This is stock number 10690. We are here at Summit Automotive in Fond du Lac, Wisconsin. Your new and used Jeep and Jeep Grand Cherokee headquarters. Today we are checking out this super clean, extremely good looking 2018 Jeep Grand Cherokee Limited Sterling Edition. This vehicle has a 3.6 liter award-winning Pentastar V6 motor. It has been fully-safetyed and inspected by our service shop. It has a fresh oil and filter change. All the fluids have been checked and topped off. The Jeep has been gone through 100% and is 100% ready to go. Bright white over granite crystal metallic is the color scheme. Never really seen one in two-tone like that. We shoot all of our videos in 1080p 60 frames per second. So if you have HD capabilities on your computer tablet or smartphone device, turn them on right now. Because it is definitely your best way to check out the vehicle quality and condition wise before seeing it in person. It comes with the 20-inch painted and polished aluminum rims, Bridgestone Acopia tires. These are 26550R20s and they have probably about 60-70% of the tread left on them. Front fender and doors are in really nice shape. It does have the projector lamp headlamps, the LED running lights. The LED fog lamps. The front bumper parking sensors. This one has the adaptive cruise control as well as the forward collision warning. I didn't see any dense dings or cracks on that front bumper and the hood is in excellent condition as well. Passengers side front fender. No dents or dings on that. And the passenger side rim is in excellent shape as well. No scuffs or scrapes on there. As you go down this side of the Jeep, take note of how clean the body is, how reflective and mirror-like that paint is. We take these HD videos so if you are far away or even if you're close by and just cannot make the trip down, but you're still interested in purchasing the vehicle, you can see the vehicle, hear the vehicle, and have confidence in what you were looking at before you even get here. You can see that it does have the dual pane panoramic sunroof. And this is why we offer the Summit Auto Fastpass option in the upper right hand part of your screen. You'll link right to our website where you can apply for financing, get pre-approved, see a payment quote, even appraise a trade off from the comfort of your own home. Back rim is in excellent shape as well. Four-wheel disc brakes and the back tires have just as much tread as the front tires. You know what I mean by the two-tone paint? This bottom valance is granite crystal. Normally that's just the plaque plastic, but I'm not sure if that's a sterling edition feature or if this one was just special made that way. The rear gate and bumper are in nice shape. It does have the full towing package which includes receiver hitch four pin and seven pin wiring. You do get the dual rear exhaust. You get the 25th Grand Cherokee logo on the back. And it does have the power lift gate. Just press that button twice. And notice it does have LED tail lamps. The back storage area is very, very clean. No rips or tears. And it does come with the factory subwoofer. You do get the jack tools and spare tire back here along with the lug nuts for the locking lug nuts. Those seats do fold out for extra storage. And to get this rear gate down, you press this button right here. It's going to beep at you three times and then come on down. You do get LED license plate lights as well. And as you go down this side of the Jeep, just as clean as that passenger side, rear quarter, excellent condition as well. And for full disclosure, this back rim, very, very nice condition too. Down the rest of this side, doors all look excellent and see any dents or dings. It does have the enter and go system.  Put your hand in there. It's going to unlock those doors for you, which is really nice. You do have the blind spot monitoring, LED side lights, and those mirrors are heated.  Notice you get the special bolstering for that Sterling Edition. No rips or tears on the seats. Both these seats are heated. Both these seats are powered. Driver side lumbar, factory floor mats throughout, auto headlamps. You do get the power tilt and telescopic steering wheel. And you do get audio controls in the back of the steering wheel. You get the black rosegrain wood trim, power windows, power locks, power mirrors, and memory driver seat. As we hop inside the vehicle here, you can see that this one has 16,676 miles. You get the 7-inch LCD display. Outside temp, yes, it is 91 degrees today. And the digital spinometer, which is a really nice feature. You get the heated leather-wrapped steering wheel, cruise controls, and adaptive cruise controls on the right. Bluetooth and information center controls on the left. This one has the 8.4C radio, which gives you AM, FM, and Sirius XM radio capabilities. It also has the factory navigation system on it. This is also where your backup camera is going to show up. You can do your climate controls here as well. Your air conditioning is blowing very well. Down here, you have more climate controls if you don't like doing them on the screen. You also have your perpendicular and parallel park assist. Your parking sensors, you can turn those off, and it does have the lane departure warning. Start, stop capabilities, you can turn those off. Eco mode, sport mode, and your stability controls right there. 8-speed automatic transmission.  You also get a neutral feature for flat towing. Passengers side, floor mat, and seat are in excellent condition as well. Smells very clean inside this Jeep. You can see it has that panoramic dual-pane sunroof so that front glass piece does open up. You got your home link buttons for your garage door security systems and lane systems. Your controls for those, for that sunroof and sunshade. You also get SOS and assist buttons in the rear view mirror. We'll take a quick look at the back seats, and then we will check out under the hood. The back seats are going to be just as clean as the front seats. No rips or tears back here.  You get that bull stream back here as well. And these seats are heated on the outboard sides, meaning the driver and passenger side seats are heated. There are those heated seat buttons, two USBs, and then a 115-bolt, 150-watt plug-in. Carpeting and floor mats are very clean.  You get that rose-grain black trim on the back doors. Child safety locks in the bottoms of the doors all look really good. You also get the capitalist fuel fill, which is a nice feature. If you've never used it, you'll love it. I'd personally like to thank you for taking a look at the video today, and hopefully from this HD video, you will have been able to tell just how clean this Jeep is all the way around inside. Now, under the hood we have the award-winning 3.6-liter Pentastar V6 motor. This Jeep has been fully-safetyed and inspected by our service shop, has a fresh oil and filter change. All the fluids have been checked and topped off. It has been gone through mechanically 100% and is 100% ready to go to see more pictures of this Jeep or one of our other 450 new and used cars, trucks, SUVs, minivans, Wranglers, half-tons, three-quarter-tons, one-tons. You name it, we've got to go to our website, www.summitauto.com. Full pictures and descriptions of every single vehicle from two locations all at summitauto.com. If you'd like to check out more HD videos, you can go to youtube.com. Remember to like, subscribe, and share on this video and all the videos that you see there. In fact, in a second, you will see a link to subscribe to our YouTube channel on your left. A link to more Grand Cherokee videos like this one on your right. If you have not been to our website on the bottom link to this vehicle on our website, click those, check us out. And we really look forward to helping you with this extremely clean 2018 Jeep Grand Cherokee Sterling Edition Bright White over Granite Crystal Pearl. Thanks again for watching.


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My friends welcome to the depression to Expression podcast Where no topic is off limits because mental health affects anything and everything we do and Of course, you can't speak about emotional well-being. You can't speak about the human condition without talking about death and as you all know from previous podcast episodes and my YouTube videos that I've been sharing for the last seven years I Speak about death a lot Which is why I am so humbled so grateful and You know a lot of people think about okay I can't wait to meet a celebrity and I'll be very intimidated. Maybe your favorite musician favorite actor. I Was it was like I was meeting a rock star Dr. Joanne catch a Tory. I was so well.  I don't even know how I'm gonna introduce her But it was such a refreshing discussion throughout this podcast episode that you're about to listen to We talk about grief. How can you talk about mental health emotional well-being? Without speaking about tragedy grief loss We're all going to lose someone that we love in this life You know in her book bearing the unbearable, this is what she discusses How can we come to terms? With this fact that there is going to be death in our lives and that we will eventually die and Dr. Joanne speaks about how she lost her daughter in 1994 and she expresses this love by Carrying the pain with her and that's why this is such a special episode and she made me cry Which I am so happy to be sad today and so happy to cry that She really gets to the bottom of of why we're here and how we can bear with the unbearable and The stories that she's heard over the years and this humanistic approach that she has and how she loves all species Being a vegan we cover so much in this episode and I am just so Grateful to have had her on Again, I could go through the credentials. She's a professor. She's an author. She's a public speaker. She's a mother of five Just what an incredible human being I had the chance to sit down with and what happened as we we began chatting And you know, I love these organic conversations on this podcast because that's what I like to listen to right? And we got to chatting which you'll hear and we discovered that there's a lot of commonalities in our work and in our message You know, I I invite people to to acknowledge that it's okay to feel The way you feel right now Now let's think about that for a second and let's feel that actually for a second. It's okay to feel the way you feel right now We always chase that end of the spectrum of emotion right the happiness to feel good We we love living in the short term and get that instant gratification but True life doesn't just Live on that end of the spectrum. It's the full spectrum and that full spectrum involves seemingly that unbearable reality of dying of loss of tragedy and Although this may seem like a heavy podcast which it is this episode Dr. Joanne has such a refreshing Perspective on this and has been through so much and continues to help so many people through her work and I just I can't wait to see her in person. I cannot wait to visit her care farm, which again will talk about and Let me tell you something with her work and I'm not just saying this with her work and her posts and her thoughts and her Her her incredible work with people and animals, you know, she's she's really pushing me to try this whole vegan thing out I gotta tell you. I'm not just saying that so I'm done chatting. Here's dr. Joanne catch a Tory in three two One dr. Joanne, thank you so much for coming on the depression to expression podcast Thank you for having me. Well, I wanted to connect for so long and last year we made plans We're going back and forth via email and you said the coolest thing to me when you couldn't make a certain time You said, sorry, I can't make that time. I got to feed my animals. I've never had that. I've never had that response before It was so cool So so where are you living do you live on a on a farm or you take care of a lot of animals, right? yeah, well, well, I started the first care farm in the world for traumatic grief and We rescue animals here. So most care farms aren't rescues, but we rescue farm animals so we have almost 40 animals and You know pigs and donkeys and horses alpacas dogs and cats of course sheep and goats and So, you know my morning my morning routine is pretty intense and they require a lot of work But we don't reproduce we only rescue and that's that's part of our whole thing is that we bring Humans who have known trauma and loss and suffering and fear and grief and loneliness and having been separated from their families We bring them together with the humans who also have known grief and trauma and fear and loneliness and they connect and You know animals in a lot of ways are Wiser and more in the moment than a lot of humans in terms of holding space for pain My horse chimaco never asks me to stop crying and hands me hand me a Kleenex He just doesn't do that. He says, you know I accept whatever you feel in this particular moment and I'll just hang out here with you And he's the great space holder. I tell people he's the best therapist I ever met so So the animals really have a potent effect. I'm actually in researching it now We have our first empirical study that's published We have several papers out but our first empirical study yielded three papers One has already been published one is under review and another one is in is in writing And then we're recruiting right now on a study with dramatically bereaved veterans here on the care farm so that So that they can have the experience of having worked with our animals in nature, you know in an ecotherapeutic setting trauma-informed care and And it's really the the results that we're getting are really encouraging and it's preliminary data, but it's helpful data Well, a lot of the research has has research been done just on, you know There's all types of when he's to volunteer at a hospital and call it the psych ward and that we'd have therapy dogs Come on, but is the research involving all kinds of different animals and the impacts of different kinds of species So the research is about their entire holistic experience here in the care farm and so people so one of the things about Interventions that I really feel and and a shortcoming of our current system is we don't have a protocol here We don't have an agenda and so people come here and they get to create their own Very individual personalized experience. So some people are really really scared of horses and Because of that, they really want to confront fear and and be able to Connect with a horse and there are some people who are afraid of horses who can't who can't approach that yet And that's just fine.  I'm not I'm not proclaiming any extraordinary prescient or You know psychic capacity of animals, but animals do rely on intuition and They have the capacity to see things that humans don't because of all of our chatter, right? And so this she just kind of sat with her Where the sheet this particular sheep are to me she doesn't really sit with people very much She's still quite fearful, but she really loved this mom So I mean the meaningful connections that happen and so people talked about that in the research about how they would have You know a two-hour session of trauma-informed therapy followed by going out to the to the you know To the outside and hanging out with the animals and the animals sort of help them process Some of their emotional experiences they had so so there are lots of things It's not about a specific species per se and more what we saw wasn't about dog versus horse versus sheep versus goat It was more about the animals being rescued which was important for people. Oh Of course because the animals had known all the same emotions that these humans knew Right like seriously, they knew pain. They knew suffering One of the horses that we rescued had been tortured literally tortured absolutely horrifically tortured And and and so a lot of the people a lot of the people I work with They hear his story and they see his pictures and they and they and they came to me and said They've come to me in their own sort of iteration of this phrase if he can survive so can I Wow, yeah, beautiful. Yeah, it's beautiful and it's profound and it and it helps us to feel more connected It yields more connection rather than let that rather than fewer connections, which is which is important Well, so is it strange for me and millions of others that I see the pictures on your Instagram of you with animals and With long these planes of fields and I'm just longing for that and I miss it so much Is that pretty normal when people come there? Are they finally feeling that connection with nature? We've lost that an eighth sense and we crave that. Yes Yes, we crave it and it's missing and it's really missing from the psychotherapeutic experience of today's world in quote mental health I don't even really like that. We call it mental health I would prefer to call it emotional health or at least Emotional and mental health because underneath mental is always emotional anxiety is a thing But it's only a thing because there's an emotion underlying it, which is fear Absent fear or worry or terror. There's no anxiety Right, it loses its potency, right the whole word anxiety means nothing in the absence of fear But we want to sound more scientific so we call it mental health, you know and and and of course I I'm always about being honest and using language carefully because I'm a writer and so in using language carefully I say go to the real world get be specific and precise with our language in the way that we describe things Because I think actually not talking about our emotions is probably one of our biggest problems in quote mental health in our culture So that's fantastic. Let's let's go with that one because I think you and I might be fighting a similar fight and I become I could use I'll say angry I become angry at what maybe mental health awareness has become and it and I saw this beautiful picture that you put on your Facebook This there's umbrella terms that we use in let's say just mental health and people say and they identify with a feeling they're saying I have Anxiety right I said hold on a second hold on What does anxiety mean that isn't that just an umbrella term and right? What about grieving is it okay? Someone's grieving. Well, what are the emotions under that right? Is there always this? it's it's like in in Medical literature or at least in mental health. There's always that one umbrella term depression and we leave it at that and we Don't dig deeper Yes, that's exactly it and so when people come into this is my office my office where I meet with clients So when people come in my office and they sit down and they say something like You know, I'm depressed. I say well without using the word depression. Tell me about how you feel because Depression to one person might mean something very different versus depression to another person It tells me really nothing about that person's very specific and precise experience And I don't want to hear the words that other people have told them that they're experiencing I want to hear it with their words, but we're very lazy in our culture. We're very we don't have time We have a 50-minute session and so we have to hurry hurry hurry hurry And and there are a few things that That concerned me as much as this sort of rushed Laconic intervention model that that we employ we're lazy and we have to stop being lazy If we expect the the mental health system or any system for that matter to really help people We have to stop being lazy. We have to start being willing to do the hard work well hard work is When it comes to emotional health, it's something that people aren't willing to do sometimes But it because for me personally it involved me getting deeper and and really discovering some Uncomfortable and nasty demons in there. Do you think as a culture? We're afraid to discover that so we'll stay on the surface for a little bit longer Well, superficiality is definitely an issue This is this is this is this is part of the happiness cult that I talk about in my book Like we all want to be happy. We feel like we should be happy all the time So if we're not happy all the time, there's something wrong with us or our lives or we're not doing something, right? And I'm like, I don't know who told y'all that you're supposed to be happy all the time But that's not life and it's not realistic and it's gonna actually add to your unhappiness Because then you're gonna be unhappy about not being happy, which is very very strange It becomes a negative feedback loop. And so what I encourage people to do You know people say I want you know if they say to me I want you to help me feel better what I always it's my pat answer and it's and I don't say it in a Superficial way. I don't help people feel better. I help them feel and Whatever better there is comes from feeling Because the reality is if we don't feel all our feelings then our lives start to get very small Because we bring the bottom up, but we also bring the top down and As we bring the bottom up in the top down our lives become a contracted version of what they could have otherwise been And I'm like now I'm willing to feel all my feelings because I I want to be I want to blow the top I'll let the bottom drop out because I know the top will also come off and I'm willing to feel it all You know my daughter died in 1994 and you know for about for a long time I felt a lot of pain and grief and that was all I felt it took up all the oxygen in the room And I was willing to do that because her life and her death were worthy of my devotion to those feelings, right? I didn't want a shortcut or bypass And at some point it's not that the grief diminished it didn't this is it's been almost 26 years since she died And and I would say that my grief isn't less what happened is the capaciousness expanded So I got so my heart and my life got bigger and bigger and bigger So now I hold all that grief, but there's room for other things now, too And that's what I wanted because to me in order to honor her I couldn't become a smaller version of me I had to become a bigger version of me I have trouble and I think people have trouble understanding that to to lose someone that you love To that degree with your story losing you losing your daughter your book is called bearing the unbearable And even just projecting myself into the future and and creating a reality in my mind that my parents Will not be here one day and the likelihood of me being here while my parents are gone is very high. Yes I don't even know if I can go there. I don't even know if I can go there, Joanne How am I supposed to how is a human being supposed to bear that incredible pain of losing so much purpose that we find in other human beings? Um, yeah, so uh, this is this is why people avoid thinking about it and because because it evokes fear and terror and the reality is that it Human beings have have borne this pain Since the beginning of human beings and animals have borne this pain animals grieve J95 the killer whale to Lake Wa who carried her baby's body for two months Two months more than two months. I think along the Pacific Ocean is where I believe she was The reason that she carried her baby's body is because she was in grief and her pod when she was tired from carrying her baby's body Her pod helped her carry her baby's body. How we bear the unbearable is through the compassionate support of the community And that's why that's so important because we live in such a superficial world that you know that that I've had so many parents greet greeting parents say You know they were pushing their their grocery cart in the grocery store down the aisle and their neighbor came around the corner saw them and literally turned the car around and went the other way Yeah, oh this happens all the time because it because it scares people to think about to contemplate and the reality is if we don't contemplate it then Then there are there are many things that we lose by not thinking about it. First of all, we lose the practice of reality like like your parent You're right. Your parents likely are going to die before you at least they hope so because yeah because they don't want to come and see me Right, right. So your parents at some point we hope that they live a very full long long life. They're probably close to my age So hopefully they have many many years to come The next thing that we lose is the capacity to practice compassion for other people who have had loss because we don't think about it We don't imagine what it would be like for us and how painful it would be for us. And so we take the edge off that that propensity for compassion And the third thing that we lose is appreciation for the people because I'll tell you what nothing will make you appreciate those you love Like contemplating the possibility that this could be the last time you see them That's amazing. It's so incredibly true. We kind of well at least in my experience I moved away from that thinking for a while or when I did think about it It didn't make me feel anything and as we spoke about before I before we recorded here I was on antidepressants a fairly high dose for 12 years and due to the current circumstances I put my best foot forward and I got off them Do you feel like and I could go with my story It was basically they handed me a box of pills and said the whole classic story of the chemical imbalance And my psychiatrist didn't even ask me why I was depressed and it was it was 12 years ago And at the time I'm feeling so terrible that I'm going to take the pills because I know the story of the pills It's like an antibiotic and it'll make me feel better, right? So do you find that with grieving and depression and the mental health culture and the awareness and getting people to talk about their feelings Are we going in the right direction with diagnosing people? Is that the conversation that's happening today? It is it's a conversation that's happening and I'm and I'm I'm pretty vociferously opposed to diagnosing people who are grieving grief is not depression but also though I mean one of the first questions This is odd to me that your doctor didn't say has anything happened to you like life changes like tell me about how you're feeling about life And part of it is honestly managed care right because an early on a psychiatrist who's written extensively is one of my favorite writers in psychiatry And he talks about this he talks about the superficiality of you know of managed care and how it has fueled this sort of brief intervention protocol that just includes writing a prescription Right so you know because how long would it take for your psychiatrist just to sit down and say let's talk right and your psychiatrist doesn't have that kind of time because of managed care And then so y'all am is pretty critical about that and I'm actually on the same page with him about that I think that that what he said was brave and actually heroic in the field So one of the things that I would actually ask the first thing I'd say is tell me about any changes that you've had tell me about what you're feeling Let's talk about your sadness right and without using the word depression how are you feeling talk about that and then if if like if you say if you were to answer me it's very rare But if you were to have answered me like nothing everything in life is great like I have a terrific family and I love my partner and my kids are great and I love my job And if you were to have answered me that way which have been which would have been very unlikely then my next question would have been is what what about your past like the distant past Have there been losses in your distant past have there been experiences in your distant past that were particularly painful for you because I have worked with for example not long ago I had a woman come out to the care farm who was in her mid 80s and she had a baby die in 1960 I think it was 63 64 Yeah, the writer Catherine Porter said the past is never where we think we left it Oh, I love that Right And so and that's something we so there's no time limit people come to the farm with losses that happened 20 30 40 50 years ago Because because the past is never where we think we left it we're affected by the past and if we didn't deal with it then we're going to have to deal with it at some point or it will deal with us We either deal with it or we deal with the consequences of not dealing with it And that and that's what happened with her I mean that's so many people like that end up on using substances they end up trying to outsmart their feelings their emotions and the trauma you know because the reality is your body knows what happened to you you can't trick it into forgetting and so so what I do is help people approach that again in a safe way even if it's been that many years now gets a little more interesting because there are so many layers like like if you've waited 40 years to confront a deep trauma and grief There are a lot of layers to sort of gently peel back to get down there right but it's doable and I've worked with many people like that and it's so important because because we want to be the we want to experience our biggest potential right I mean that's who doesn't want that for their lives So what what have you learned because I know you've met so many people over the years and heard countless stories Does it not weigh on you a lot to have these people come and share and this could be with really any any psychologist to does it not wear on you to hear these stories of of tragedy and death and mourning and grieving on almost a regular basis how do you separate that or do you separate it Well okay so in my area of research one of the things that we found is there's a difference between cognitive empathy and affective empathy and and I'm a big fan of empathy but I mean an even bigger fan of compassion and the word compassion actually means calm which means with and passion means to suffer actually And so what I find is I've been doing this work for almost a quarter a quarter of a century and I get to ask this question a lot and yes I feel deeply with other people I suffer deeply with them and I cry a lot I'm a prolific cryer lots of cry Yeah I'm great at crying and I find that actually my life is bigger not smaller and that I actually have more internal resources now I have a good self care regimen right so I have a Zazen meditation practice I I hike barefoot I have my animals I have my horse my therapy horse to Mako who is always there hold space for me I eat clean clay dirty move my body a lot get lots of sunshine so I have a good self care routine I do take really good care of myself I love bibliotherapy This is my office and it's 360 degree books all around me so so I have something a strategy that I use to help take care of myself so there are times I say okay all right I want to take some time and I pull the energy in turn my heart inward and now tend to my own heart but I I don't I'm not I'm nowhere near burnout I'm not vicariously traumatized I'm not my life is not diminished doing this work I can't imagine doing anything else more worthwhile How isn't that just a good feeling I'm not going to say all the time but to have that compass and purpose that you found through tragedy years ago is that is that somewhat of a strange strange feeling to know that this came out of something so horrific and terrible Yeah oh I mean you know there are many times I say to myself in my mind I would give everything back to have my dead child but I don't get that choice so I do this you know not to make meaning of my pain more I do this to make meaning of my life I do this more because because I have this grief and I can't change it and grief is an energy just like all emotion they actually the word emotion comes from a Latin word move here which means to move through and so So I fully inhabit my pain my grief my despair my guilt my shame my anguish my longing my loneliness my fear my anger I fully inhabit all those emotions that are associated with my grief and when I fully inhabit them I can stay with them and then they they transform And in being transformed and this is an ongoing process by being transformed then I can turn them into an energy to do something and for me the energy is fierce compassion in the world and so I have this sort of tireless compassion and I have a lot of energy for an old lady And I think the energy that I have actually comes from fully inhabiting my emotions I think the energy that I've been able to employ in the world and saving animals and helping lots of humans doing research teaching running programs at the university all the energy that I have to do a lot of hats that I wear comes from all the emotions that I experience and can fully live with and create space for So, you know, yes, in a very tangible way, it's a very strange thing to look back 26 years and see that these were that all of this stuff has been stepping stones setting me up for where I am in my life today, I would give it back and a heartbeat in a heartbeat without any thought at all to have my child but I don't get that choice so the Then the only thing that I can do is make the decision to to to to live for both of us I suppose in a way. What do you think you've learned through people coming coming to your, what would you call it? Not a ranch care farm it's a care farm care farm care farm sorry. What have you learned from people coming to the care farm? Are there certain outcomes and things that people realize that are in common or is every single individual something so different? Are there common themes that that come up during therapy or when people come and they connect with nature and get this this idea of meaningful work and get involved and connected? What's the outcome here? Are people feeling the same things?  There are really common themes, but then when you get into the specifics, then you see the nuances that are different that are also important. Right. So, for example, one of the themes that I found in my research with people who came here was this connection to the animals, especially because they're rescue. But when you get into the specifics, why they were important so what for one person they're important because it helped them process emotions for another person. It's important because it helped them realize that the sort of the oneness capital oneness and suffering right that everything suffers all being suffer right and so she didn't feel so alone. So, so yes, there are things and yes, there are even nuances within those things. So at the macro level, there's a lot of commonality. The same way that you would say that I might say I feel today I feel deep deep a wellspring of sadness because my child isn't isn't here. My son's getting married next next year. So let's say next year at my son's wedding. I'm feeling this immense wellspring of sadness, which I probably will be feeling because the whole family isn't there because we have a missing person and she doesn't get to see her brother get married. Right. And so, so there's this sort of wellspring of sadness that comes up for me that might be different from someone else's sadness on that particular day. So my sadness might be at a broad level the same. But if you get into the nuance, it's that it's that shy is not here experiencing her brother's wedding and it's that the whole family. We will never have a whole family picture again. All of us together will never have these different things. And so, so I think that that's one of the reasons that individualized care is so important. When we use a check sheet, which many therapies do, they use a check sheet. Not existential therapy, of course, which is why I love existential therapy and not humanistic approaches, but so many of the other therapies use a checklist approach. And I find those to be they lack intimacy, they lack personalization, they lack efficacy in my view, especially with catastrophe. They're not culturally sensitive and they're not familiarly and individually centered. So they tend to try to take the person and fit the person into the therapy rather than approaching the person as a unique individual and a unique family system and a unique cultural and experiential system. And then we provide the kind of care that works specifically for him or her. Does that make sense? I absolutely love that. I couldn't agree more. It's just, you know, you said we have this this medical care system that is really stressed on time. So in my experience, like probably millions of other people, I went to my GP first and she had the checklist for depression and she said, fill it out. Okay, have you felt in the last two weeks? Have you felt low? Have you lost your appetite? Have you had suicidal thoughts? And it was like, everything except suicidal suicidal thoughts. I'm like, check, check, check. And it's like ding, ding, ding. There you go. Here's the slip of paper. So with the words are so important. That's what I've realized. They have so much power and value. So I guess my first question would be, do you think the mental health will call it a crisis with with depression on the rise and anxiety disorders among children, especially there's so many different factors. What do you think is increasing this kind of the statistics of anxiety on the rise? Is it because we're diagnosing people more with disorders? Is it because more people are talking about and googling this word anxiety? So we see the keyword research is just off the top of, right? Like what's going on here? What's with the increase? You know, I can't really respond to that in an empirical way. I can respond to it in a sort of what my opinion is. And, you know, here's what I think about. I think about the Holocaust. And I think about the fact that there wasn't social media during the Holocaust. And I often think what would have happened if there was social media during the Holocaust, which was an unfathomable trauma for millions and millions and millions of people in that generation and also intergenerationally, because that's that kind of trauma is the trauma that keeps on given. I certainly think that when we pay attention to things, we see them more often.  And then they go out in the world and because they're in that state, they're noticing other people who are pregnant, other women who are pregnant. And then all of a sudden it seems like everybody's pregnant when it's probably not any more than usual. It's just you don't notice it because you're not paying attention. Right. So there is this sort of we are paying attention. There is also this thing that we're probably a little less connected, even though we're kind of technically more connected because of social media, we're more superficially connected. You know, we have had to move like our organization, I run the nonprofit, the Miss Foundation, which is for parents whose children have died or are dying. And so we've had to move to a Zoom model because we can't meet in person, but we don't want to completely not be available for families who need us. So we've moved to a phone mentorship system and Zoom and and it's not good. I mean, it's better than nothing, but it's not good. Yeah.  We don't have a very strong sense of community in a lot of places, not all, of course, but in a lot of places that is true. So I don't know what the rise is, except that yes, there probably is more diagnosing. I think there's a lot of fear of mental health problems in part because we're talking about mental health more. I wish we were talking more about emotional health, but I understand that it's a paternalistic system and men do tend to not like feminine emotions, what they perceive to be feminine emotions. I mean, that's what hysteria was all about, right? I mean, there was a diagnosis and psychiatry of hysteria, which comes from a Latin word for the uterus. Right, hysterectomy. No kidding. Yeah, no kidding. When was that not diagnosed anymore? Well, I mean, I think to some degree, they still diagnose that they just use different words because hysteria is offensive and feminist, you know, sort of said. You know, the reality is that feminine emotions are often categorized as irrational and unwarranted and sort of marginalized, and we wouldn't want, don't be emotional about it.  That's all someone has to say to me. And then you're calm down. Ma'am, you're going to have to calm down is not something that I'm going to appreciate, right? And you see this problem with, because it's minimizing, it's degrading, it's marginalizing, right? Right. And so you, there's a longstanding history of pathologizing feminine emotions and psychiatry. Because we have to be rational rather than emotional. It's not, you can't be rational and emotional. I am a really rational person. I'm a scientist. I engage dialectical thinking all the time. I'm a pretty intelligent person, but don't intimate to me that my emotions are irrational. Right. Because emotions are not irrational. Now, what we do with them, if I'm angry and I punch someone, that's not an irrational emotion. That's an irrational behavior. You don't get to get angry and punch someone, but anger is not irrational. It's the behavior. And so what we do in our culture is we focus on behavioral health and mental health and we leave emotion completely out of it, which is utterly ridiculous and misguided, in my opinion. How do you even get to one from the other? It's like you can't skip over the emotional part. Right. Exactly. I mean, exactly. And all you need to do is look at a three-year-old or preschool, right? So you've got two three-year-olds and one three-year-old takes the toy away from another three-year-old and that three-year-old feels frustration and anger and bites the other three-year-old. What they focus on is the bite rather than the emotions underneath it, right? Ah, of course. We're not teaching children how to express their emotions in other ways.  But we can't express what we can't, what we don't have self-awareness about and we have virtually no self-awareness about emotion. I can't tell you how many times I ask people, tell me how you feel about something and they'll tell me about their body, their physical or they'll tell me about something they did. Their behavior. But very rarely do people are people at least immediately until they've been working with me for a while. Very rarely do they automatically go to, I'm noticing this sense of despair come over me and I'm feeling really lonely about it and hopeless, right? So we don't even know how to talk about our emotions in therapy. Right. Right. And it's the one place where you can say anything. Therapy is the best. Theoretically. Now I will tell you that there are many therapists who know less about emotions than I would like. Yeah. That is again. The pedagogical models fail. The pedagogical models are failing. So we're taught about mental health and behavioral health, but we're not taught about emotional health. That's a massive problem when someone actually wants to go express themselves freely in that room with a trained psychologist or therapist and they don't have the tools or recognition of how we're feeling. It comes also down to that language piece that we don't even have the language sometimes to express what we're feeling because we've seen the word depression all the time. We've seen anxiety there all the time. So we automatically just identify with, yeah, that's probably it. I saw the symptoms. Okay. It's anxiety. This is what I'm feeling anxiety. I think it's so great that you go deeper into that. Right. Well, because you have to in order to really understand the suffering person sitting across from you. If you don't, you're doing them a great disservice and you're being very psychologically lazy and quite frankly, I think endangering them. Quite frankly, I think it teeters on malpractice because we have to be willing to be fully present with what's happening and what's unfolding right now. And we have to be confident in our skill set and that includes emotions. And if you're not confident emotionally, then you probably shouldn't be a therapist. I mean, do your own work for God's sake. I cannot tell you the number of therapists who have not done their own grief work. It is vast and terrifying actually because that shows up in therapy because then when the client comes in to sit with you and her mother just died and your mother died 28 years ago when you were 14 too, but you never did the work. And now this client comes in, you're going to have a harder time relating in a way that has meaning for this client because you didn't do your own work. If you do your own work, you can take people to the depths. If you haven't done your own work, that comes from that comes from Pema Children's work. So Pema Children said you can only take people to the depths you're willing to go yourself. And it's true. What do you think, you know, does I guess grieving like different emotions, these umbrella terms grieving can be obviously felt differently by other people. Do you feel like with social isolation now, are people feeling, can we use the word grieving for once was and the state of normality? Because sometimes grieving, it is a heavy word. It's like when people come home from work and they're like, I'm exhausted. I'm like, yo, you'll reframe that exhaustion.  You're cooking dinner. Are you emotionally exhausted? Is grieving too heavy a word to use to describe how we're feeling right now with social isolation with COVID-19? It's a great question. And so what I invite people to do is rather than, you know, use that word automatically, really sit with what that means. And so what are you really feeling? Be specific. And what most people are feeling when I probe, like my neighbors, because I only work with traumatic grief. So the people I work with are grieving and re-grieving, right? Wow. But when I'm talking to my neighbors and my friends, what they say is actually it's probably not grief. It's more loneliness and a lot of fear of uncertainty, some frustration, some anger.  And what I mean by at times like this is that there are people whose loved ones are actually dying. I work with a bereaved person, a man, whose wife and two children were run over intentionally.  Yeah. Right. I mean, we really should be very sensitive to people whose loved ones are dying. Horrific deaths right now inside and outside the pandemic and who are experiencing exceedingly traumatic grief. I don't want to take ownership of this word grief and I don't tell people what they can and can't feel. I just, I'm, in my research, one of the things that I talk about is the idea of primary victims. So one of my studies, I researched families after the Sandy Hook shootings, families whose children were actually killed. And it was important to them that people understood that their grief is different from the community grief. That life for them never goes back to what it was before even remotely because their child is dead and was shot at school. The magnitude of that, the magnitude of that, most people get to go home and tuck their children into bed. These people don't. And so I'm sensitive to primary victims because that's the work that I do. And so I'm not inclined to tell people what they should or shouldn't feel. But what I am inclined to do is say, really dig deep and explore. Is that what you're really feeling or is there some more nuance to it? Right. What I find in my own corner of the world is that most people aren't actually feeling grief. If they're, if they haven't lost someone or someone's not critically ill, most of them are feeling fear, frustration, loneliness, anger, a lot of different emotions. Right. And so I think, I think what we again try to do is get lazy with words and try to just find the quickest word that describes it. Yeah. So yes, in a way it's a loss and maybe there's sadness to that loss. So what's the difference between sadness and grief? Sadness might be more of a specific emotion. Whereas grief, I wrote, you know, in that, in that umbrella grief is sort of so many different emotional experiences. And then on top of it, physical experiences, right? Because, because we experienced physical, global pain, gastrointestinal problems, headaches, sleeplessness. I mean, all kinds of things that come along with the death of a loved one that are physical, existential, cognitive, emotional, all of that. Right. So I invite people to a deeper conversation about it, generally speaking. It's very hard for me to talk about it in a sort of a hurt or abbreviated way. Yeah, of course. Talking about the pandemic. Of course. And when we're kind of, we're talking about going deeper into emotion and really, really feeling things, which I've had the pleasure of doing since getting off of antidepressants. You mentioned that you do some kind of, I didn't get the exact name of the meditation. What was the name of the, was it yoga or meditation that you practice? Oh, it's meditation. Yeah. And meditation is that, does that help us be more in tune with the emotions and what we're feeling in the moment? If we have a good teacher, yes. Wow. I think that it's important. I mean, I think like the app apps are great and they can help us calm our nervous system. Those are wonderful. In fact, there's a great app called calm and it's wonderful. But I think for people who really want to get serious about practice, it's good to have a teacher. And so look for a good teacher. You know, I'm a member of Zen Garland Order and I have two Roshis, two Zen teachers who helped me. And I think that it's important to have Asanga a community if meditation is something that interests you. Certainly you can use meditative techniques to calm your nervous system because like during the pandemic, for example, a lot of people, their nervous system is on overdrive. Like, you know, we have a lot of time now to think and feel things that we haven't thought and felt before because we've been busy and distracted. So discursive mind is an interesting thing. And so what I tell people is, you know, if you're interested in it, find a really good teacher and then follow that, you know, interview some teachers and start your own practice. I think that meditation and this is empirical too has helped a lot of people in many ways, but it is definitely for me, it's not calming. It's it just is it's just meditation. It's a practice and the idea isn't to relax.   And it's a constant, you know, it's a marathon.  Yes, there's all kinds of different narratives out there for mental health, which which is well, let's say for meditation.  So that's the narrative there. And then with mental health, sometimes the narrative, it couldn't be, OK, you deal with this emotion. And if you deal with too much of it at a certain time, then you have a diagnosis or a mental illness. The narratives almost need to to switch. And this is why I absolutely love your work with really feeling the emotion fully and going deeper into pain. That's something that you really teach. It's like to not scratch the surface of pain to go deeper. Right. Go deeper. Go deeper because and let me add the caveat to this, though. It's hard to go deeper until we feel safe. And so it's hard to feel safe unless we have someone who who has the capacity to hold all of that pain.  Feel safe somewhere before because I think it's important. You know, when we start to approach the hard work, the reason that we back out is because it's too scary. But if we have a stable, solid presence of someone who helps us feel safe, then we can approach the fear. In the absence of that, it becomes too overwhelming for our nervous system. Physically, it becomes too overwhelming, but also emotionally because we feel threatened. Right. So this is this is incredibly important that we feel safe. The tradition on the podcast, Dr. Joanne is to give you the mic for the last few minutes and you can, you know, a lot of people on the podcast sure are dealing with all sorts of mental health issues, emotional issues. We could we could say some are maybe in a process of grieving right now because it's such a broad audience. Any message that you like to say to someone struggling right now, the mic is yours. Well, I mean, I didn't know this was coming, but that's okay. I can add that. I mean, the reality is if you're in grief, if you're in suffering, if you're feeling pain. I think one of the most important things that we can do for ourselves and for our family and for the world is to feel our pain is to find someone who has the capacity to hold that witnessing to bear witness with them. And to help us feel safe to feel that pain. And when we can be with it, when we can be with it, then we can create space for it in our lives and really feel. And when we really feel this is the great gift that keeps on going because you start to learn how to trust yourself in ways that probably you've never trust yourself before. And as you build trust in yourself, you build in a sense emotional muscle. And with emotional muscle, we start to learn that we can carry a lot more. We can bear that which we think we thought at one point we could never bear. Coming full circle back to your comment about your parents, Scott. So you build emotional muscle and then you start to trust yourself. And the trust in oneself is in my opinion one of the greatest gifts that we can give that will endure our lifetime. I endured the death of my child. I would have never thought I could endure something like that without dying. And maybe in a way sort of metaphorically I did die and was reborn, right? But I trust myself with everything now. There is never a moment in my life where I think I can't handle that. I haven't had that thought since 1994 since my child's death that I couldn't handle something else. And the reason is because I 100% trust myself with everything. And that is a gift that my dead child gave me for which I'm thankful that I would return in a heartbeat but for which I'm thankful. Now having said that, one of the most important imperatives facing us today is what I call fierce compassion or radical compassion or unrestricted compassion. And we as a world have got to get better at doing that. We have got to get better at feeling compassion for others who are like us, for others who are different from us, for others who are a different species from us. And for the earth that holds us all. Because if we don't do that, we will continue to repeat the cycle of trauma and re-trauma over and over and over again. Once we have reached that capacity to extend our circle of compassion beyond ourselves, beyond other people like us, other people different from us, other species and the earth. Once we can do that, what we will find is that compassion turns inside out and upside down and toward us. And then we feel ultimate compassion toward what's here. I know self-compassion feels like a very hard thing to cultivate. And so practice self-compassion for sure. But one of the ways that I practice self-compassion is through connecting with others in compassion. And by others I don't mean just our species. I mean outside of our species and the planet. So one of the things that's important to us here is the care farm is sustainable. We don't use any pesticides. We take care of the mother earth. We take care of the land. Because the land is what sustains us. And until we understand that we have to take care of the structures that sustain us, then we keep abusing this, even consciously or unconsciously, abusing the structures that sustain us. And so like a lot of the people who come here to do the work that they do, they start to realize that. They start to realize self-compassion and other compassion. So they look for their own story exactly in the stories of others who are grieving. So someone has lost a brother or sister and they want to find someone else on the farm who lost a brother or sister. And then they start to see others who have lost parents and others who have lost children. And others who are homeless, who haven't had lost or via death. Or others who are struggling with substance problem. They start seeing suffering broadly speaking. And then they start seeing the connection between themselves and a horse who knew loneliness or who was separated from a brother or sister. And then they start to understand how that compassion and tenderness can extend to the world. Once we get into that cycle, then I really feel like it's that awareness and that practice that's going to change the world for the better ultimately. I don't think that we'll ever have peace really on this planet until we do that. And I think that it's people who have known deep loss and catastrophe and suffering who can bring it because of their capacity to hold pain and their capacity to transform that pain into fierce compassion in the world. I'll say it for the first time. Dr. Joe, thank you so much. That was absolutely beautiful. I told you folks, I would cry on this podcast. I told you thank you so much for your time. This meant so much to not only myself, but to all those listening. Thank you from the bottom of my heart. Thank you everyone. Thanks so much for listening. Stay strong. Keep being you and don't forget to express yourself.


This is the Freeport Business Network for our monthly meeting. We're joined here with local business owners and managers. Our goal is to refer business to one another and support one another's local small businesses. Freeport Business Network is a group of local business owners and managers that are here in town working together to help refer business to one another and to build this community with the wonderful community support we have. We have several business owners that founded the organization. We have our own Facebook page and we work together with social media and with one another to help other local organizations and parks etc. We host the Spring Fling every spring that's in coordination with our yard sales and we have a block party and lots of music and great activities for the kids to do that day. Very successful and is a great representation of what the business network does here in town trying to give back to our residents and communities. It's really nice to be able to see people from outside areas come in and enjoy that day and they get to see what the business is here on our main street have. Our Fifth Street corridor is a wonderful business opportunity. It has several open storefronts that we would like to see filled with great and profitable and friendly businesses that can take advantage of our great community network and our great residents here in town.


Felly, we fed our patient through the tube and our patient died. He was at the opposite end of life to Grant. He was a grandfather, soon to be a great-grandfather. But the months of life that should have been there for him to enjoy were lost. And it happened on my watch. Yesterday and this morning we've heard the term second victim used to describe staff involved in a patient's safety incident. I have to quickly say I hate the terminology of second victim and I can understand why it makes some of the bereaved and patients who've been harmed incandescent. When we get things wrong, the patient is the first victim, but everyone who loved them and knew them is the second, third, fourth, up to several hundred victims. But it's not to say there isn't truth in the concept. I know my team from 15 years ago is still scarred by the error we made. And the patient's family forgave us far more readily than we ever forgave ourselves. So every case of nasi gastric tube misfeeding represents not only a tragedy of preventable harm to our patients, but also preventable harm to our staff. The executive summary checklist of the nasi gastric tube apps highlights what we should do. But I need to mention a couple of important points that the full version of the app says we shouldn't do. It tells us never to use air osculation as a verification method. Air osculation involves listening with a stethoscope as you inject air into the nasi gastric tube and channelocate where that faint whooshing sound of air exiting the tiny tube is coming from. Research dating back to the 1990s shows that air osculation is less reliable than tossing a coin. In test conditions over 80% of clinicians failed to detect tubes in the lungs. In England, air osculation is something we banned over 13 years ago. But when preparing for this panel, I was shocked to realise just how commonplace this method has remained in some other countries. I found materials teaching parents, teaching nurses, teaching doctors to use air osculation apparently totally unaware of the research and the risks. When I tell you I found that rather alarming and I really would urge you to take very seriously the requirement in the apps to eliminate its use, you may have to adjust the volume on the emotional dial. I'm British. I'm a nurse from a generation of relentlessly nice nurses. So please translate that into the equivalent of me sobbing, pleading and pounding on this lectern. This hasn't only been a journey of eliminating outdated methods. We sometimes worry health care is too slow to embrace innovation. But in laser gastric tube safety we've seen the opposite. With some new and expensive technology automatically assumed to be superior when it was not. Our national safety team in England and the FDA in the USA has hatchery issue warnings related to some of these technologies. And the apps also helps us understand their limitations. But the apps makes it very clear there's more to safety than just using the best techniques for laser gastric tube insertion and verifying placement with the evidence-based methods of pH strips and X-ray. It's also not giving staff the training, the equipment, the confidence to do that as well and as safely as possible. So seven years ago in England we began to emphasise the importance of education for nurses in the tricks and techniques that support testing via pH strips and education for doctors replacing the traditional X-ray interpretation method that caught my doctor out all those years ago of just checking the tip of the X-ray. Instead, it's vital we use the four criteria systematically checking the X-ray at four specific points along the laser gastric tube's path. That training can be given and assessed in less than an hour. And we've not yet seen a single X-ray misinterpretation occur when that four criteria technique is used. But it needs executive leadership, good governance, good educators, good managers to ensure no staff have been left out or left behind. And to create a fair and open culture where if we get things wrong we report them, we investigate them, we share our findings with patients and their families and we act to address the underlying causes. Professor Don Berwick says many wise things about improving the quality of health care but my favourites are around the need to bring joy into our work and he reminds us that we can't sustain improvement without it. That's difficult for patient safety because the patients we fail, like Grant, have names, pictures, stories that touch our hearts whilst the patients we've saved from harm are forever nameless and invisible. A colleague and friend of mine found a way of helping bring back a little joy that I'd like to share with you. Whenever you sit down at the favourite feast or celebration in your culture, Christmas, Eid, Thanksgiving, Hanukkah, Diwali, Chinese New Year, picture in your mind the families that might have had an empty chair. Because of all that you in the room have done and will do, and all that the panel I'm about to introduce have done and will do, there is a family that doesn't have an empty chair. They're happy, or at least happily arguing if there are anything like my family's celebrations. And the circle of chairs is still complete. So, for all of you as leaders in the room, whether as parents, patients, executives, philanthropists, clinicians, technology, politicians, civil servants, as I introduce the panel, I'd ask you to remember it's a great joy and a great privilege to be able to take advantage of the actionable patient safety solution on nasogastric tube placements and verification. Please welcome our panel. And I'm going to ask the panel to introduce themselves, but we do intend to give as much time as possible to your questions, so do please remember that via your smartphone apps you can ask questions for the panel. I would like to ask you the first question because you've so kindly shared the story of your little boy. We know you've been active in patient safety efforts since Grant died. Would you tell us a little about why that was important to you and what you've been participating in? Definitely. So, after a couple of years after Grant died, I got to thinking about the things that we had worked with the hospital that they were going to implement. And I wondered to myself, how do I know that they really actually followed through with those promises and how do I know that those changes worked? So, I called the hospital and I scheduled a meeting and that's when I met Chris. And, sorry. But when I sat there and I talked to them, I learned that they had actually implemented the changes and she was actually able to tell me that day that they knew that they had saved four babies' lives because of the policy changes they made. And through their work, I had learned that a pH strip, if it had been used to verify Grant's feeding tube placement, he might have been here today and had he lived, he'd be 10 years old in April. But when I was sitting there and after she told me that she knew four babies' lives had changed, I got to thinking, well, how can I improve that number? How can I make sure that this becomes a never event in the US? And so I then asked how I can be a part of the hospital patient safety team to make sure that changes continue to take place and to get involved with being part of that change. And so I started sitting on their patient safety committee and then through that committee and being focused on NG2 placement verification and they introduced me to Beth and the novel project that she had started up, which is looking for that gold standard, which eventually led me here to be at the Patient Safety Foundation Movement Conference because I pitched the idea that, how can we universally find a gold standard so that nobody lives the consequences I did? Thank you so much, Diana. And the story we will have today, I think, is all of us finding the babies and the adults that we can use Grant's story and the wisdom of our panel to save. There was one part of Grant's story which probably echoes with all of us in that you felt something was wrong, didn't feel listened to. Obviously it's highly important we listen to parents, to patients. But what's tragic to me is often also the clinical staff in these situations who felt something is wrong. So I've known a junior doctor who's been perhaps uncertain whether they're reading the x-ray correctly but hasn't quite followed their instinct through to asking for more expert help. I'd like to ask all of our panel in turn what more they think we can do to listen to parents, listen to patients, but listen to colleagues and listen to our own instinctive unease. Christine, perhaps? Yes, so having policies and procedures is obviously very, very important but I think the biggest thing with Grant is the signs of when a feeding tube can go into lungs, really mimic respiratory distress, gagging, sometimes even vomiting. But it's really following your clinical judgment and your intuition and really knowing that if you're putting a tube in and you're getting some form of distress then you need to stop. And we have a motto in our hospital that we use saying pause to care and we've had so many families comment on that and it is taking that minute to pause and realize this isn't working, we need to take it out, we need to try again. And I think just that message in itself, yes you need to follow the right procedure, you need to do confirmation through pH or your x-ray. But any clinical sign of distress should make you stop and until you can figure out what's going on that patient you have to assume it's that nasogastric tube or oral tube. And I really believe in Grant's case, Deanna spoke up and we didn't listen and that's what's really tough is making sure not just the parent but the clinician at the bedside. If there's not something that feels right, you take it out. David, perhaps on the perspective of also educating doctors to have that confidence, what would you like to add? Well, I think that this is a very good situation that signals to the fact that we need a better communication in every case where we have a safety problem. You have to listen to the physician, you have to listen to the patient, you have to listen to the nurse and as it was mentioned yesterday, you have to listen to the team that takes care of the individual. That is a good way to avoid errors and to avoid mistakes. And self-confidence in anyone is a very bad thing. You have to be humble enough to listen. I think communication is a big effort. So I think that's the point I hear from all my panel that modesty is a virtue in patient safety and I have a very wise but also very modest panel here, I think. Beth, do you have experience of not just teaching the technical skills but that ability to realise when you're out of your depth and something might be wrong with your own scenes? I think that all of us in clinical practice have started a procedure, whether it's an NG tube, an IV catheter or whatever and found out that things weren't going well and having that index of suspicion. I think that we start as novices not being able to recognise that and develop in our careers knowing when to take a pause, as you said. One of the biggest concerns that I have about this issue is that many of our hospitals in the United States are not even giving nurses or clinicians. We have some physicians as well in the United States placing NG tubes but they're not using evidence-based approaches to even verify placement. And in one study that we did with the novel project through Aspen, most children's hospitals in the United States use oscultation or aspiration for NG tube placement verification. PH and an X-ray were way down the road and so when a nurse takes a pause, uses critical thinking skills but doesn't use an evidence-based approach, they're still not going to get where they need to be. That's what concerns I think many of us. I'm shortly going to ask you about some of the novel technologies Beth, but I think it's worth us talking through. We actually have technology that's been around a long time. We have PH strips, which are a fairly straightforward bedside test. We've certainly been using them for more than 13 years. We find about 90% of placements can be verified. We've got clinical research that says it's very, very rare indeed under test conditions to get acidic PH from the lungs. And in practice, because of our voluntary and mandatory reporting systems, we suspect that if there is an error rate with PH strips, it's something in the region of one in 30,000. Now alongside that, we have air osculation which has no evidence-based, no reliability. Why do you think we have clinical practice that is it's so dedicated to one and somehow we've left the research evidence behind? David, would you perhaps like to first comment from the perspective of a country that perhaps hasn't got as many established protocols and then Beth and Christine from a USA perspective? Well, for example, in Mexico, I think it's very important to have guidelines. That's the first thing you need to make sure you have guidelines. In Mexico, we do not have national guidelines for placing a tube. You tend to think that it's a very simple thing that you can learn, you can put the tube, and you sometimes miss the opportunities of having guidelines. That's the first point. The second point is it's not compulsory to report side effects of a nasogastric tube. You only report them when you have a severe and a threatening situation, actually when there is the risk of the person dying. But that's not the only side effect. You have other side effects when you place a tube. So I think it's important. We're now in the process of developing national guidelines with the Nutrition and Gastroenterology Association and also to make compulsory reports of side effects. It's not only the big mistake, but the ones that are recovered because most of the times, for every time that you have a death, you probably have a significant number of complications which delay the length of the stay of the patient, develop pneumonia, develop resources, and it's very costly. So I think it's very important to the projects which you have, the novel and the Aspen protocols. And we have made, for example, in the recent years, in the last year and a half, we have made a study in which we have a protocol at the institution. And that has made a big difference, not only in the side effects, but in the length of stay and the percentage in which you achieve the results of a good natural gastric feeding. What is the purpose of putting the tube and what is the result you can measure after you place the tube? Thank you. So David has the challenge of establishing protocols and good practice. In the USA, you've probably got the challenge of changing what is established, normal practice, if not good practice. Any advice to everyone in the room on how to go about that? Well, as most people can probably guess in the room, this went down as a sentinel event. And so that I was pretty much pulled in. I'm a clinical nurse specialist, so my specialty is pediatric cardiology. But because this event happened in our area, I was pulled in to then basically change our policies and procedures related to nasal gastric feeding. And that's when when I did the literature review, it was very clear that auscultation was a very old practice. And insertion of an NG is not the only example in our health care system in America where we sometimes hold on to old practices because it's what we learned. I'm going on 30 years now of being a nurse and I can tell you that that's how I was taught 30 years ago in nursing school. And some of these things take much longer to change. And I do think because it's not a mandatory reportable event. And when you look in the literature, there's always a range of misplacements and it's not a very good range. It's anywhere from three to 20%. And part of that is because it's not reportable, we don't have a lot of data and numbers around it. So we did change the policy. It was the right thing to do. But I do have to say is even when we took that auscultation out, I really had to go to a lot of our nurse managers. I had to go to our home health agencies and I had a task force that I had recruited. So I really should say we, we had to do all these things because there was a lot of resistance to changing that policy. So when we went to go educate to implement the policy, we had to take a step back. And what we did is we told Grant's story. And that was really powerful. It was really hard for people to hear, but they realized this is the right thing to do and it's also what the literature supports. And so my biggest thing is I don't want it to take a Sentinel event to make a change. I hope most people in this room, you don't have to go through that because it's really hard. It's hard on everybody. And but the patient and family is the one that it's all about. So it's really bringing it back to the patient and the family, you know, to make that change. But it wasn't just about changing the policy and procedure. It was really having to do, go to the leadership and tell them why we were doing this and tell them the story of Grant as well as some other patients that had misplaced tubes that weren't harmed as significantly. And this is why we have to do this. I think on a national level, your experience would be mirrored among many hospitals in the US. Part of the issue with measuring pH in the United States is that it's a CLIA event, a point of care testing that requires annual competency and color chart reading and all of these kinds of things. There are other products in the market that will circumvent that and I think you heard about one yesterday. But essentially, there are barriers within institutions because they don't want to go through the whole area of point of care testing. In NICUs in particular and in the United States, 60% of children who have an NG or orogaster tube are in a NICU. There are many people that believe, including me by the way, that pH would not work in that environment. And we actually did finish a study, the novel project did. It was done at my hospital. But 97% of the time when a pH is done on a neonate, we were able to get a level below five and say that we did not need an x-ray or another method of verification, which for us would be an x-ray. So I think that there are really attitudes. I think most people know that pH is the right way to go and certainly anyone who's followed this literature would follow the UK example of what they've done over the years and know that their track record is really quite stellar in this area. But it's really more an attitude and convincing people that this is even an issue. We did submit a multi-center study to the National Institutes of Health in the US and the reviewers were not convinced that this is a problem. So I think we're kind of at that level and I've heard from two of the panelists that we don't have a mandatory reporting system and in fact there's a very strong impetus not to report sentinel events in the United States due to issues about litigation and that is tripping us up in this area as well. But if we want to get to zero, we have to have measures how to implement them. If not, we're not going to get to zero. So we need that. And I would like to make a comment. In adult patients in which you have people with dementia or people with a cerebral vascular accident and they don't get the reflux the same way, the gagging, the coughing, it's a particular risk factor, a very important one. And the other issue is that a lot of patients are put on pump inhibitors. And by the time you want to put a nasal gastric tube or nascentaryl tube, the measurement of the pH is affected by the use of these drugs. And then you have to remember other ways of how to measure it, including the x-ray which you showed and which I think it's very important to disseminate the knowledge of the important point which you need to check in the x-ray. It's not only seeing the x-ray and seeing the tube in the left side and saying it's in there. And I just, I did want to just add to what Beth said was really important about the point of care. And on that task force, we actually had our point of care manager from the laboratory. And I have to say, this is the other thing too and you want to make change is have the right people at the table. She was, that was not an issue. She was like, if this is what we need to do, we're going to bring pH paper in. And she made that happen. And she wrote that piece of the policy and that was just wonderful to have such a team player on that. This is not going to be a barrier, so. I'd like to add too. I know that a lot of organizations are resistant to one of the other items that we've listed. So pH being the first go to and x-ray being the second. And I know that there's the concerns with the radiation and stuff and this is going to sound horrible to say but I always tell them, I'd rather have a radiation baby than a dead one. Because I can at least live and grow with my child with going through radiation therapy and have a life and get to see and know him. I got 11 days with my son because I wasn't an option at the time. So my memories are wishful memories. What would he have been like? What would be his favorite color? What sporting activity would he have liked? That's all in my imagination. Very powerful message, Deanna. Thank you. I think to pull together some points from the channel, from the panel. We know these are rare events but it's also a very everyday practice. It's the points we're making in terms of actually finding out if you try pH paper, whether it is adults on PPI's or whether it is little babies in neonatal intensive care units, you will probably find you get an acidic pH more often than perhaps the naysayers would tell you. You do have X-ray as a second line verification and when it's needed, it's needed. We should never X-ray unnecessarily. But the day-to-day process of actually checking our doctors have those skills, our nurses have those skills is something that's quite easy to measure because that's something that's carried out day-to-day. Ananna, Christine, you have some interest in electronic medical records, as I know the room does more generally, not just a way of auditing good practice but helping remind people what good practice is in relation to nasiogastric tubes. Yes, so when we... I really do like our policy and procedure team in our hospital. You know, there's been, I'd say over the last six or seven years, really good changes and once again, it's not just writing the policy but it's also about educating and implementing which includes what you're going to put in your electronic medical record. So in our electronic medical record, when a nurse or provider inserts a nasiogastric or oral gastric tube, they are prompted on the confirmation and if they've done it by pH or X-ray and also where the marker point is on the nose and so that in the chart, it should be easily referenced to where the marker is, also any signs of distress as well too. Now, saying that, this work, it's never done, right? I mean that it's always maintaining and we recently, it's strange how things happen but there's a couple of things that happened before I came to this, the patient safety movement and I think it just reminds us of how our work is never done and how we always have to stay on top of it but we had a misplaced tube in our pediatric ICU. The tube was actually put down for decompression which is basically not for feeding. You're actually, it's to take liquid out of the stomach and remove gas and it actually had been inserted in the lung and the nurse did get a gastric aspirate, however she didn't test it with the pH because in our electronical medical record, the options is gastric aspirate and then a separate optrin for pH and so an X-ray was taken and that's how it was found and the tube was removed and there was no harm done to the patient. However, it just made me realize, okay, we have to change that in electronical medical record having gastric aspirate separate from the pH can be confusing to our staff and in this case, the nurse did not get a pH. David, and then we'll ask a little more about new technologies I think. I think it's very important to remember that the natural gastric tube can be put in place for aspiration, as Christine was saying, but when it's used to fit the patient, that is the most risky part of the procedure and one has to make a difference between why are you putting the tube and what you're going to pursue with the procedure. Very helpful. Beth, I know your novel project has tried to also look at new technologies and not every new technology has been a true dawn. I wonder if you can tell us a little more about that work. So the novel project stands for new opportunities for verification of aneral tube location and it was started by the American Society for Parental and Internal Nutrition in 2012 and we specifically seek out, we have 14 odd members of physicians and nurses from all over the United States, Canada and Australia and we have a nurse in Brazil. And it was specifically started to disseminate best practice, kind of following the United Kingdom model and also to work with inventors and industry to develop technology. We do not think that there is a one size fits all approach for this and currently the novel project focuses on pediatrics and neonates but it's going to expand to adults as well but we really seek out industry members to give them feedback and things because the technology that's out there right now doesn't quite hit the mark for pediatrics and there was a recent FDA alert about one product that actually has been the subject of the National Health Service patient safety alert system in the past. And so we do need very simple technologies to be developed so that a staff nurse at the bedside could verify NG2 placement and then in real time reconfirm placement. So it's one thing to get the tube in but it's another thing to make sure it stays where it's supposed to be and this really is needed for I think actually both adults and pediatric patients. I'd like to add to that. One of the things that when Grant's feeding tube was put in the nurse actually turned to me when I was asking her all the questions about her placement verification. She told me she said you know you're going to have to learn how to do this when you go home because there's a possibility he could pull out his feeding tube. So those technologies not only have to be for staff members at organizations but it also has to be for a family member who might be put on call to put it in. Very powerful. What we were keen to do was spend as much time as we could on questions from the audience which happily have come in at some good speed. A lot of these do relate to education and I just wanted to do say one thing that's probably a lead up to when you hear Matthew Syed speak this afternoon. That there's an aspect of how our minds work called cognitive dissonance which means if we've actually done something for a long time and believed in it and if we believe we're good clinicians and good people it's very hard to believe that the old fashioned thing we were doing was wrong and that has quite a profound effect in change. It's perhaps one of the reasons why it's easier to change to exciting new technology than it is actually to change to something we could have been using 13 or 15 years ago because it makes us question our own practice and our own values and what we've done. Within that we've got questions that are very much on this critical question and tie back to the session we heard yesterday on patient safety as part of curriculums. What would your advice as a panel be in terms of considering someone in the room who has their own hospitals or hospital chains who is trying to change policy, change the training they provide for their nurses, doctors, parents. Where would you suggest they start? Can I share my story? I have learned through Children's Hospital that it was very impactful for their staff and I actually had a full 360 moment one time when I was doing rounds when the hospital was initiating their target zero which is much like this, zero harm by 2020. And when we were rounding with the staff, I noticed there was a patient on a feeding tube so of course I started asking that nurse very leading questions, how did you do your placement? How do you know it was right? And so she's telling me the techniques that they use that I already know that are supposed to be in place so it was nice that she's using them. And as I'm asking her a few more questions she turns to me and she says, you know, several years ago we lost a little boy. His name was Grant and he died because a feeding tube was put in wrong. And I looked at her and I said, thank you. You have just shared my story to me and validated that the reason his story is used is powerful and useful. So use his story is the first thing I'll say because having that patient's story really does emphasize the need and it puts a face to the reason why those policy changes are needed. And I think that certainly a story we hope to make sure you all know how to access and use after the conference. And I just wanted to add to the other thing that Deanna does is University of Northern Colorado has her come every semester and incorporate her in teaching the BSN students to tell a story. And it's really, it's about Grant's story but it's really about listening to families and it's about patient family engagements. You know, so much was taught yesterday at that panel. And I think that's a wonderful way to adapt into curriculum. Being a clinical nurse specialist I have a lot of different roles but one of the things I've really gotten involved in the last five years is high fidelity simulations. And I do think that simulations are a really good way of teaching things that can happen to a patient and doing a misplacement and seeing how the team responds. And that way it's not just about, we keep talking about collaborative education and our high fidelity simulations it incorporates all of our team members. Our physicians, our pharmacists, our nurses, our RTs. And when you do that debriefing and if you do a really good debriefing it's really powerful and it helps so much with those team dynamics but then you can also address things like this with patient safety concerns and why they're important. So I highly recommend if you're able and you have access to high fidelity simulation to be able to use that in the curriculums as well too. David, would you like to comment perhaps on medical training as well building on giving doctors a story? No, I think this is very important. I would like to add that we put a lot of intravenous catheters at the institutions and we have a team that goes around and sees that you don't get an infection, you supervise, et cetera. I think this cooperative team which includes the nurse, includes the nutritionist, includes the resident, the physician is very important to have a team that should go around the institute or the hospital and see the amounts of tubes you place in a week and see the status that these tubes have. I think that surveillance is very important to the safety. We tend to forget. We look to the vesical catheters, to the intravenous catheters but we don't think the same way when you put the nasogastric tube or nascenteral and you also mentioned, Christine, the fact that it's not only putting the tube but what's happening the days after you put the tube because you can have complications not only in the placement of the tube but in the days after you put the tube. So recently I made a video on NG2 placement verification. It will be on the Aspen website, it's a YouTube, it'll be a YouTube video and we are going to allow our parents to download it. The Feeding Tube Awareness Foundation in the US is going to use it and it actually has a sim lab aspect to it but it also has actual patients and it shows me almost getting kicked by a 10-year-old darling child. And so it's very real world as well but I think education of healthcare professionals using experienced people and best practices is a very important thing and then I will dovetail on to something you say. I am part of a nutrition support team and we do have a team of people and part of the nutrition support team there's an internal access team because we do see that the vascular access team that looks at our central lines has made a huge improvement in central line complications and the internal access team looking at feeding tubes not just nasogastric but the gastrostomy tube that gets placed in a child that has a TE fistula and things like that. We deal with those as well and I think that's very important. And I think the parents is very important because many times the patients go home and they continue with the process of feeding. It's not only at the hospital but at home and I think getting the parents involved into the process is very important. I'm aware we're coming close to time and we're definitely going to let Deanna have the last words. In terms of the questions we haven't been able to get to some are quite technical why we're recommending what we recommend you know why, how will we stop tubes being removed how would we worry about subsequent verification. I think between us, between the full version of the apps the Aspen materials some materials from the UK that I'll tweet we should be able to answer most of the technical questions offline. We've also got some interesting challenges for new technology we've had suggestions as to how much does ultrasound and sonography have a role to play. I'm not going to attempt to answer that from the panel but the panel will I'm sure pick up questions and I know Beth is particularly knowledgeable about some of the potential for new technologies. But we would like to end as we started and Deanna you have a right to challenge all of us and all of the room and tell us what you want us to do to make sure we protect other people's babies other people's grandfathers other people's loved ones. One of the things that I learned through the process is that when Chris was rewriting the policy she had to look to see what literature was out there. And then in reviewing that literature discovered that you know what they had currently in place was incorrect. So what I have learned you know that was a starting point but I've learned that most organizations they only know that there's a change needed if they read the literature. So we have spent a lot of time creating this app and so I implore you to go to your organizations or people you know in organizations to get current on the literature to read our app and understand the importance of being current and using the technologies that are currently advised and to discourage the ones that are no longer valid or have been invalid for a long time. Because when with the novel project we learned that so many hospitals were still using an antiquated process because they did not read the current literature. So that is my challenge to you as I implore you to go back and encourage and enforce that everyone needs to be current and read the app that we have designed so that everybody can be doing it the right way. And one thing to add on to that as well too the other thing is with we're actually doing a current revision right now of our policy and we've actually made it a yearly review. So usually most of our policy procedures are every three years because of all the work that's been done in this and the risk to our patients we do it every year but our neonatal intensive care unit brought a new tube in and the new tube when I was reading the packet insert the packet insert calls for auscultation, for confirmation. So I would just ask you as well when you're picking products and looking at products be aware of what the package insert is because a lot of staff and doctors when they're inserting they could just go to that packet insert and bypass the policy. So it made us realize that we have to be we really have to be think this new tube in that packet insert so but when you ask that question in the beginning of why auscultation is still used another barrier in the way is the products that are being made include the wrong information. To add if you're here as a manufacturer get current. Unless we have another burning word I would like very much to have left Diana the last word so it reminds me to say thank you so much to the panel for everything they have done will do. I think you've been given your orders as a room and I know you'll take those orders on board. Thank you very much indeed.