Tag Archives: emotional intelligence

“It’s a Fine Line” – Myth vs Reality

Every now and then somebody trots out a phrase like, “It’s a fine line between madness and sanity” (or words to that effect). It makes me cringe a little every time I hear it.

This version of “It’s a Fine Line” paints an unrealistic and unkind picture. It creates an impression that anyone who is “sane” (whatever that is) could, in a random moment, cross a line and become “insane” (whatever that is). It also creates an impression that jumping back across the line should be just as quick, just as fateful. This version of “It’s a Fine Line” is a dopey dichotomy – it divides humans into two tribes. It creates an illusion that you can only be one thing or the other, but could not be a bit of both or somewhere in-between.

Rubbish. It’s a passé cliché. It’s a myth.

finelinemyth

There is not a fine line to cross. There is a fine line that we all slide along – first one way, then the other.

When it comes to mental health all of us travel somewhere along a fine line that connects the extremities of “very well” to “very unwell”. We all are on the same line; we are not all on the same section of the line at the same time.

finelinereality

If we are lucky we will spend most of the time somewhere along the continuum between the middle and the “very well (thanks)” point at the end. 100% “sane” (whatever that is) is not achievable. If it is achievable, it’s not achievable 100% of the time. Even the Dalai Lama would have bad days.

Nelson Mendela seemed better put together than most of us (in a healthy-mind-kind-of-way, that is). Was Nelson Mandela 100% sane 100% of the time? Nope. None of the heroes of humanity and none of us ordinary peeps are 100% sane 100% of the time. We are not statues on Easter Island. We are human. We all change. We are all affected by what we experience. We all have good days and bad days.

I have worked with people who have been really unwell psychiatrically. People who have experienced “3D” in a not-so-good way. That is, these 3 Ds:
1. Dysregulated emotions
2. Disordered thoughts
3. Disturbed perception
When this combination happens people are prone to experiencing psychosis (ie: loss of contact with reality). I have not kept count of the people I’ve worked with who have experienced psychosis – certainly hundreds, probably thousands. However, I’ve never met someone who is 100% “insane” (whatever that is) 100% of the time.

People who experience mental illness are on the same line as everyone else. On occasions they spend some time closer to the difficult “very unwell at the moment” end of the mental health continuum than they would like. They are not statues on Easter Island. They are human. They all change. They are all affected by what they experience. They all have good days and bad days.

Of course, these things are true of us all. Don’t believe me? Try substituting “they” with “we” in the paragraph above.

The “It’s a Fine Line” Myth divides us. The “It’s a Fine Line” Reality is much different, much better.

There is a fine line. It does not separate us, it connects us.

We are all sliding along the same fine line.

finelinereality

End

Thanks for reading this far. As always, your comments are welcome below.

Short URL: http://meta4RN.com/fineline

Paul McNamara, 1st October 2014

A Blog About A Blog About Suicide

I’m going to keep this short.

On the eve of the second anniversary of the meta4RN.com blog we (guest writer Stevie Jacobs and I) have finally released her powerful, gutsy post “These words have been in my head and they needed to come out (a blog post about suicide).” I thought by opening up meta4RN.com to occasional guest posts I would save myself some time and effort. Ha! Stevie’s post has had the longest, most difficult gestation of all of the posts on this blog.

Why? It’s not because of Stevie’s writing – she writes very well – It’s because of the content.

It’s because we don’t know how to talk about suicide.

mindframe I remember as a 14  year old learning about suicidal ideation via the famous Hamlet soliloquy which starts: “To be, or not to be, that is the question…” Shakespeare didn’t seem to be as afraid as getting the tone/message wrong as Stevie Jacobs and I have been.

Luckily, we don’t have to navigate this tricky territory without a map. Mindframe – Australia’s national media initiative – have some very handy tips aimed (mostly) at media. They also have info for universities, the performing arts, police and courts. It would be silly to replicate all their information here – cut out the middle-man and visit the Mindframe website:
www.mindframe-media.info

The only thing I want to make sure is included here is that we, the health professionals, remain mindful of responsible use of language in social media, including blogs (and Facebook, Twitter, Instagram etc) . Melissa Sweet of croakey (the Crikey health blog) has used the term “citizen journalist” to refer to us non-journos who are active on social media. I have shied-away from that label because I have zero knowledge/pretensions of being a journalist. However, when it comes to talking about mental health and/or suicide, I reckon that those of using social media as health professionals should take some ownership of the “citizen journalist” tag.

Health professionals are used to being informed by evidence-based guidelines, right? That’s what the Mindframe guidelines are. They are guidelines for how language should be used by journalists. Those of us who are blogging/Tweeting/Facebooking/whatever can, if we choose to be safe and ethical, abide by the same code of good practice (here).

Let’s watch our language.

Let’s edit and re-edit.

Let’s reflect and think about our impact. Let’s do that slowly.

Let’s be safe. ethical and kind.

Let’s do no harm.

Let’s follow the Mindframe guidelines when we’re blogging about mental health and/or suicide.

End.

That’s it. Thanks for visiting.

If you haven’t done so already, visit Stevie Jacob’s guest post here: meta4RN.com/guest02 My favourite part is the middle part (the meat in the sandwich?) which is honest, powerful, raw and gutsy. I hope/think that the edits made have been in keeping with the Mindframe guidelines. If  not, that is my responsibility. Please let me know and I will fix it as soon as possible.

Paul McNamara, 23rd September 2014

Short URL: meta4RN.com/mindframe

Lalochezia

Many nurses and midwives are so adept at swearing that they can make truckies blush. Sailors and sportsmen gather at their feet to learn the fine art of uttering profanities.

There is, however, a small rightious subset of health professionals who are absolutely determined to take offence every time a patent gets a bit sweary.  These people seem to have no tolerance for the use of vulgar, foul language to express and relieve stress or pain. There is emotional release to be had when uttering indecent or filthy words.

The phenomenon of emotional release through swearing even has a name: “lalochezia” – a word formed from the Greek lalia (speech) and chezo (to relieve oneself). Sources 1 + 2

lalochezia

 

Words only have the power that we ascribe to them. As a judge sitting on cases regarding obscene language charges said, the use of swear words in Australia is very common in music, poetry, drama and literature, by ordinary people in the street, and by those in the corridors of power. The notion that they cause offence is an individual’s decision to react, not because of the rarity or harshness of the words themselves. Source 3.

Anyway, if we are fair dinkum about being patient-focused then swearing can be very useful.

Swear words are great adjectives – think of them as something akin to the pain scale. Instead of using the ” 0 = no pain and 10 = worst pain imaginable” routine, some of our patients will use their own qualitative and quantitative pain scale. It might include descriptors like “no worries”, “a bit of an ache”, “painful”, “bloody painful”, “really bloody painful”, “bastard of an ache”, “as painful as fuck”, etc.

Maybe its those dopey “zero tolerance” signs (and the dopey attitudes they engender) that make some clinicians react to swear words as if they are weapons. As I have argued previously (see meta4RN.com/zero), we should have zero tolerance for zero tolerance and not spend so much time and effort trying to shut-down people from expressing their distress.

Swearing not only communicates emotions but, as per the definition of “lalochezia”, acts as a pressure valve for those emotions. In clinical practice we should not be too quick to try turn off that pressure valve – it may prevent an explosion.

Suggested Further Reading

Stone, T. E. and Hazelton, M. (2008), An overview of swearing and its impact on mental health nursing practice. International Journal of Mental Health Nursing, 17: 208–214. doi: 10.1111/j.1447-0349.2008.00532.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1447-0349.2008.00532.x/abstract

Print (PDF version): LalocheziaPrint

End

As always, comments are welcome.

Paul McNamara, 12th July 2014

Short URL: http://meta4RN.com/lalochezia

 

 

 

Football, Nursing and Clinical Supervision

When I started this blog in September 2012 I made a half-joke that watching Adelaide play in the AFL can inform clinical practice (see Number 8 meta4RN.com/about).

Well, as it turns out, this is absolutely true. Please let me explain. 

 

The Adelaide Crows, like all elite sporting teams, spend a lot of time preparing to play. For those unfamiliar with Australian Rules Football (AFL) it’s a fast, free-flowing, physical game that is played weekly during the winter months. Here’s a sample of play:

A game of AFL is played over four quarters, each lasting approximately 30 minutes (nominally each quarter is 20 minutes, but the clock stops when the ball is out of play). So, any player who stays on the ground for every moment of the game will play for two hours.

Guess how much time the player spends preparing for that two hours.

Crows warm-up at training. From left, Jarryd Lyons, Ian Callinan, Daniel Talia and Taylor Walker. Picture: Sarah Reed via Herald Sun.

Crows warm-up at training. From left, Jarryd Lyons, Ian Callinan, Daniel Talia and Taylor Walker. Picture: Sarah Reed via Herald Sun.

Think about what goes into preparation: recovery from the previous game, keeping-up and improving fitness levels, practicing individual skills, practicing team skills, discussing and developing team strategies, having coaches give feedback on what you did well and what areas could be improved, developing on-ground leadership and communication skills, nurturing confidence in yourself and your team-mates, learning about the team you’ll be playing against next week. The list goes on.

My brother, Bernie McNamara, has seen the Adelaide Crows up-close and personal over the last few years. Bern says that typically during the season a player will have about 25 contact hours each week with the club, and be expected to do about 10 hours of preparation away from the club.

So, each week, a diligent AFL player will spend  about 35 hours preparing for no more than 2 hours play.

How does that preparation:work ratio compare for clinicians?

IMG_0423

It’s not just the explicit hands-on knowledge that counts, it’s also very important that we make time for thinking-about, discussing and reflecting on our clinical roles. Clinicians, like footballers, have a desire to improve, but we may have to fight for support to do so. As noted at a recent seminar regarding clinical supervision, “in a time of austerity, high caseloads and increasing problems, the organisation is often satisfied with a ‘good enough’ (work task) rather than seeking excellence. This tends to reduce supervision to a control function rather than aspiring to best practice.” Source: Talking about supervision: conversations in Bolzano and London 

I have written about clinical supervision previously (in “Nurturing the Nurturers” meta4RN.com/nurturers), but perhaps undersold it – some have commented that it seems like a feel-good exercise for clinicians. There’s more to it than that.

Clinical supervision is a key component in providing high quality services with positive outcomes for those who use health services. Clinical supervision promotes a well trained, highly skilled and supported workforce, and adds to the development, retention and motivation of the workforce. High quality clinical supervision also contributes to meeting performance standards, meeting the expectations of consumers/carers/families and goes a long way towards developing a learning culture in a changing health care environment. Source: ClinicalSupervision

Clinical supervision guidelines are very modest compared to the preparation:work ratio of AFL footballers. Clinical supervision requires nothing like the investment of 35 hours of preparation for 2 hours of play, instead, it’s something like 1 hour of preparation for every 80 or 160 hours of work.

Are nurses, midwives and other clinicians worth the expense?

I’ve been thinking about this tweet lately:

I’m wondering whether we can tweak that sign a little – maybe something like this:

The Financial Perspective: “We can’t afford to spend money on nurses and midwives sitting around talking, thinking and reflecting.”

The Patient Safety Perspective: “We can’t afford not to.”

IMG_0449

 

As always, your feedback/comments are welcome.

Paul McNamara, 27th April 2014

Trying to Stay Focused

PatientFocused Some days it feels like a cruel conspiracy.

Those are the days when it feels like the time and space I have made to speak one-to-one to the patient* is in the middle of a sports arena. The patient and I walk into the middle of the empty playing surface and make our preparations for meaningful discussion, for emotional catharsis, for education, for counselling, for disclosure, for discovery, for therapy.

Then the grandstands of the arena start filling with people with loud voices. These people are not providing frontline care, so we would like to think of them as supporters. However, they all seem to think of themselves as coaches. They each have their own special area(s) of interest and shout well-meaning advice from their seats in the grandstand.

It gets very rowdy and distracting. SystemsFocused So many supporters coaches. So many systems**.

Systems are what makes airlines so safe – apparently that’s why hospitals have become so system-focused over the last couple of decades. I think it is a bit silly that public health systems try so hard to align themselves with profit-making airline systems. The cost of a regional hospital redevelopment ($454m) is about the same cost as two Boeing 787s (source), However, they serve very different purposes: the hospital is filled with critically ill people aiming to become less unwell or die with dignity. Commercial jets are filled with tourists and business people going on a planned journey. The hospital is a place of unknowns: discovery, diagnosis, treatment, trials and strong, unpredictable human emotions. A commercial jet is a trumped-up bus that travels at a scheduled time on a scheduled route between clearly defined destinations, carrying only people who are wealthy and healthy enough to travel long distances.

Hospitals and airlines have such very different clients, expectations, control and outcomes – can they really teach-each other much about systems?

Nevertheless, I understand the rationale for systems, and will make no effort to argue against them. Still, wouldn’t it be nice if there was one healthcare system? As it stands in my workplace, the emergency department has a system (EDIS) that does not speak to the ICU system (MetaVision), which does not speak to the general hospital system (ieMR), which does not speak to the mental health system (CIMHA). And that’s just within one hospital – imagine how fragmented it gets when we start thinking of the primary healthcare and rural/remote outpatient sectors.

I understand that some of these systems, some of these competing demands, are very important – but not all of them are. For example, it is not important that a clinician spend time away from their patients to transpose a bit of information that is in one hospital system into another hospital system –  this is a matter of dumb systems.

Which is why nurses and other clinicians know that sometimes the safest, most compassionate, and most ethical thing to do is to turn their back on the distractions created by dozens of disjointed systems, and make the priority to simply be with the patient.

Why? Because we are trying to stay focused – patient focused.

*Clarification re using the word “Patient”

In mental health over the last couple of decades nomenclature has changed from “patient” to “client” to “consumer” or “service user”. I understand the rationale for this – it is to move away from the passive (i.e.: “patient” as someone that the “expert” diagnoses and fixes) to participant (i.e.: “informed “consumer” of a service). In my current role I provide mental health assessment, support and education in a general hospital – the people I see are, in this context, first-and-foremost medical/surgical/obsetric hospital inpatients. It is these people’s physical health that had them admitted to an acute general hospital as “patients”, hence my use the word here.

**All the systems named in the “Systems Focused” cartoon are real, as is the claim that using each one is VERY IMPORTANT.

Tech Tip

I used an easy-to-use iPad app called Notes Plus to draw the cartoons. As you can see, my artistic skills have pretty-much plateaued since kindergarten, as has my spelling. Nevertheless, I think the cartoon might have been a little better and a lot easier to draw if I had used a stylus – that’s what I would recommend if you plan to do something similar.

End

As always, your thoughts/feedback is welcome in the comments section below.

Paul McNamara, 6th April 2014

Cyclone: Alert, Not Alarmed

Dear Mum and Dad (and anyone else who is interested),

outlookIn a couple of days you may see on the news that a cyclone has spun-up out in the Coral Sea. At the time of writing the cyclone is predicted but not named. The forecast map (see bottom of the page) suggests that Townsville is more likely to cop it than us.

I think it’s a good idea to put you as fully in the picture as I can. We kind of like the way cyclones get named: it seems to give them each a distinct personality. We’ve had a few cross the coast nearby since we moved to Cairns.

katrinaCyclone Katrina mucked around for a couple of weeks, but never got organised enough to cross the coast as a big blow. Katrina did not cause any deaths in Australia, but a man in Vanuatu lost his life in her rough seas, and hundreds of homes in the Solomon Islands were damaged or destroyed. We were OK in Australia.

800px-New_Orleans_ElevationsCyclone Katrina was much more benign than Hurricane Katrina. The other difference is that although Cairns is not a long way above the high tide mark, at least parts of it are not below the high tide mark as New Orleans is. That’s why so many people died because of Hurricane Katrina: it was not the wind, it was the water. That’s true of most cyclone deaths: flooding and drowning is where most danger lies.

CairnsHospital

Cairns Hospital, 165-171 Esplanade

Luckily we do not own a house on the beach front (there’s also the small matter of not having a lazy couple of million dollars lying around). Storm surges that coincide with cyclones can be a bit of a worry, but at least our place is not in a red zone like the local hospital. Feel free to check our address using storm tide surge address search/evacuation maps here or (just in case the council’s website goes offline) here.

justinThere was heaps of flooding after Cyclone Justin: I remember water lying around for days. Justin is responsible for lost lives In Papua New Guinea and a boat at sea. Closer to home an Innisfail boy was electrocuted by power lines bought down by the cyclone, and a lady was caught in a landslide near Townsville. All that rain and the buffeting wind was bad for crops and trees (some of which fell on to homes).

larryAfter Cyclone Larry we did not have power for five days. It’s amazing how often we still automatically reached for the light switch when entering a room. The reflex of a life time of luxury, I guess. Did you know that about 25% of the world’s population does not have electricity? Info about that here. Going a few days without electricity is a nuisance, but we know it will always come back on. We are better-off than many.

steveCyclone Steve made things a bit soggy for a few days too. The Barron Falls were pumping – if we get another cyclone crossing the coast be sure to checkout the webcam here for a view of the falls in full flood – spectacular! All the tourist operators trot out this cliché at this time of year: “You can’t have rainforest without rain!” It is the wet tropics, after all.

yasiCyclone Yasi looked like it was going to give Cairns a shake-up: so much so they even evacuated the hospitals – the biggest hospital evacuation in Australia’s history. Cairns was lucky that Yasi took a slight turn south before crossing the coast: Tully, Cardwell and Mission Beach really copped a belting though. Yasi was a big, powerful cyclone, but did not directly kill anyone. There was one indirect death: a young man suffocated after bringing a generator inside.

header_logoWe are used to preparing for cyclone season. Every year the Cairns City Council issues information about preparing for cyclones – it’s just part of the annual ritual. we have done it 19 times now.

We have enough food to last a few days. We have containers to store water in, if required. We have batteries for the radio, so we can stay informed about what’s going on if the power goes out. We live high above sea level. We take cyclones seriously. We are prepared.

imagesHowever, we don’t take the hyped-up TV coverage seriously. If the TV shows start shipping their main in-studio people up to Cairns for live crosses please switch of the telly. These shows need to create drama and suspense to make the story compelling, but the truth of it that it’s just weather. Weather that we’re used to. Weather that will be nuisance to many and maybe even dangerous to a few. However, the reality is that it will be more dangerous to drive to the airport to pick you up when you next visit than it is to live in a city with strict building regulations. Houses can still sustain major damage of course, but they don’t blow away anymore. Those images of houses completely blown away by Cyclone Tracy are a thing of the past: Tracy changed building codes right across the Australian tropics.

forecastPlease don’t be worried. Please don’t get seduced by the inevitable media hype. I’ll call/text when I can, and give live updates on Twitter using the @WePublicHealth handle if a cyclone comes close to Cairns this week, otherwise i will use my usual @meta4RN handle. The purpose of Tweeting will to be to provide a non-alarmist account of what’s going-on. The mainstream media are not very good at this, so (to borrow a term from Melissa Sweet ) it is up to citizen journalists to do so.

Well, citizen journalists and the Bureau of Meteorology, that is: www.bom.gov.au

Speak soon.

love, Paul

27th January 2014

Nursing’s Peculiar Privilege

Dear Reader: please don’t read this blog post if you are offended by strong swear words or find talk of suicide a trigger for unsettling/risky thoughts. Kind Regards, Paul.

Who is Going Behind the Curtains?

Working over Christmas and New Year made me especially cognisant of one of the peculiar privileges that we nurses have: we spend a lot of one-to-one time with the person who is medically/surgically recovering after a suicide attempt. My current role is Consultation Liaison Mental Health Nurse – a role that provides mental health assessment, support and education in a general hospital (more info about the role here). When the person is admitted to the general hospital after a non-fatal suicide attempt we are asked to be involved in planning and providing their care.

There are few things more privileged and more important than spending time with the person who is alive after deciding not to be. I do worry that this role is sometimes delegated to the least qualified (and lowest paid) member of frontline clinical care: the Assistant In Nursing (AIN) when there is “nursing special” in place (i.e.: when there are concerns that the person may abscond and/or harm themselves again).

Naturally, being an AIN does not mean you are incapable of sensitive, compassionate, safe care. I just think that “going behind the curtains” to assist in holding and containing the often very strong emotions of the person who has survived suicide is incredibly important. I don’t feel comfortable that someone without mental health qualifications or clinical supervision is tasked with sitting at the bedside for hours at a time. It may not be good for the either the person/patient or the AIN.

Suicide rates per year. Chart courtesy of www.mindframe-media.info

Suicide rates per year. Chart courtesy of http://www.mindframe-media.info

Parallel Processes

In clinical supervision we often explore the parallel processes and how they apply to our clinical work. When working in perinatal mental health I aimed for the therapeutic relationship to be a template for the parent-child relationship: kind and nurturing, responsive and interactive, empowering, educative and enjoyable. The idea being that, at some level, the qualities/values that inform the therapeutic relationship can then have a knock-on effect for the relationship the parent has with their baby. Not many perinatal mental health clinicians have an abrupt, cold, clinical style of interacting with their clients: they tend to be warm, gentle communicators.

When nursing the person who has survived suicide we need to think about parallel processes again. Julie Sharrock (a rock star of consultation liaison nursing) first introduced me to the phrase “holding and containing” as a part of the therapeutic relationship. Traditionally the notion of holding and containing has been attributed as a function of the inpatient setting/building: a place to keep people safe. Julie introduced it to me as a way to keep people safe, by reframing it as a concept for interpersonal therapy. That is, we nurses can assist and model the act of holding and containing difficult emotions.

For the person who has unexpectedly found themselves alive and in hospital after intending to end life, we may need to hold and contain the person physically for a short time, but (to my way of thinking) it is even more important to support the person to hold and contain their thoughts and feelings.

Thoughts are slippery, and prone to be dropped.

Feelings are brittle, and prone to cracking.

Holding and containing such difficult-to-secure, fragile things is fraught: the clinician needs their thoughts and emotions held and contained too. Its a parallel process: as I’ve discussed previously we need to nurture the nurturers.

Suicide rates per age group (2010). Chart courtesy of www.mindframe-media.info

Suicide rates per age group (2010). Chart courtesy of http://www.mindframe-media.info

Profound Moments

Some of the most profound moments of my working life have occurred while supporting the person who has survived suicide.

The incredibly dark humour: “I’m such a fucking loser I can’t even kill myself properly!” said the very nice man. He was not laughing out loud, but smiling at the grim absurdity of his situation. He was alive, but physically worse-off than when he decided to die: now fractured, urinating through a tube, receiving fluids and antibiotics via an IV line. More wounds. More pain. Yet, despite the extra physical insults, he was pleased that he had survived.

The worry: “Is my brain OK? I feel really agitated and confused.” asked the lady who had been in intensive care for a few days. Her brain was OK in the long-term, the distress she was experiencing was mostly short-term stuff:  delirium is really common amongst ICU patients. Hypoxic patients aren’t so lucky: they sometimes never recover the former function of their brain.

“You are the biggest fucking cunt that has ever existed in the whole world!”, said the man after being told he was unable to leave hospital. I was filling-in paperwork that would mean he was an involuntary patient as per the Mental Health Act. I didn’t think I was being particularly nasty. The mental health act is handy because there are times when I need to say, “It seems to me that you don’t have the capacity to keep yourself safe at the moment. So,  I’ll take some of the responsibility of keeping you safe for now. Naturally, we will hand the job back to you when you come good.” Using that framework, filling-in the paperwork for the mental health act is sometimes the most nurturing thing I can do. That’s why i was genuinely surprised, not offended, when he said, “You are the biggest fucking cunt that has ever existed in the whole world!” I asked, “Really? Worse than Hitler?” He laughed and said, “Yeah, Definitely.” I laughed too. Take that Hitler.

The person who had two high perceived lethality, but fortunately non-fatal, attempts to take his life in the fortnight before we met reworded Shakespeare’s famous opening line to Hamlet. Instead of saying, “To be, or not to be, that is the question”, he said, “After what I have experienced in hospital, I now think that it is better to have a difficult life rather than no life at all.” I was so pleased to hear him think that way, and at the same time felt so sad for those people who do not have the opportunity to reconsider: those people that bypass the hospital wards and go straight to the morgue.

These are profound moments in the lives of people.

Nurses, myself included, have the peculiar privilege of being with the people who are experiencing the most important days of their life: the first few days of life that they planned not to have.

Let’s not take that peculiar privilege of nursing lightly.

In Closing

Talking and thinking about suicide can be distressing. Australians can access support via:

 Lifeline – 13 11 14

Suicide Call Back Service – 1300 659 467

MindHealthConnect www.mindhealthconnect.org.au

phone_hotline-40Outside of Australia and not sure where to get support? Google usually displays a red telephone icon and your country’s suicide support phone number when searching for a suicide-related topic.

As always, comments and feedback on the blog post is welcome. Suicide can be a sensitive topic to comment on, and this blog is the public arena; so, before wording your comment, please check-out this: Mindframe guide

Paul McNamara, 19th January 2014