The harrowing hospital night shift nothing could have prepared me for

The most important part of every night shift is matching your scrub top to your bottoms. Odd shades, bad luck. Match for the best chance of success.

I’m full of superstition because fate doesn’t follow conventional rules. I sit, cross-legged comparing until I’m satisfied with my choice. I pull my clothes off and my blue scrubs on. Stethoscope, badge and water bottle. Downstairs, grab phone and rush to handover, hoping I’ve remembered my pen.

Back of house, but this is no theatre production. A list of jobs to mop up from the day. Twelve wards, the nurse practitioner and me, “Let’s hope they all behave tonight”.

First up, fluids. Ward 50 needs a cannula, or two, or three – while I’m there. A couple of bags of normal saline go up and it’s time for me to go down to ward 20 where a lovely woman has slipped off the commode. She’s ever so embarrassed. A check from head to toe, some reassuring words and an offer of a gingernut. Then back to the desk to scribble down the story.

The phone rings, again and again, sore foot, chest pain – blood pressures through the floor and in the clouds. A woman sobers up and wants to leave – listening, persuading, assessing and eventually letting her sign the papers to walk out the door, no doubt next week we’ll meet again for the same dance.

A warm hand on my shoulder and cup of tea beside my hand. “Do you want some cake doc?” – I want nothing more. The 3am slump is here and sugar is my drug of choice. I sit, and chat – and melt into the ward for a few minutes.

An unfamiliar sound from round my neck – I answer, crash call. I drop everything and run. Down two flights of stairs, along the corridor. Turn right. I see a set of anaesthetic greens in front of me. “Bay four, bed six” a voice shouts, we pile in.

A man lies on the floor, breathing hard. Oxygen on. Pulse felt. No response to voice, grumbling to pain. Eyes deviating to the left. I grab the notes and start piecing together the history. Mild upper body weakness, query stroke, a head scan showed nothing much. Back to airway, gurgling noises from his throat. A tube down the nose to help get air into the lungs. We take an arm each, one for arterial blood and one for venous. My hands don’t shake.

Stabilised, we need imaging and fast. I ring the radiologist, ready to plead my case. “Send him down” she says. The ease of the phonecall doesn’t fill me with hope. My senior house officer grabs the emergency drugs from the crash trolley and a fresh faced nurse clutches the oxygen ready to transport. They follow him down. The ward becomes quiet.

I flick through a thin set of notes to try and build a picture. Lives with a loving wife. Walks his dog every day. Gave up smoking years ago – drinks a couple of pints on a Friday. Not too bad for a man in his 70s. Children and grandchildren.

A bed slides through the doors and he returns, the report is back. Large bleed. Blood pushing the brain against the skull. Neurosurgical opinion advised. My registrar arrives, talking fast to someone. I hear “grave”, I hear “imminent”. The bleed is too big and his brain is crushed. There is nothing we can do. Keep him conscious, keep him comfortable, next of kin.

The newly qualified nurse goes white. The notes are in my hand. “I’ll call,” the words leave my mouth before my lips move. A 4am phonecall to a telephone number. A quiet voice answers. She only left at 11pm, the nurses say. “I’m calling from the ward, about your husband, things have changed and I think you need to be here”. She’ll be here as soon as she can. Panic seeps through the phone and into my hand. “Will I make it?” her voice cracks. “Will I see him before he dies?”.

“Call me as soon as she arrives” my registrar says. I nod. She leaves. I stay, breathe in, walk around the corner, shut myself in the clean utility and put two hands up to my wet face. These aren’t my tears to cry but they still come. I push them all back in. Professional.

Years of training do not prepare you for this. Nothing prepares you for your role in someone else’s tragedy. I will leave the hospital in four hours and his wife will still be clinging to his hand. I will come back in 16 hours and they will both be gone. A new name earmarked for his bed. Another story that might end a different way.

The phone rings, and someone needs something. A temperature, a catheter and some laxatives. I glance down at my trousers. They were a perfect match.

Some details have been changed to protect patient confidentiality.

If you would like to contribute to our Blood, sweat and tears series about memorable moments in a healthcare career, read our guidelines and get in touch by emailing sarah.johnson@theguardian.com.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

The harrowing hospital night shift nothing could have prepared me for

How Prepared Are You for an Economic Collapse?

How Prepared Are You for an Economic Collapse?

These days almost everyone is talking or is aware of our national debt, ongoing militarization and near brink of an economic crisis.  In fact, throughout history, especially in the 19^th and 20^th centuries, economic crises occurred several times in our own country.  From the greenbacks introduced after the civil war to the great depression even to the gold standard act in which citizens could be criminalized and jailed if they did not turn in their gold.  During an economic crisis the majority of the average citizens’ property value and even business worth are taken against their will by their own government in eventual return for an inflated ‘newer’ currency.  Of course, the citizenry has to suffer first in each economic crisis before submitting to the new form of controlled currency at an inflated rate.  This leads to the question.  How prepared are you for an economic collapse?

 

Trade and Bartering

A crisis will begin and currency will be no more.  Instead, especially as witnessed in Venezuela, trade and bartering will become the new way of life.  This means what skills you can offer or provide will become your new way of earning an income or at least just food for you and your family.  Learning as many trades as possible will give you the chance to offer other people your skill set if currency and rule of law are no more.

Trade and bartering date back to before currency became a controllable commodity itself.  For example, in the ancient days of Greece the people met every day in the Agora to talk news, trade supplies and even make deals, arrangements and pacts.  Everyone traded with everyone, what you offered eventually became of value to the right person in every town.  Often times many people offered several different trades or specialties helping to advance scientific theories, technology and methodologies of their time.

This form of trade died out once currency became the main commodity to gain access to which you seek.  Small businesses and trade squares were squashed to make room for supermarkets and supermalls owned by few very powerful corporate identities.  Fortunately though several communities have picked up a form of “agorism” both knowingly and unknowingly and have begun trading their specialties amongst themselves in place of the current currency sinking in value.  From food to massage therapy many individuals have even picked up farming in order to increase their own knowledge and trade value.

Homesteading

Just to avoid the fact that rule of law is no more families will take up homesteading.  If they’re not growing crops than they will be raising livestock.  Many of these families that conquer homesteading will become small communities that will be able to sustain themselves in any crisis that comes along.  It is possible learn the trades of homesteading even if it is just harvesting meat to be able to offer a specialty amongst a community that must take these tasks on.

Many people avoid the fact that in case of an economic crisis they will have to hunt their own food to survive.  It’s these people that are prepared for this fact of life that are the most prepared for an economic collapse.

 

Bug Out Bags

Even a basic bug out bag properly stored is a step up as opposed to scrambling for all of your important supplies while looting and rioting is happening in your neighborhood.  Will you really remember your photo albums, birth certificates and passports during a crisis like that as well?  The key is to prepare as much as you can even if it is just the very upmost essential supplies in a basic bug out bag for the entire family stored and ready to go.  Expanding beyond that would be wise as well preparing a bug out bag for each individual and keeping them close to hand.  Copies of all of your important documents kept safe and prepared will also help you in a recovering situation as well.

 

Survival Kits

Survival kits range from SHTF toiletry kits to basic IFAKs (Individual First Aid Kits).  Depending on what you foresee for you and your family will determine what survival kits you are keeping on hand.  For those who see themselves defending their family and communities IFAKs are purchased or prepared so they may have the proper medical supplies on hand in case of injury.  Toiletry kits are prepared so that the entire family can maintain basic hygiene in order to maintain preventative medicine.

These survival kits can be kept anywhere from the home to the car such as the survival kit in a pill bottle which provides basic supplies in case your vehicle breaks down in the wilderness.  There are a range of survival kits that should be thoroughly researched as they are an advantage of foresight that most people already are not taking advantage of.

 

Weapons Handling

How prepared are you for an economic collapse?  Honestly ask yourself. Gangs, thugs and small bands of militia will rise up and take to the streets once rule of law is no more.  Essentially everyone will be out to establish their own rule of law.  Will you be one of those people?  Weapons handling is essential to modern day survival whether for basic hunting or defending against intruders and those who would do you harm.

Starting with your basic hunting weapons begin to master the elements of hunting in your region.  Research what common prey are around, how far and what rifles will take your game down with as much ease as possible.  Meanwhile research what weapons are suitable for your home and residential area.  Having a rifle for self defense that allows you maneuverability in an urban environment is your American right to preparing yourself against both domestic and foreign enemies.  Understand what rifle will allow you this than take the time to research your training.

How Prepared Are You for an Economic Collapse?

The Guardian view on scientific discovery: be prepared | Editorial

The discovery that there are bacteria in mucous in the human nose that secrete an antibiotic that kills other, more dangerous, forms of Staphylococcus before they can kill us, illustrates some important truths of science. The first is that properly trained minds can make the study of almost anything, however unlikely, rewarding. Microbiota turn out to be a playground for the enquiring mind. If the new substance is proved to work in humans as it does in mice, it may save thousands of lives a year from MRSA infections. The second is that, from the discovery of antibiotics to the methods of gene sequencing and now gene editing, modern medicine often depends on co-opting to our purposes tricks that nature has already found. The human ingenuity consists in recognising the prior ingenuity of evolution. Science has often appeared to depend on chance, although what looks like chance may be more to do with the scientific mind. The attention to detail that makes the unexpected plain to see, and, once it’s identified, the capacity to ask questions about it, are often the essence of discovery.

The Guardian view on scientific discovery: be prepared | Editorial

Are We Prepared For Synthetic Heroin?

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Many of the synthetic drugs streaming like toxic rivers through American cities have their origins in labs that weren&rsquot making an attempt to develop addictive street medicines. But as soon as a potent psychoactive compound&nbspemerges from a lab–meant&nbsppurpose notwithstanding–its physical appearance on the street is only a matter of time. Being aware of that, it&rsquos concerning that [...]

Are We Prepared For Synthetic Heroin?

Sneakernomics: The Internet Modified The Sneaker Business Permanently Get Prepared For A lot more!

The internet has had a huge role in shaping today’s sneaker business.  The game has changed forever.  And we can expect even more changes in the next next few years.  This blog will explore the history of sneaker sales on the internet and then opine on what’s coming next.

History

Only recently have the sneaker retailers become serious about eCommerce. A decade ago, many sneaker retailers opted to outsource their eCommerce business. At the time this was an expeditious decision to grab easy profits with no expenditure, but it set the industry back a decade.  Retailers lost years of sales data on some of their best customers.  Sneaker stores gave up the ability to communicate and develop relationships with their fans on the web.

With outsourced ecommerce, the prices weren’t the same; the assortments were different; Products bought online could not be returned to physical stores.  But worst of all, the retailers had no idea who was shopping on their site, where they lived and what they bought. Plus there was no way for them to communicate with these customers. It set the industry back a decade.

Online only retailers flourish

This huge strategic misstep allowed internet-only sneaker retailers to flourish.  Out of nowhere, Zappos became the largest sneaker retailer on the web and they did it without the #1 brand, Nike.  The online portion of Eastbay, Footlocker’s direct mail/online business, grew like crazy but the nameplate sites struggled.  Other pure play online sneaker retailers took significant share. Sneaker brand sites had an open playing field.

Physical stores get in the game

In the last few years, physical store retailers realized that they had given tremendous market share to their brand partners and to the pure play competitors.  Some of the physical retailers realized the missed opportunity and began to try to claw back lost share. The key brick-and-mortar players in the sneaker business have all had terrific growth in the lost three years.  As an example, Dick’s posted a gain of nearly 70% in 2013 for their ecommerce business.

Internet sales drive comps

Over the last few years, sales growth on the internet has vastly outpaced the sales growth in physical stores.  According to my analysis of the data from SportsOneSource.com, Sales of sneakers in physical stores grew in the low singles in 2011, but were up by more than half in on the internet. In 2012, sneakers sold through brick and mortar doors again grew in the low singles while sales on the web increased by a third. In 2013, sneaker sales in physical stores grew in the low singles while eCommerce grew about 20%.

One interesting side note is that 2013 sales on the web could have been higher but for the massive growth in marquee basketball. Mall retailers count on release shoes to prop up the smaller C&D level stores. Therefore, retailers limit how many pairs of limited releases are available on the web, in an effort to sustain the marginal stores.

In 2013 sales on the internet at Footlocker Inc. grew about 20% while comps grew in the mid singles. Sales on the internet were 11% of all Footlocker sales. Ecommerce sales at Dick’s grew about two thirds last year, while comps were only up in the low singles. 2013 Sales from the web at DSW DSW improved about 20% in 2013, with comps flat. ECommerce was 10% of DSW results. Finally last year at the Finish Line, Internet sales grew almost 25%, with comps up mid singles. Web sales were 12.5% of Finish Line sales.

Growth of sneaker sales on the internet will continue

Based on my research, sneaker sales on the web were 16% of total sneaker sale last year and grew about 20%. In fact, in in 2012 and 2012 sales of all sport footwear on the internet grew about 20% each year. If we assume 20% growth for internet sales and low singles growth in physical stores, in 5 years, sales of sneaker on the web will approach a third of all sneakers sold.

What’s Next?

• With so much of the growth in sport footwear coming from the web, retailers who do not have a fully developed ecommerce strategy will lag in comps behind the industry leaders.


• Marginal stores will become more marginal. The growth in internet sales has to be coming at the expense of the smaller C&D level stores in retail chains.  In these smaller stores, the assortments are the weakest and most basic.  Inventories are lean. Consumers, unable to find what they want, will head to the web, further marginalizing these stores


• On the web, the brands win over the retailers.  Brand sites over a greater content, larger assortments and more exclusive products.  These factors will drive more customers to brand sites over retail sites. Nike just announced that they had 100 million views in 7 days of their World Cup “Winner Stays” commercial.  There is no way physical retailers can compete with that kind of consumer experience.


• We’ll see more limited releases move to the internet. Limited releases have always been problematic for sneaker retailers.  Systems have to be put into place, extra personnel hired and there is always the risk of bad behavior.  As brands and retailers figure out how to handle the web traffic, we’ll see more shoes released via the web.


• Post millennials and millennials are eschewing the malls. They don’t need to congregate at the food court any longer; they can do that on their phone.  With immediate and robust access to every brand and virtually every store right in their pocket, there is no need to go to the mall any longer.


• Using feedback from social media, brands and retailers can use that feedback loop to better tailor their assortments to what kids want to buy and when.  This predictive ability will make decision making more correct and timely.

The internet has had a profound impact on the sneaker business.  We are in a much different place than we were a decade ago.  I dare say we are not prepared for the changes that will happen in the next 5 years.

Sneakernomics: The Internet Modified The Sneaker Business Permanently Get Prepared For A lot more!

Angela Merkel prepared to offer you Britain constrained EU opt-outs

Angela Merkel is believed to be willing to grant ‘limited opt-outs’ to David Cameron’s government. Photograph: Sean Gallup/Getty Images

Angela Merkel is prepared to grant David Cameron special assurances in a revised EU treaty to ensure that the interests of Britain and other non-euro members are protected in the European single market.

In a sign of the lengths the German chancellor is prepared to go to to ensure Britain remains in the EU, authoritative sources in Berlin say Merkel is also prepared to grant “limited opt-outs” to Britain and to ensure that EU regulations are enforced in a more flexible way.

One senior figure in Berlin has raised the prospect of giving the NHS an opt-out from the working time directive – a contentious measure criticised by Eurosceptics – which gives workers a series of rights.

The thinking among senior figures in Berlin has emerged on the eve of a visit to Britain by Merkel on Thursday in which the German chancellor will meet the Queen, address a joint session of parliament and hold separate meetings with the leaders of the three main political parties.

Downing Street believes Merkel will be the pivotal EU figure if Cameron wins the 2015 general election and embarks on a renegotiation of Britain’s EU membership terms before a referendum by the end of 2017.

The Foreign Office is advising Downing Street not to lose sight of the fact that Britain will need the agreement of all other 27 EU leaders if it is to achieve a favourable revision of the Lisbon treaty. One source said: “There is perhaps too much optimism emanating from No 10. We have to be a very hard-headed about this and bear in mind that the bedrock of the EU is the Franco-German relationship. There is only so far the Germans will go. We should be making a much bigger effort with the French.”

Senior figures in Berlin have outlined a series of concessions they would be prepared to grant Britain to help the prime minister win a referendum campaign. They say Merkel believes new governance arrangements for the eurozone will have to be introduced in “targeted” treaty change. This would go beyond a straightforward “simplified revision procedure” but would fall short of a full “inter-governmental conference” change that would take at least five years.

The prime minister regards treaty change as vital because it would hand Britain, which would have a veto, a chance to table its demands.

One senior Berlin official said: “Cameron’s assumption that there will be treaty change is almost certainly correct. I am confident that a number of legal routes exist to get through changes in treaties, depending on political constellations. We are not speaking about rewriting the treaties but making targeted changes or submitting an addendum. It might extend beyond a limited treaty revision under the simplified revision procedure (on the model of the treaty facilitating the establishment of the European Stability Mechanism); but Germany does not want a general treaty revision.”

The thinking in Berlin is outlined in a paper drawn up by the City of London Corporation and the Policy Network thinktank. Officials told the authors of the paper that Berlin is prepared to countenance offering:

• Assurances that Britain and the nine other EU members outside the euro will not be outvoted when rules are drawn up for the single market, which covers all 28 members. Cameron has voiced fears that the non-euro members could fall victim to “caucusing” by the 18 members of the euro because the rules of the single market are decided by “qualified majority voting” in which no member state has a veto. One senior official is quoted as saying: “Germany is sympathetic to British demand for assurances of non-discrimination in single market given eurozone integration. However this cannot extend to a reversion to unanimity over financial services regulation. […] In negotiations on a new treaty, I could see the inclusion of a new clause to protect the UK against discrimination as a euro out.”

• Limited opt-outs for Britain, though these would fall short of repatriation of powers. One idea is the NHS exemption from the EU’s working time directive. British workers can opt out of the 48-hour working week but other requirements in the directive, such as holidays and rest breaks, are mandatory.

• The implementation of EU regulations in a less intrusive and prescriptive way. This would apply across the EU and would be designed to meet British concerns that EU regulations fail to take account of the concerns of businesses.

A senior Berlin government adviser is quoted in the paper as saying: “There is too much lifestyle regulation coming out of Brussels. It is important that the EU looks at its core business in times of crisis and does whatever it can to promote economic development. Germany might be prepared to countenance the abrogation of some secondary legislation.”

One senior Whitehall figure said that Merkel was keen to help Cameron but there were lines she would not cross. The source said: “Angela Merkel wants Britain to stay in the EU and wants to do what she is able to do to help with that. But she is not simply going to throw over key German interests and that includes the stability of the euro.

“Merkel and Cameron have a shared vision about the existential economic challenge facing Europe as a whole – the need for competitiveness, to see the emerging economies as an opportunity as well as a challenge. She regards Cameron as one of the few European leaders who gets that. It is true she wants us in because of where the balance of the economic argument lies and also because a British exit would damage the EU in the eyes of the world beyond.”

But Sir Menzies Campbell, the former leader of the Liberal Democrats, said the Tories were wrong to think Merkel would be able to grant major concessions. Campbell said: “Anyone who believes that Merkel, who is after all the leader of a coalition, is going to come to London with the kind of agenda that would satisfy the most rabid anti-Europeans in the Conservative party has got another think coming. Germany and France have been the engine room of the EU, often resentful of the fact that Britain appeared from time to time to be disconnected. Why should Merkel offer some kind of unique relationship for the UK under a Tory party which embarrassed her by leaving the European People’s party [in the European parliament] as soon as the 2010 election was over?”

David Cameron and Angela Merkel have forged such a strong bond in recent years that aides like to debate the exact moment when they clicked.

There was the time when they went for a walk minus aides, accompanied just by their security detail, up Coombe Hill near the prime minister’s country residence in Chequers in the Chilterns in the autumn of 2010.

Then there was the box set of Midsomer Murders DVDs Cameron handed to the German chancellor at the end of the Chequers weekend after they had spent hours watching Merkel’s favourite detective drama.

Others say it is important not to forget the prime minister’s visit, accompanied by his wife and children, to the German equivalent of Chequers at Schloss Meseberg in April last year. Merkel is said to have been particularly attentive to the Cameron children.

The strength of their bond shows that the two leaders have come a long way since Cameron announced during the Tory leadership contest in 2005 that he would take his party out of the main centre right grouping in the European parliament.

Even before his appointment as prime minister in 2010 Cameron worked hard to rebuild relations with Merkel who now regards him as a “naughty nephew”, one No 10 source told the Mail on Sunday.

Cameron calculated that he would be unable to achieve much in Europe without the support of the leader of the EU’s largest country and economy. Merkel was encouraged by Cameron’s relatively constructive approach towards the EU after he became prime minister.

But their relations suffered a blow at the end of 2011 when Cameron vetoed a fiscal compact for the eurozone, forcing the eurozone members to agree a separate treaty outside the architecture of the EU. The fallout from that row, which prompted fears in the German chancellery that Britain could leave the EU, ended up strengthening their relationship. Merkel advised Cameron in the run up to his major speech on Britain and the EU in January last year to argue in favour of reform across the EU. She said that would be the best way of building a consensus across the EU.

The German chancellor is determined to see Britain remain in the EU. But the Foreign Office has warned Cameron to bear in mind that any German chancellor will also put Berlin’s relationship with France first. Nicholas Watt

Angela Merkel prepared to offer you Britain constrained EU opt-outs

Marathon Coaching: Are You Prepared to Go the Distance

Prior to you run a marathon, you need to follow a coaching routine to equip your physique. You want to make certain that you have the bodily strength and stamina for obtaining this outstanding accomplishment. Preparing yourself both physically and emotionally beforehand is critical to completing a marathon effectively.

Marathon Training

Regular alterations in fitness instruction: To commence with, you want to make a decision on a training regimen that fits your body variety. When you introduce minor alterations steadily, your physique adapts far better. You require to begin from scratch instead of aiming to commence from the spot in which you need to be. As a result, the initial education need to coincide with your present fitness plans, perhaps with a tiny a lot more endurance instruction. It is a gross blunder to opt for a plan which introduces a dramatic modify in intensity you can finish up injuring by yourself and you could be forced to drop out of the race last but not least. Your physique will start responding favorably when you progress slowly. Taking one particular stage at a time is the crucial to succeeding in a marathon.

Check with your physician: Before determining on working a marathon, you must ideally check with your medical professional. This is due to the fact the marathon coaching schedules are very demanding, grueling and hectic. Unless you are physically fit and lively, you could encounter injuries that could turn out to be fatal.

Appropriate diet program: To run a marathon, proper nutrition is important. A carbohydrate wealthy diet plan is advisable due to the fact it will contribute glycogen. Proteins will help to fix muscle tissues. The two girls and men will need to get in as many as 2000-2500 calories in a day. The key portion of the energy is derived from carbs although some sum is also obtained from proteins and unsaturated fats. Your diet plan must also contain vitamin and mineral sources you can also consume vitamin dietary supplements.

Finally, a great deal of calcium and iron is advisable for marathon runners. Merely due to the fact you want to strengthen your body for running a marathon does not mean that you are totally free to consume anything. You need to stay away from processed sugars and grains unless of course you eat them throughout your routines or instantly afterwards. These may possibly result in undesirable spikes in blood glucose amounts that results in physique fat. Participants of Marathon can use the providers of meal delivery applications to chalk out a healthful diet prepare. Meal delivery companies like Nutrisystem have an professional team of nutritionists and counselors working with them. When you approach them with particular wants, they can provide a complementing diet program for your athletic occasion. They may propose adding further protein to your diet to supply endurance.

Stretch exercises: To equip your body for a marathon, you need to stretch on a every day basis. This assists to make your hamstrings and back muscles sturdy.

Sleep: Because you have to have a strong entire body for running a marathon, you require to consume well, drink lots of water and get satisfactory rest. Rest is required for reenergizing your body. A marathon runner need to ideally rest for eight hours each evening. Considering that the exhausting physical instruction sessions can wear you out, this rest is critical for recovery.

Occasionally a great recovery drink can operate wonders for your marathon coaching. When you can recover nicely from any exercise session, you can complete even better in the subsequent a single. This drink does not have to be a protein drink only it ought to ideally contain higher glycemic carbs like dextrose. The most effective drink for recovery should have a four:1 ratio of carbs and proteins. It is essential to don’t forget that there is no magic potion to prepare your physique for a marathon. Even with the most efficient education prepare, you might fail. So, it is crucial to stick to your program and carry out the modifications recommended in a slow manner.

Jessica Robert avidly blogs about bodyweight loss suggestions and diet plan ideas. Her site The Diet program Circle displays informative articles or blog posts on difficulties cost-free dieting techniques and fat reduction suggestions.

Resource: Racing Fat: How to Get Lean for Peak Overall performance

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Marathon Coaching: Are You Prepared to Go the Distance