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.

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 defib is charged and 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 spread the notes 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.