might like to read the whole study and reflect on its relevance and similarity to your own experience.

Powell, Idona. “Can You See Me? Experiences of Nurses Working Night Shift in Australian Regional Hospitals: a Qualitative Case Study.” Journal of Advanced Nursing (2013).