Metal Nurse Spaketh: Critical Thinking

Critical thinking. It’s an important aspect of life and living. If there is one lesson I learnt in uni was that critical thinking was probably the most essential part of becoming a nurse (Yes, people will say care and compassion are more important, but care and compassion can be done wrong if done without critical thinking). It is also the reason why it’s a three year course. That might seem like overkill, but just look at how long doctors have to train and thank your lucky stars.

My personal tutor always made a point of it when we talked about evidence and the use of it in good care.  It is one of the many reasons how student nurses become nurses. One of the biggest parts of their studies is how to critically evaluate the evidence, the research and how to critically appraise it. It is to learn how to distinguish between a bad study (that can hinder your care for someone, for example The Wakefield study) and a good study, as in a study that can, will and does positively impact on your patient group.

In our profession we have to deal with a plethora of different medical professionals, some of course more difficult than others. Because of this we have to learn how to think critically and also make sure that our evidence based practice is up to snuff. This does not mean that we know better, we don’t (always), it means that we should know when to ask the right questions, and also when to accept the answers. But with that, we should always make sure that we follow up on those questions and if we feel that we do know better we should be able to say so and back it up. This is why nursing education is so broad and this is why as a profession we are encouraged to adopt life-long learning, it does nobody any good if you just decide that you want to stay in your present role until you retire. That is not a good enough reason to stop learning. Even if you stay as a Band 5 throughout your career you still have to learn how to move with the times.

As nurses we shouldn't just do stuff, we shouldn't just carry out tasks without thinking WHY we are carrying out those tasks. Which is why there is always a big push for evidence based practice. It doesn't just apply to doctors, it also applies to nurses. We are not there to be at the beck and call for doctors, we are there also to work as safety nets for our patients. We are there to make sure that our patients get the best care and that does not only apply to regarding personal care. It also applies to the medical treatment they get. Since doctors cannot be there all the time, we have to be their surveillance system. Seeing as the doctors care of patient  is so dependent on the reports they get from the nurses. But along with that we also should be able to work with enough autonomy and knowledge, in case something needs to be done there and then.

And this is why it boils my piss when I come across nurses who should know better. There are way too many nurses (minority, yes, but still too many) who seem to follow trends and not the evidence. When I hear nurses spout of stupid stuff like “MMR vaccine causes Autism” or “80% of the immune system is in the gut”, “I’ve never had the flu, so why should I bother with the vaccine”. Or use words like “toxins”, “detoxify” or “chemicals” without proper context. Or dabble in homeopathy. Or claim that organic is better. Or read the Daily Mail for health advice. (Don’t get me started on the diet talk)

We should know better and the fact that I know nurses who do and have said stuff like that makes me a little sad.  We have come a long way from being essentially doctors handmaidens. We are not just the task-oriented workers of yore (Though, you’d be hard pressed to believe that when you meet some of us). But sometimes it feels like we are still battling through those days.

Just in case people get the wrong idea, I am not saying that us nurses (Just me) should be all knowing and perfect in everything they do. It would be nice, but it is never going to happen. What I am asking is that nurses take their time in following the evidence up. If they read an article that says somewhere “A recent study...” then please before quoting the article, see if the study is actually referenced and if it is, to actually read the study in order to confirm that the article represented that study well or completely misled the reader. If they have that niggling doubt to make sure that they follow up on that. Be skeptical, but do not deny. Accept the answers when the evidence is overwhelming.

Good evidence trumps anecdote and intuition. A nurse who works with good evidence in conjunction with finely honed intuition that has been developed over the years is even better. But in the meantime, while the nurse is getting that experience it helps to learn critical thinking.

The most important lesson every student nurse can learn is that there is always more to learn and that your knowledge base can always be broadened, widened and stretched.   Or in the words of Neil DeGrasse Tyson:

Usual Locations: KeMPR

Couple of months ago I had this urge to track down a musician I used to listen to. His name is Richard Kemp. I got to know him a few years back when I lived in Ulverston, saw him play in several open mic nights and generally got to know the guy. Then things turned a little sour, and I moved to Lancaster. And contact was lost. I sort of tried to keep at least one eye on what he was doing musically, but then it just seemed to go quiet one day. But as I mentioned, I decided to go on a little Google/Facebook hunt and see if I could track him down again. And lo and behold I find him, under a new name. KeMPR.

Now for a little background (Pieced together from some fragments of my memory). Richard Kemp (mostly known as Kempy, when I knew him that might have changed since) used to be in a band called 12ft Machete, that apparently created quite a stir on the Furness peninsula. From what I've been told mostly through Richard's phenomenal stage presence. Sadly I moved to late into that area to actually ever get to see them play.  The only track I could track down by them is a song called 'Albino Twist' but only as a remix by master local Furness producer Howie Venton. Which to be fair is a cracking remix and makes me really want to hear the original. But on this track you can hear what a great rock singer he is and why 12ft Machete managed to create a name for themselves.



 When 12ft Machete called it quits out of those ruins came essentially two(Now three, possibly four) different projects. One that I became quite fond of was/is called Runt Hörnet, who play a delightful punk rock music with some aid of home made instruments like their monobass (Usually played by Howie Venton) that is played with wrench instead of a plectrum


for cryin out loud from runt hornet on Myspace.

and Lobe which had Richard Kemp in it and they played more of acoustic ballady stuff with some folky over tones. 

Stars Above Headlights from Lobe on Myspace.

Since then Lobe has disbanded for whatever reason. (With one half now doing instrumental acoustic stuff under the name 'dogmusiC'.) I had heard that they had been active around the open mic arenas around the Furness peninsula. The last song was from 2007. And then on-line activity seemed to cease from them. The Grapevine had been telling me that there had been a few personal issues that needed to be resolved and suchlike. Which just saddened me because Kempi (Kempy, Richard, whatever!) always struck me as someone who really could go all the way with his music. Thankfully, due to some Facebook browsing and Googleing, I managed to find him. Only to find out that he had relocated to Halifax and thankfully was still making music!

Few years back I used to own a album of Richard's (Kempi's, whatever!) in which he worked with Howie Venton, and I loved it. But due to many many computer formatting, rebooting and rescheduling those music files were lost. Amongst those songs was an orchestral version of one of his most played songs



Though my personal favourite song from that album was a cold industrial song called 'February'. This song always somehow made me feel a little homesick.



Currently he seems to be making a name for himself both as a musician and as an artist. And has recently published a new album called 'Some Days are Harder Than Most'.

Since renewing my interesting in his music what I have found both excellent and surprising is the fact that he's pretty much continued with the folk/acoustic stuff from Lobe. And that's not a complaint by any means. Kempi has a very gentle singing voice which also makes you feel so much better about yourself. Most of the songs do seem to centre around not losing hope knowing that there are friends around. Even during the most dejected and downtrodden song 'Reject-0' has that element to it.

Possibly the best example of this Hope Prevails/Friends song type is "We'll be around".



In amongst those acoustic songs we get surprises like 'Supersizer' a delightful raunchy rock n' roll song.



I do hope he just keeps on cranking the songs out. Hopefully go on a bit of a tour. There is no doubt about it, he's got the song writing skills and he's got a bloody good voice, both for ballads and rock. And he's got the personality.

Student Nurse Perspective: Stroke Care

Seeing as my first job as a qualified nurse is going to be on a stroke unit. I thought for my own sake that I write a little about strokes. With that I thought I'd tie in with a little bit of information about thrombolysis. Mostly I am writing this as a refresher for myself and at the moment this looks like to be my last Student Nurse Perspective article. Due to be renamed Icelandic Metal Nurse. But I do hope that it will be useful for others as well, I will try my best to write it in such a way that everyone can read it and understand it (well, hopefully).

Haemorrhagic Stroke

Stroke (Apparently called Brain Attack in the US) is the common name for Cerebrovascular Accident (CVA). Every year around 100,000 strokes occur in the UK. It mostly occurs in people who are over 65. But it can affect everyone. It is a very debilitating condition and depending on which area of the brain it happens the symptoms vary. Mostly the effects are irreversible. Symptoms vary between what part of the brain is affected, and the larger the stroke the more areas of cognitive ability it will affect. Stroke accounts for over 46,000 deaths per year making it the third largest cause of deaths in the UK and it is the most common cause of adult disability.  There are big financial implications for society as a whole, total costs to the NHS is over £4.4 billion per year and to society due to lost income and informal care it is £9 billion.

Survival rates from a stroke is currently 20-30% after one month and 30-40% after one year, but those numbers do not mean a lot to the individual. Generally in terms of better prognosis is based on severity of the stroke, age of the patient, what type of stroke, ethnicity and co-morbidities. Physical recovery is based on how much function the patient has in terms of activities of daily living and it usually reaches it's peak six months post stroke.  Whilst we have come a long way in treating acute strokes and hospital rehabilitation for stroke patients, we have not progressed very well in terms of long term management and community based treatment for stroke patients who suffer from some of the more long term affects of strokes like psychological and social problems.

Ischaemic Stroke

Strokes fall into two categories, ischaemic strokes and haemorrhagic strokes. Ischaemic strokes accounts for 85-90% of all strokes. Ischaemic stroke occurs when there is a blood clot occluding any blood flow to a portion of the brain. Haemorrhagic stroke is when an artery in the brain has burst and blood leaks into the brain tissue. Haemorrhagic stroke can also be further divided into Intracerebral haemorrhage (bleeding in the brain tissue) and subarachnoid haemorrhage (bleeding on the surface of the brain). There are also some conditions that are sometimes known as stroke mimics, for example hypoglycaemia, epileptic seizures, severe migraine attack, encephalopathy and Transient Ischaemic Attacks. There are certain lifestyle factors that increase your risk of having a stroke such as smoking, alcohol consumption, poor diet, lack of exercise, obesity and drug use. There are also certain medical conditions that will raise that risk such as  high cholesterol, high blood pressure, atherosclerosis, diabetes and atrial fibrillation.

• There are of course plenty of actions you can take to reduce your risk of getting a stroke. If you are a smoker then there is nothing better you could do than to quit smoking. I mean seriously. Just stop. Now. That stuff is bad for you.
• Reduce your alcohol consumption. Those cans/wine glasses add up, especially when you are pairing gluten free German beer with French wine as smorgaswine.
• Lay of those drugs. Or at least reduce your usage drastically. Please.
• Pick up regular exercise. It doesn't have to be anything major. Just get of that sofa and go for a nice brisk 30-45 minute walk every day. Get a dog or failing that get a ferret.
• Increase your intake of fruit and vegetables. The importance of a good diet cannot be underestimated. Sure go for the occasional fast food, but don't forget to include some salad with it.
• Lose some weight. No I am not saying that you have to look like a sculptured Greek god/dess. I am saying that that apron you have around your waist needs to go.
  
• If you're diabetic make sure that you keep your blood sugar ticking between 4-10 mmol/l. Fluctuating blood sugar can be a little disastrous. 

F.A.S.T.

Thankfully due to the excellent FAST campaign most people know what signs to look out for if someone is having a stroke. But I'll go over it briefly again just to recap. When stroke begins the symptoms are pretty quick to show, first thing to notice will be if the face is drooping to one side (can they smile), if they can raise both arms and keep them raised for say 10 seconds or so and if their speech is slurred. Time is of essence here so if you suspect that a loved one is having a stroke phone the emergency services as soon as possible (999, 112 or 911, depending on your location). While there are lots more signs and symptoms those are the ones you should look out for. Symptoms also vary depending on where the damage is happening in the brain, if the symptoms are visible on the right side of the body then the left side of the brain is affected and vice versa.

Carotid Artery

If you've been found to be in a particular risk group then your doctor might decide to put you on some medications in order to reduce that risk. This is mostly medication based using drugs like statins, these are used to control and lower your cholesterol. Anti-platelet, such as aspirin or clopidogrel, are also per standard. These work by inhibiting platelets forming clots. Quite possibly the most important one, or possibly the most well known, you will also be prescribed a tablet from the anti-coagulation group, most likely Warfarin. Like the anti-platelets these work by reducing clot forming usually by inhibiting vitamin k production. As far as side effects are concerned there is the risk of bleeding. If you were diagnosed with high blood pressure you would also be put on either beta blockers or ACE inhibitors.  All of these drugs would also be used as a secondary prevention. If you had suffered from Transient Ischaemic Attacks your doctor might suggest that you have what is called Carotid Endarterectomy, this procedure is used to remove plaque from the carotid arteries. If this procedure is done in a timely manner post TIA's then lives can be saved and strokes averted. Not only that it is also sometimes a suggested operation to prevent another stroke from occurring and again time is of the essence. The sooner this operation is done the better outcome there is for the patient.

Recombinant Tissue
Plasminogen Activator

If ischaemic stroke is caught soon enough and time of onset is known then this type of stroke can be partially reversed or at least contained using a medical treatment called Thrombolysis. The alternative name for it is Alteplase and this is made from recombinant tissue plasminogen activator. It is biotechnology at its finest. This treatment is a bit of a controversial one, mainly due to the perceived ineffectiveness, the risk and the price.  About 1 in 7 actually benefits from it and there is the danger that it might turn an ischaemic stroke into a haemorrhagic one. In order to qualify for the procedure you have to have a CT/MRI scan to confirm what kind of stroke you have had. The time of onset has to be known and has to be within 4 hours, though the treatment is said to work better if it is within 3 hours. And the patient has to be weighed. If it has gone over 4 and half hours then you are in danger of damaging the brain even further. When it is effective then it is very effective, a study found that after three months from treatment around 30% of patients were back to normal or at least near normal neurologically and a further 30% had mild to moderate neurological deficit. Up to 50% had become independent in activities of daily living and 15% were moderately independent. But on the other side of things it also found that it up to 9% of patients who had received this treatment had died due to intracranial haemorrhage.

So in conclusion. Regarding strokes time, is of the essence so if you suspect that a loved one (or a stranger for that matter) is having a stroke get your phone out. Don't waste your time taking pictures, and phone for the emergency services. But it isn't just important to get them into the hospital for treatment it is also important to make sure that they end up in a specialist stroke unit as their chances of recovery are much better on there than on a general medical ward. The multi-disciplinary team on there should be made up from (besides nurses) Occupational Therapists, physiotherapists, Clinical Stroke Specialist Nurse, medical consultant and a registrar. Ideally after the hospital stay there should be an outreach team to assist with activities of daily living and further rehabilitation.

Statement.

Just in case I hadn't made it clear and to shed some light on my thinking process. Education is a wonderful thing. Not really that many years ago I used to be a fairly big believer in herbal medicine, I had actually seriously considered studying herbal medicine, that organic food was better, and a fence-sitter regarding vaccines.

Obviously as most of you will have noticed my stance on those things have changed. And changed for the better. The things that changed it were a culmination of a lot or things, firstly my duaghyer when she was very very young developed bronchioloitis but for a while me and my partner were convinced that she had whopping cough(truthfully I still think that might have been the case, but the GP hadn't seen a case of whopping cough for 10 years. Let that sink in a little) and as I started my course I started meeting more Polio survivors, all 70+ years of age.

At its finest modern medicine is based on herbal medicine, the difference is that the volatile compounds have been isolated, purified and made more potent. The rest of herbal medicine just tastes nice on chicken.

As for opposing GM technology, well that has got to be the most self centred, first world problem that I can think of. To oppose technology that creates drought resistant and pest resistant seeds that will create more food, with more nutrients, not just for the booming population of the first world (be grateful that you can waste money on organic) but also the starving population of the third world is, as stated before, self centred and selfish. Oh and if you oppose GM technology then you are wishing death on insulin dependent diabetics. And Haemophiliacs.

So here's the rub. In the next six months I will (grading pending of course) qualify as a nurse. And I will be using evidence based practice. And if some idiot then tries to convince a patient of mine that chemo is useless, that vaccines cause more problems then they solve, if they just generally advocate the use of untested, unproven and dangerous treatments instead of proven, effective safe treatments, they will feel my shoe firmly lodged into their posterior.

If you want to use these methods fine. I can live with that, but don't you fucking dare get in the way of me doing the best for my patients. And not just for my patients but the community as a whole.

This might all come across as close minded, but it is anything but. I have been willing to look at the evidence and the evidence changed my mind. Being open minded is what evidence based science is all about.

Mother Country Music Loving, Part four.

This will be my fourth(duh!) part of writing about bands from Iceland. If you'd like to catch up here is Number One, Number Two and Number Three.

Ask The Slave, 2010

Ask the Slave, is an Avant-Garde metal band. I first heard of them and heard them when I attended Eistnaflug in 2008. The little I do remember from my alcohol induced haze was that I really enjoyed their music. Someone had remarked that they were the Icelandic version of Faith No More, I personally after listening to them would say that they are more akin to Mr. Bungle. There are a lot of genre lumped together into one song, lots of rhythms shifts and melody changes, but most of those don't sound out of place or forced. Valurs vocal does sound like he went to the Mike Patton school of Vocal Tormenting. He's easily the most versatile singer to come from Iceland. But everything he does regarding the singing is for the betterment of the song. Which is the wonderful thing about this band, while Valur could/would/should be the stand-out member, but he isn't. They all function like a well oiled machine, if one of the other instruments would be taken of the songs it would fall to pieces. So far there are two albums, "Kiss Your Chora" and  "The Order of Things" out and one B-Side collection called "The King of Prunes", with a new LP, called "Good People, Bad Things" which is meant to be out next year. And yes I am looking forward to it. They also make some excellent music video's for example the song "Sleep Now" which sounds like a lovely ballad up until you watch the video and realise how creepy it actually is. It is one of those instances where the video makes a good song great.
Both their albums while being all over the place manage to suck you in and keep your interest throughout. And I personally am looking forward to the day when they open up for Mr. Bungle and Mike Patton walks on the stage then drops the mike stating he can't keep up.

Dr. Spock

Dr Spock, is a very unusual rock. Again we are looking at the Avant-Garde section of things. Most of all it is plain and simple good fun rock and roll or in their own words "Heavy Metal Cabaret with a dash of Surf-Porn Cartoon Funky Polka". By all accounts their concerts are once in a lifetime experience. Which doesn't really surprise me, in their ranks they've got the gruff voice from HAM, who continues barking orders and sounding like he's cursing the entire world. In the most jovial manner of course. It is very chaotic music that is on display, but at the same time even with my rather low-fi laptop speakers I feel like dancing like a mad cow and thrash my living room, the song "Sons of Ecuador" being the perfect example of this manic musical genius that is going on. But as far as I can see nothing new has appeared since 2008, which is a crying shame. But even with a short life they've left a long lasting legacy and much like HAM their reputation seems to be growing with their absence. And if only they had actually got into Eurovision with their song. It would have been perfect. But Ottar Proppee finally did manage to perform on the big stage in 2014.

Börn

Börn, now there is a certain amount of nepotism going on here in the sense that I probably wouldn't have given this band a chance if it didn't include family members. But to be clear I don't write blogs  about a band that I don't like. It just so happens that this band includes my youngest sister on vocals and her boyfriend on the drums. They have been playing together in various forms of punk bands. The earliest incarnation that I know of was Tentacles of Doom, which then got changed into Norn, but they had to reconsider their name choices when it turned out that there is a black metal band in Iceland using the same name. So here we've ended up with Börn. And unfortunately I giggle probably way more then I should when I type in the url of their BandCamp site. On the whole I'm not a big fan of the punk scene. Never have been though of course like other genre's there are always bands that manage to captivate my attention. Börn being one of them. What this album reminds me mostly of are the first two albums by Killing Joke. There is this almost joyous tribalism running throughout this smog of despair. It all sounds exceptionally simple, all the instruments seem to be geared towards being rhythmic and, well, dancable. Alexandra barks out her lyrics with pure unbristled ferocious commanding singing, all about self-reliance, equality and independence. On this album she sounds like she could and should command armies. It would be great to see them and It Hurts To Be Dead play at the same gig.

Top 15 songs over the last 12 months

These are the songs that have had the most listen according to my Last.Fm profile. There is a marked difference from last time with a huge portion spent on The Dear Hunter.

Top 15 played Artists from 2013-2014

Well it's been just over a year since I first published a similar list. This is done using my Last.FM profile. The list has changed quite a bit, but that is probably because I have started using Last.FM more in order to keep track on what I have been listening to. Well enjoy.

1. The Dear Hunter
2. SepticFlesh
3. Joe Hisaishi
4. Samael
5. Rammstein
6. HAM
7. Antonio Vivaldi
8. Queensryche
9. Marillion
10. Bruce Dickinson
11. Long Distance Calling
12. Iron Maiden
13. Fjoergyn
14. David Bowie
15. Devin Townsend