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Take a look at the amazing results our customers have had using Green Coffee Bean Revolution along with a sensible diet and exercise routine.
Very simply put, Green Coffee Beans are Coffee Beans that are fresh and have not been roasted; the coffee we brew has been roasted and this is why it is brown, rather than green. Coffee Beans naturally contain a compound called Chlorogenic Acid, which is the active weight loss compound in Pure Green Coffee Beans. Roasting Coffee Beans destroys the Cholorgenic Acid.
Green Lean Coffee Bean Harnesses The Weight-Loss Effects Of The Purest Extract From Green Coffee Beans.
When roasted at 475 degrees, coffee beans are sometimes described as rich and full-bodied. But for the full-bodied person who is not so rich, unroasted coffee beans - green as the day they were picked - may hold the key to cheap and effective weight loss, new research suggests.
A study has been presented where, 16 overweight young adults took, by turns, a low dose of green coffee bean extract, a high dose of the same green coffee supplement, and a placebo. Though the study was small, the results were striking: Subjects taking the full dose of the green coffee extract lost an average of 17.5 pounds in 22 weeks and reduced their overall body weight by 10.5%!
Green Coffee Beans have been shown to inhibit fat absorption and also stimulate the activation of fat metabolism in the liver, both major supporters of weight reduction. The Chlorogenic acid found in Green Coffee Beans is a natural phytochemical that is found in a wide array of plants, with very high concentrations in Green Coffee Beans. It has been found to inhibit the release of glucose into the blood, particularly after meals, and appears to help people lose weight as a result. Chlorogenic acid may also be able to induce body fat loss by increasing body heat produced, thus promoting thermogenesis, the natural burning of fat for energy. It is also believed to reduce the generation of new fat cells due to its superior anti-oxidant effects.
Complementing your diet with Green Coffee Bean provides exciting results for people that want to lose weight. Dedicated, healthy consumers of Green Coffee Bean were surprised to see that within 12 weeks, the results are remarkable. Some have reported that after their 12-week effort, there was a 10% loss in body weight and a 16% loss in overall body fat.
Normally, I don't recommend "weight-loss" supplements, especially weight-loss supplements that claim "easy" weight loss or "fast" weight loss. As a nutritionist, I strongly believe that the key to weight loss is a healthy diet and exercise, but there are some incredible superfoods that can deliver an added boost. One superfood in particular, the green coffee bean, is creating a major buzz, and the research has me truly amazed.
Take one capsule in the morning, right as your metabolism gets ready for the day. With a healthy breakfast, an active metabolism, your body will have an easier time slicing up fat and burning it off.
Take your second capsule with your evening meal two hours before you go to sleep. Your body will begin to break down its supply of carbohydrates. As you sleep, your body will be burning away unwanted fat tissue!


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If you need Bakery or Cakes or even Bakeries in WI, look no further. www.hotfrog.com showcases more than 502 Bakery businesses across WI. To find more related businesses and to filter by locality, use the left navigation menu.
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Madison, WI
Lanes Bakery & Gifts : - Baked Goods Breads Sheet Cakes Roll Kringle Whipped Cream Cakes Other Cakes Round 2 layer cake Cupcakes Lanes, Lanes Bakery, Lanes Bakery and Gifts, Park Street, Madison, WI
Neighborhood BakeryPhoto CakesSheet CakesCakes
Pulaski, WI
Smurawa's Country Bakery is a family owned bakery located in the heart of Pulaski Wi. We strive to provide to you the highest quality bakery, coffee and customer service. Come in and enjoy one of our famous Paczki in ou…
Family Owned BakeryCOUNTRY BAKERYFamily BakeryRetail Bakeries
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Thiensville, WI
Mila's European Bakery has been serving greater Milwaukee area since 1981. 'Best Bakery 2007' award. Famous for their wedding cakes, birthday cakes, large pastries, rye bread and more
Mini PastriesScratch BakeryHamburger BunsEuropean Bakery
Oostburg, WI
Oostburg bakery has been serving Oostburg and surrounding areas with delicious products for over 80 years Everybody knows Oostburg Bakery for its hard rolls and creme filled coffee cakes Our bakery was st…
SnackCakesBakersRetail Bakeries
Appleton, WI
We invite you to step through our doors and savor the aroma of a real home town family bakery Voted the best Bakery in the Fox Valley 12 years in a row, we hope that once you taste the exceptional quality of o…
BreadCakesFamily BakeryBaked Goods
Menasha, WI
Cakes, Bakery:Bakery CakesCommercial BakeriesBread
Welcome to Quaker Bakery, Wisconsin's leading manufacturer and marketer of homestyle fully-baked, frozen breads, buns, and rolls servicing leading foodservice distributors and restaurants in Wisconsin, Minnesota, Iowa, …
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Oakhouse Bakery was established in 1981 as a cookie company using old family recipes Our Mission is to produce quality bakery products cost effectively in an environment that is safe, clean and friendly for ou…
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Whitefish Bay, WI
Regina's Bay Bakery has been designing and producing wedding cakes, custom designed cakes, French pastries and bakery in Whitefish Bay on Silver Spring Drive since 1932
SnackFrench PastriesBaked GoodsWedding Cakes
Franklin, WI
Baptista's Bakery was born out of the sale of Gardetto's Bakery to General Mills in August of 1999 We specialize in healthy baked snacks The competitive niche which we chose to fill revolves around produc…
CakesBaked SnacksMultigrainSnacks
Oak Creek , WI
Body Bakery is calorie free guilty pleasures for Body and Bath. I have a created a special Bakery, Confectionary, and useful natural products for everyone. Good Clean Fun with just a hint of Naughty! A great gift for ma…
Bakery ProductsCakes
Barron, WI
Barron Bakery is Northwestern Wisconsin's premier bakery. We make the finest baked goods using only the best ingredients available. Delicious and irresistable breads, buns, donuts, cookies, and seasonal specialties are …
CakesBaked GoodsSeasonal Specialties
Brookfield, WI
Visit National Bakery & Deli at our Milwaukee, Brookfield, and Greendale locations for a delightful dine in or carry out bakery & deli experience We offer only the finest in fresh baked goods and deli items …
Sweet RollsBakery & DeliPhoto CakesSheet Cakes
Milwaukee, WI
If you are looking for a bakery in Milwaukee, or looking to treat yourself to the best baked goods in town, our bakery is the place to visit
Baked Goods
Neenah, WI
Welcome to Simple Simon Bakery These immortal words were spoken by Sylvester Simon, founder of Simple Simon bakery, in Appleton, Wisconsin
Commercial BakeriesCakesWedding CakesBread Cake & Related Products
Racine, WI
Kringle from Racine Wisconsin and Lehmann's Bakery, Order online for individual, fundraisers, retail, wholesale and distributors wanted
Manitowoc, WI
Bakery On State - your local source for delicious baked goods and extraordinary cakes
Wausau, WI
Crumbs Bakery LLC in Wausau Wi features designer cut-out cookies. Crumbs Bakery, a licensed in-home bakery at 2200 Franklin St., will be open from 9 a.m. to 3 p.m. Tuesday through Friday until the end of August, and wil…
CakesBaked GoodsDesigner CookiesHalloween cookies
appleton, wi
Sturtevant, WI
Lehmann's Bakery is the oldest continually operating bakery in Racine, and has carried on the tradition of making the original Danish Kringle
Stoughton, WI
Fosdal Home Bakery Norwegian bakery located in southern Wisconsin, Stoughton, Wisconsin, serving Wisconsin and beyond
BreadCakesBaked GoodsDonuts
Wauwatosa, WI
Simma's Bakery - Voted one of America's Top 25 Bakeries. Milwaukee, Wisconsin's best wedding cakes, best cheesecakes and best traditional cakes as well as a full line of pastry and bakery items
Mount Pleasant, WI
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Pewaukee, WI
Petlicious Dog Biscuit Bakery, The Gourmet Pet Treat
, All Natural Pet Treats and Unique Gift Ideas For Your Best Friend
Retail BakeriesBakeriesDog cakesDog Biscuits
Adell, WI
A Sheboygan County bakery with world class products. Always hand made, always fresh
BreadCakeButter CreamPastry Chef
Suring, WI
Fresh baked for your pup with a dash of love and a pinch of sweetness. Natertot Bakery dog muffins, cookies, sweets and treats are made with all natural human ingredients. We never use
artificial flavors, colors or p…
CakesGourmet Dog TreatsDog BiscuitsSnacks
Contact our bakery shop in San Diego, California, and discover delicious baked goods and wedding cake designs
SnackPastriesBaked GoodsWedding Cake
Egg Harbor, WI
We are a well established restaurant and bakery, offering catering, excellent food and sprits, bakery goods to our friends and visitors.
Restaurant And BakeryCakes
Fennimore, WI
Each custom cake by Amazing Cakes by Arni of Mrs. B's Bakery is made using the best ingredients, made by "scratch", designed and created just for the special bride and groom. Amazing Cakes by Arni specializes in fondant…
Bakery ProductsDecorated CakesPhoto CakesHoliday Cakes
Hayward, WI
From fresh baked bread, pastries, cookies and cakes to a large selection of Wisconsin cheeses, custom gift baskets, and catering for all size parties, Hayward Bakery & Cheese Shop in downtown Hayward is an old fash…
BreadCakesWedding CakesCheese Shop
Green Bay, WI
All of our fabulous bakery products we had before are still available for pick up in our store front like our mini cakes, cupcakes and cookies Since we decided to stop our savory side and focus on just our bak…
Bakery ProductsCupcakesCakeCupcakes and Cookies
Check out http://daisycafeandcupcakery.com! Popular Atwood Avenue Cafe, Cupcake Bakery, and Coffee shop. Serving a full Breakfast/Lunch menu daily, and Dinner Tuesdays through Saturdays. Featuring updated American food …
Cream FillingButtercream FrostingCupcakesAmerican Food
Baptista's Bakery was born out of the sale of Gardetto's Bakery to General Mills in August of 1999 We specialize in healthy baked snacks After pursuing different courses of growth through various product in…
Baked SnacksMultigrainSnacksBRANDED FOOD
We let the experts from Uncle Mike's Bakery and Breadsmith in Green Bay and Don's Bakery in Luxemburg bring you the freshness & consistency that years of experience brings Jerry, our meat department manager, f…
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kenosha, wi
Paielli's Bakery also has many specialties including, but not limited to, Miniature Eclaires, Miniature Cream Puffs, Miniature Canoli, Genetti, and Biscotti
BreadCakesBaked GoodsBuns
madison, wi
The International Dairy-Deli-Bakery Association is a nonprofit membership organization serving the dairy, deli, bakery, cheese, and supermarket foodservice industries. Member companies enjoy many benefits and services. …
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Ralston CrawfordAmerican, born Canada (Saint Catharines, Ontario, Canada, 1906 - 1978, Houston, Texas)
Grain Elevators, Buffalo
1942photograph | gelatin silver print
Not on view at this time; find out where you can see works from our collection at locations around the Bay Area while our building is closed for expansion
6 5/16 in. x 9 3/16 in. (16.03 cm x 23.34 cm)
Collection of the Sack Photographic Trust
© Ralston Crawford Estate


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The Museum Day Live! ticket provides free admission for two people.
In the spirit of the Smithsonian Museums, which offer free admission every day, Museum Day Live! is an annual event hosted by Smithsonian magazine in which participating museums across the country open their doors to anyone presenting a Museum Day Live! ticket… for free.
Click here to view the list of 2015 participating museums.
Read about some of the participating museums here.
For more information on our special March 2016 Museum Day Live! event, click here.


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HAMILTON, BERMUDA--(Marketwire - Nov 23, 2012) - Golar LNG Limited ("Golar" or the"Company") advises that World Shipholding, which is indirectly controlledby trusts established by John Fredriksen for the benefit of his immediatefamily, has extended its TRS agreements relating to 500,000 shares inthe Company. John Fredriksen is Chairman of the Board, President andDirector of Golar.
The new expiration of the TRS agreements is February 25(th) 2013. The exercise price on the agreements is NOK 227.29 per share. WorldShipholding's affiliated ownership in Golar consists of 36,755,080 shares,representing 45.71 per cent of the Company's issued share capital, and hasTRS agreements with exposure to a further 500,000 shares.
Golar LNG Limited
Hamilton, Bermuda
November 23, 2012
This information is subject of the disclosure requirements acc. to §5-12 vphl (Norwegian Securities Trading Act)
This announcement is distributed by Thomson Reuters on behalf of ThomsonReuters clients. The owner of this announcement warrants that:
(i) the releases contained herein are protected by copyright and
other applicable laws; and
(ii) they are solely responsible for the content, accuracy and
originality of the information contained therein.
Source: Golar LNG via Thomson Reuters ONE[HUG#1660404]
- Finance
- Investment & Company Information
- John Fredriksen
Chief Accounting Officer & Group Financial Controller
Tel: +44 20 7517 8600


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The Crom Corporation designs its structures under the supervision of professional engineers; trains and certifies its key employees; selects and uses the best available construction materials; and adheres rigidly to high standards of quality construction.
Economy is a natural by-product of the prestressed COMPOSITE design - lesser quantities of materials and labor are utilized than is possible under conventional reinforced concrete design. Of greater significance is the quality of permanence inherent in the construction materials used. Shotcrete is a durable, impermeable, high-strength building material whose long life under minimum maintenance procedures is universally recognized. Under most operating conditions, interior surfaces of the tank do not require painting. This is a major cost benefit. Exposed exterior surfaces are usually painted for beautification.
In prestressed COMPOSITE tanks, the soft texture of the shotcrete finish assures lasting beauty with a minimum of care, and the low silhouette dome roof, pleasing in line and shape, completes the structure's architectural appeal.


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The Best PA Speakers and PA Speaker PackagesA little extra can go a long way when it comes to a PA speaker. The best PA speakers will deliver consistently with clarity and precision, making them invaluable to have. With sizeable our range of low-cost speaker systems and outdoor PA speakers, you are sure to find what you need. Find other equipment like a DJ speaker or other speaker system! As always, our team of dedicated specialists are standing by to make your shopping experience as pleasant as possible.
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Air Jordan Retro 1 staying
Forums home -> Softimage -> Air Jordan Retro 1 staying
Air Jordan Retro 1 staying
By haffaelloano56 on Jan 02, 2014 09:20 AM
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Minnesota Timberwolves v Detroit Pistons
Viacheslav Kravtsov of the Detroit Pistons attempts a foul shot... News PhotoAuburn Hills,Basketball - NBA Pro,Basketball - Sport,Detroit Pistons,Effort,Foul,Match - Sport,Michigan,Minnesota Timberwolves,Palace,Shooting Baskets,Sport,Taking a Shot - Sport,USA,Vertical,Vyacheslav KravtsovPhotographer B. Sevald/EinsteinCollection: National Basketball Association 2013 NBAEAUBURN HILLS, MI - MARCH 26: Viacheslav Kravtsov #55 of the Detroit Pistons attempts a foul shot against the Minnesota Timberwolves during the game on March 26, 2013 at The Palace of Auburn Hills in Auburn Hills, Michigan. NOTE TO USER: User expressly acknowledges and agrees that, by downloading and/or using this photograph, User is consenting to the terms and conditions of the Getty Images License Agreement. Mandatory Copyright Notice: Copyright 2013 NBAE (Photo by B. Sevald/Einstein/NBAE via Getty Images)


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Brutus is finally sound again! We won't be jumping for a while but I'm still super excited about it. He has like the best form over fences of any horse I've ever ridden, and the most eagerness and love for jumping :) So as a way of coping with my excitement I thought I'd brag on him some, because even if I can't jump him talking about him jumping is slightly therapeutic, lawlz :)
Brutus doing 4'3" Before you argue with me on the height, as has happened on a previous occasion, the standards are about 6 feet, Brutus is roughly 14.1h, the green barrels are roughly 3'6", and I think the white block things are 3 foot. :) The highest he's done is 4'9" but it was not caught on camera :(
Haha this one is a bit blurry and a major overjump but he refused to canter and trotted up to it instead :P Silly pony.
Please note that its him I'm bragging on and not myself :P A lot of these pictures are from last summer and even some before it and I'd only been jumping a year and a half so it was all a learning experience, and my eq was (and still is) horrendous.
When we get back up to where we were before with physical shape (both of us, I've been slacking off a bit while he's been off :P) I want to do A and AA pony jumpers with him :) And I want to go to pony finals, and I want to school some cross country, and I want to do some combined training, and I want to eventually compete 3'9" jumpers, and I'm rambling :P Haha excuse my general over excitement, and shameless bragging, I'm just soooooo happy he's sound. He's been visibly lame since late February, "mysterious bucking" (early signs of soreness, just not visibly lame is what I'm thinking) appeared in late September and went on through December and we basically weren't doing anything then. It stopped for like 2 months and then the visible lameness went in. So basically since late September I've gotten 2 months of working with him. I'm super siked to be riding him again :P


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How Can I Lower My Electric Bill?
It seems that rising energy costs have been taking a large part of the monthly budget lately, and you might be asking "what can I do to lower my electric bill?"
All the talk about energy shortages and high gas prices certainly doesnt't seem to help things, but there are some things you can start do now to start paying less.
We'll go over a few easy, simple actions you can take to reduce your electricity bill.
- Limit Your Use of Electricity – Start with the room you are in right now. Are lights or electronics on that don't need to be? What if you were called into another room by a family member, would you turn off the lights? Small steps like these soon turn into habits that the whole family can use to make the energy bill a little more friendly.
Make sure you are aware of all things that consume electricity, not just the obvious things like lights. Every TV, computer, and radio plugged in may be draining electricity, and dollars from your pocket every month.
Lower my electric bill with Green Energy
- Make a few smart investments: You may have seen compact fluorescent light (CFL) bulbs at the grocery store, and noticed how expensive they are compared to your incandescent bulbs.
Good news: these CFL bulbs are coming down in price, and they last up to 7 years! The best part? They use far less energy than traditional light bulbs.
- Use appliances wisely: It's not the number of appliances that you have that's draining your pocket, it's how you use them.
- Thermostat: Install a programmable thermostat and set it 10 degrees cooler at night. You can save up to $100 per year! Check your thermostat, it might already be programmable.
- Clothing: if it's cold, wear socks and a sweater while indoors. You'll be able to lower your thermostat by a degree or two!
- Unplug electronics when you are done using them. Even if you turn them "off," they still use up electricity when they're plugged in.
- Rooms: if they're not frequently used, close the vents and shut the doors.
- House: Add another layer of insulation. If you have less than 12 inches of insulation, you could use a little more
- Refrigerator/Freezers – If they are old, they may be inefficient and run constantly. Consider buying new ones (or slightly used) to actually save money over the long run.
- Call Electric Company for tips. Usually they will come out and give you tips. See what discounts they offer during non-peak hours, ask about light bulbs, sometimes they give them away for free!
Here are some tips to make better use of your appliances:
- Use the dryer only with a full load of clothes
- Switch off the computer monitor when you leave the room
- Do not leave the DVR on your TV "paused" for extended periods of time. Turn off your TV.
- Make a habit of always turning lights off when you leave a room.
While it may seem hard to start these habits, it will only take a few days until they are second nature. Remember that you will not only save money, but influence those around you (family and friends) and help the earth at the same time! It's win-win all around, and hopefully you won't be asking "how do I lower my electric bill?" anymore.


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Website: http://www.terrazza.com.au
I have always considered this place to be a direct competition to similarly styled restaurant Tiamo at the other end of Hampden Road. I still think it is some form of competition but ultimately they do serve different types of food, and I prefer the ambience in this establishment. In the realm of food, I don't have the luxury of being able to judge since I haven't tried the main courses at Tiamo much at all.
In any case, it was Ash Wednesday when the church girls decided to go for dinner together, and we decided to look around for a place where the crowds didn't seem too much to overcome – and Terrazza was perfect!
The interior has great lighting because of its open shutters, so the place always has this brightness and liveliness to it even without people populating the restaurant. The cake counter is where all the yummy desserts are sheltered, with a good amount of wine bottles and other alcoholic beverages neatly shelved. Beer taps are on the side of that with even more bottles of liquor decorating the nice wooden shelves.
On this occassion (due to the need to fast/abstain over the day), the three of us decided to go for no-meat. Here were our final choices:
Turkish Bread (with dips!) – V.A was way too hungry to skip entree, so we got this to share
Fettucine Al Salmone – S.C's choice
Fettucine (something! I can't remember. DANG) – V.A's choice (this was served with prawns and some snow peas)
Seafood Risotto – My choice
Small Becks
Chocolate Sundae for Desserts
The turkish bread was abit of a disappointment altho' very nicely presented to us. It was served cold, and the serving of the dip did not exactly compliment the amount of bread given – we even had to eat the last bits of the bread without any dip which was really just eating to fill our tummy :( The plus side tho' was that the dips were really quite tasty and did suit the taste of the turkish bread. Pity they could not be a tad more generous with the dips.
The mains were definitely a step better than the rather disappointing entree we had. I have tried the two pastas the other two ladies ordered, and thus I knew what to expect (assuming the quality/standard of the cooking hasn't changed). The fettucine al salmone is always quite a favourite with myself because of of my love for smoked salmon. The pasta's cooked quite nicely with a good amount of gravy soaking the broad pasta… (why couldn't they do the same with the turkish bread?!). The sauce itself was tasty and so it wasn't difficult for S.C to finish the plate.
The other fettucine was a tad more bland due to the missing 'smoked' taste that the salmon gave the other dish. The gravy used for this is exactly the same as that of the salmon which is something I thought should be highlighted – lack of variety.
The seafood risotto is by far my favourite dish from this establishment! It was lovely. I was taken by surprise when it came out, smelling oh-so-good, making my mouth water. The texture of the risotto was definitely to my liking… I don't know what the general standards are but this was just nice, and the taste of it was slightly tangy with a rich composition. The serving of seafood was rather generous as well, and I thought it was great how they included a nice side of salad so that the risotto wouldn't make you feel as tho' you were eating something too heavy.
At the end of the mains, we were clearly reaching our tummy limits, but as what many would say… there will always be space for desserts!! It's no different for V.A who ordered the chocolate sundae.
We got a shock when we saw the tower of cream that stood on top of the little glass containing the ice cream and hot fudge. It was somewhat overwhelming. But upon digging in, we soon realised (or well, V.A soon realised) that the tower of cream was nothing but a cover for the scoop of ice cream that was sitting right underneath it. Think of it as hair to the head.
I did not try this and thus will not be able to speak too much for it, altho' V.A did mention that she's definitely had better ones.
Presentation was definitely tops for this. And the amount of chocolate fudge at the bottom of the glass…. WHOA!
The service that night was really good with the girl really paying attention to all the nonsense we were doing. I reckon she did a great job in serving us with patience :) Two thumbs up there!! I am not too sure about the rest of the waiters/waitresses tho'.
The ambience as I have mentioned before is top-notch, something that I love – relaxing and bright (during the day of course). It's got an ample amount space between the tables as well… which is always a plus for people like myself!! =P
Overall I would go back to eat but it wouldn't be too frequent. The prices charged for the food they offer is a tad on the steep side in my opinion – but it must cost them quite a bit to maintain too.
Rating: 3 out of 5 stars
Rating by: S.T
Terrazza Nedlands
Telephone: (08) 9386 1399
Address: 156 Hampden Road, Nedlands, Western Australia


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Posted: 01/10/07
Tokyo Game Show this past September was the big coming out party for the PlayStation 3 in Japan. However, a little game from Konami for the Wii called Elebits ended up taking the award for best of show. We were puzzled, perplexed, and more than a little surprised. All the gorgeous games on the floor and a seemingly simple title featuring a bunch of electrified rodents wiped the floor with them? Now that we've had a chance to play it for ourselves we're beginning to understand why.
We've heard of kids hating brussel sprouts, brushing their teeth, or going to bed, but electricity? What good-natured child would hate electricity? How could they play video games? Well, that's exactly the setup behind Elebits. A child wishes that all the electricity in the world would go away, and as luck would have it, all the planet's juice is supplied by the tiny elebit creatures. They go into hiding and the child, realizing that it was a mistake, sets off to capture the elebits and restore the power.
Far-fetched? Yep. Ridiculous? Yes on that one too. Making matters worse, the story is told through a collection of hand-drawn art and some god awful voice acting. It's just an excuse to set up the gameplay, but far too many launch games this season have been taking this easy way out. Elebits is no exception.
So how does a kid go about zapping small, electrified creatures to recapture the world's power? Well, apparently there are guns for that, and this kid's got one. Elebits plays from a first-person perspective. You never even see the gun, and there are so many lapses of logic that you have to institute a healthy suspension of disbelief to get into it.
For all intents and purposes, Elebits is a puzzle game. You begin each scenario in a particular area and it's your job to figure out how to access new parts of the territory to collect as many elebits as possible. As you collect the critters a wattage meter will grow, and each area has an overall wattage target that you must hit to complete it.
Additionally, each area is littered with electronics that require a certain level of wattage to activate. Once they spring to life, they'll spill out a different kind of elebit that increases the power of your gun, allowing you to move heavier items and find even more elebits. This cycle repeats over and over throughout the game, though it's never really explained why you need a certain amount of power just to open a door to a new room.
A variety of X factors are eventually tossed into the mix to keep things interesting. There are tons of different power-ups to help you find the elebits. Some bait them so that they come out of hiding, some paralyze the varmints, others provide gun upgrades like a lockon feature, and there are other tools like a radar that helps you track them down.
There are several different types of elebits and each one accounts for a different number of watts. Some just lie there, waiting to be zapped. Others will teleport or take to the air, making it a little more difficult to get them, but the rewards always justify the effort.
The single-player option is surprisingly robust, with dozens of areas to complete. The difficulty ramps up perfectly for an adult, but kids will probably start having issues about 10 missions in as you'll have to manage over 10 different electronics, several doors, and hundreds of elebits, all under a strict time limit. Eventually they'll also start giving you a quota of breakable objects. Break too many and you'll have to start all over again.
Aside from the single-player campaign, there's a wealth of other options to take part in with up to four players. This semi-cooperative multiplayer option has one player controlling movement, while all the players zap away at the environment. There's a good bit of strategy involved here as the player controlling movement can effectively lock out the other players once a lead has been established. There's also online functionality where you can build your own levels using templates and then send them to friends via WiiConnect 24.
One part of Elebits that falls well short is the graphics. Compared to games on the PS3 and Xbox 360, it can look downright prehistoric. This is remedied a bit by being able to interact with every last shoe, box, and dish, but the simple visuals will certainly turn off the graphics tarts.
Elebits is a surprisingly big game that has a lot of features you wouldn't expect. In addition to the meaty single-player mode, it's also the first Wii game to have any sort of online functionality. Toss in a fun, but limited, multiplayer option, and you have one of the larger games available for the system.
Playing Elebits is all about physics. Granted, the physics engine makes the objects in the game entirely too floaty, but it's fun just to grab stuff, give it a toss, and watch how it interacts with the rest of the environment. As your gun increases in power, you'll be able to pick up bigger objects, which is when things really start to get fun. One caveat is that you must break the power-ups before using them, which can be difficult to do as they tend to gently bounce around.
The game controls just like a first-person shooter. You aim with the Wii remote, press the A or B button to fire, and move and strafe with the analog stick on the nunchuk. You can also duck to see under objects to hunt down the more elusive elebits. You'll pick it up in no time, but there are some issues that will have you fighting the urge to give your controller a toss in the later missions.
There are many doors you'll have to open throughout the game, and they all appear to be spring-loaded. You'll open them, and then they'll immediately try to close again. The only remedy is to be extremely delicate while opening them, but with the always-changing power of the gun, it can be difficult to gauge. There's no hit detection on a lot of the doors so you can't really jam your body in there to keep them open. In fact, the hit detection, overall, is suspect. A lot of the objects in the game will block your shots when they shouldn't be. Also, the gesture for turning doorknobs can be a little hard to get the hang of, and overall there's a lot of things that could be tightened up for a sequel.
While the targeting with the Wii remote is dead-on, turning around can take a long time, and just like a lot of other Wii games, once the cursor goes off the screen there's no telling what's going to happen. But after you've played the game for a couple hours, you'll start to learn the ins and outs, and you'll realize that Elebits, regardless of its shortcomings, is one fun game to play.
So many of the Wii launch games basically have the remote functionality tacked on at the last minute to make a buck. Elebits is not one of them. It's not a particularly attractive game and there are some gameplay quirks to work around, but it's easy to forget the issues when you're making a total mess of things, tossing objects from one side of the room to the other and letting gravity take its course.
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This article was produced by JEMS and features Mark Meridith.
Learning Objectives
>> List the five causes of altered mental status in pediatric patients.>> Recognize the signs and symptoms of a pediatric patient with altered mental status.>> Review the proper assessment techniques for pediatric patients with altered mental status.
Key TermsDiabetic ketoacidosis (DKA): Altered level of consciousness due to an inability of the body to use glucose for metabolism.Differential diagnosis: Any condition having similar signs and symptoms that must be considered during patient evaluation.Encephalitis: An inflammation of the brain, primarily from infection that results from the bite of an infected mosquito.Hematoma: A collection of blood in a localized area within an organ, space or tissue.Hyperglycemia: Increased glucose in the blood, most often linked to diabetes mellitus; diabetic ketoacidoisis may result.Hypoglycemia: Decreased glucose in the blood, usually called by excessive insulin or low food intake.Intussusception: The telescoping of intestines causing a decreased blood supply to the affected segment.Meningitis: Any infection or inflammation of the membranes covering the brain and spinal cord.Primary survey: The initial, rapid examination of a patient or scene for life-threatening conditions.EMS is dispatched to a residence for an "unresponsive child." On arrival, a frantic mother is waiting at the door and directs the crew to the living room. EMS providers find an 8-year-old male who's only responsive to deep pain. While one paramedic assesses the patient, their partner obtains a history from the mother. The mother states her child was complaining of a headache for the past week, and says it worsened earlier today. He's an otherwise healthy child. A full primary survey reveals that airway breathing and circulation (ABCs) are intact. The patient's vital signs are a heart rate of 60, respiratory rate of 8, blood pressure of 160/120 and oxygen saturation of 90%. An IV is established, and a glucose check is administered, revealing a blood sugar of 95. The patient will only respond to deep, sternal rub. IntroductionPatients with altered mental status (AMS) are some of the most challenging EMS calls. AMS in pediatric patients adds another level of complexity to the scenario. The younger the patient is, the less that they can tell us about what happened and what they're feeling. EMS providers must remember that AMS isn't the primary diagnosis. It's always secondary to a cause, such as trauma, poisoning or a disease process.
AssessmentThe primary survey for any patient should consist of the ABCs, with the addition of disability and exposure (ABCDEs). This assessment should be performed in a systematic approach. It's vital to address the key findings that cause life-threatening challenges during the primary survey, but it can be difficult when caring for the patient with AMS because they may not appear critical. All providers, whether assessing a scene in the field or walking into a room in the emergency department (ED), get a first impression and can usually tell "sick" or "not sick." This is easier said than done sometimes, so the primary survey must be performed on every patient, every time.Often dispatch information isn't clear, leaving the prehospital provider wondering what they're going to walk into. Create an algorithm that can be reviewed briefly when you're dispatched to any medical or trauma case involving a pediatric patient. This algorithm is crucial because the stress of knowing you're about to care for a pediatric patient is enough to cause any provider to overlook key assessment findings. Several tools can be used as guides to assist the provider. One of these tools is the American Heart Association's (AHA) Handbook of Emergency Cardiovascular Care for Healthcare Providers. This excellent resource can provide critical information for the providers to use during their care. For example, how many of the 11 reversible causes can the provider recall when caring for a critical pediatric patient?1 If the providers are caring for their own child, you'd expect them to recall all 11, but that's unlikely. So healthcare providers should use these tools to feel more confident in conducting assessments because they're doing so.When assessing the patient with AMS, the healthcare provider should never assume that they know the cause because your tunnel vision will lead you down a wrong path. One example is a case in which the EMS providers responded to a scene with mother who was altered with evidence of ethanol and drug use. She was breast-feeding an infant who was also altered and "sleepy" with no evidence of trauma. The crew assumed it was due to the mother's intoxication; however, the cause of the infant's AMS was actually due to head trauma after the child was dropped numerous times throughout the day.
ABCDEThe two parts of the assessment that are easily overlooked in pediatric patients with AMS are disability and exposure. The goal in the disability assessment is to check the neurological status. This starts by checking the alert, verbal stimuli, painful stimuli and unresponsiveness scale and pupils. For the patient with chronic medical problems, this may be difficult to define; the provider may find it useful to ask a reliable caregiver to advise what's different. When assessing exposure, the emergency provider must look at the patient's entire body, including the posterior surfaces. Failing to properly expose a patient with AMS can cause the EMS provider to miss the source. Everyone wants to be an expert when it comes to the basics; properly exposing a patient to complete the primary survey is a big part of that. Remember that the only way to get proficient at pediatric patient assessment is to do an assessment the same way every time, regardless of whether you're examining an adult or pediatric patient.The last part of the assessment of the pediatric patient with AMS is obtaining a complete set of vital signs. These patients should be placed on a full monitor to obtain heart rate, respiratory rate, blood pressure and pulse oximeter reading. The use of capnography is recommended to assess air exchange and work of breathing.Although not all EMS providers carry thermometers, a basic assessment of whether the patient feels hot or cold should be done. Glucose isn't a vital sign, but it's vital that patients with AMS have a glucose obtained. Correcting hypoglycemia early in the field can decrease morbidity and mortality.
CausesChairman of Emergency Medicine at Vanderbilt University Medical Center and JEMS Editorial Board member Corey Slovis, MD, FACEP, is notorious for teaching that there are five causes for everything. Well, for patients with AMS, there are five main causes to examine.2 Although the specific causes for pediatric patients may differ from those for adults, the general categories hold true.
1. Vital Sign Abnormalities Hyperthermia/hypothermia: As previously stated, obtaining a full set of vital signs should be a priority in these patients because vital-sign abnormalities are one of the top causes of AMS. Many kids become altered when they have a fever. They can become lethargic or irritable, making examining them difficult. For the patient who's severely altered and febrile, the concern for overwhelming sepsis or meningitis is higher. Your concern should be whether the patient is suffering from a heat stroke if the patient has been outside in a hot environment and presents with hyperthermia and AMS. If this patient is suffering from heat stroke, the EMS provider should immediately cool the patient by undressing them and using ice packs to the axillae and groin.Hypothermia is also a cause of AMS. For patients who are found outside during the winter months or who have suffered trauma and been undressed, care should be taken to ensure that the patient is kept as warm as possible. A patient begins to be coagulopathic and their blood begins to not clot well when their temperature drops below 96° F.3 Hypoxia: Who knew that the pulse oximeter (SpO2) would change how we practice as much as it has? You could argue that there are patients who don't need an SpO2 reading, but every patient with AMS needs to be monitored continuously with one. Patients with increased work of breathing, wheezing, trauma to the chest or hypoxemia should be addressed quickly and placed on 100% oxygen via a non-rebreather mask. Placing a child with AMS on 100% oxygen is always the right thing to do—except in rare cases, such as the child with cyanotic congenital heart disease.Hypovolemia: The most common cause of hypovolemia causing AMS is acute blood loss. EMS providers should realize, however, that hypotension is a late sign in pediatric patients. Once the child is hypotensive, they're in decompensated shock and are at an increased risk for morbidity and mortality. Also, hypovolemia should be considered in patients with a resting heart rate above baseline for their age. Normal pediatric systolic blood pressure = (age x 2) + 90.1Tachycardia/bradycardia: Although not common causes, tachydysrhythmias and bradycardia can both cause AMS in pediatric patients. Infants can present with fussiness or unresponsiveness secondary to supraventricular tachycardia. If the patient has a heart rate above 220 and it isn't variable, a 12-lead ECG should be performed to look for this; if found, it should be treated appropriately with vagal maneuvers and/or adenosine.
2. Toxic/MetabolicHypo/hyperglycemia: Every patient with AMS, whether an adult or child, should have their glucose checked. Too often EMS providers make excuses for not sticking for a glucose because the patient is a child. That excuse isn't valid and can't be tolerated. If a patient is hypoglycemic, then the brain is also hypoglycemic and is at risk of permanent damage. Hypoglycemia should be corrected rapidly in the prehospital setting, either through oral glucose if the patient is awake or through IV dextrose if the patient is altered.>> Infants: Administer 5 cc/kg of D10W;>> Children: Administer 2–4 cc/kg of D25; and>> Adolescents: Administer 1 cc/kg of D50.Hydrogen ion excess (acidosis): This can be a cause for AMS, but unless your service carries a blood gas machine, you won't be able to know whether the patient is acidotic. The most common condition leading to acidosis and AMS is diabetic ketoacidosis (DKA); this is treated with fluids and an insulin drip in the hospital setting.Toxic (overdose): All too often children find medicine that isn't theirs and ingest it. In the toddler age group, this is often because they find pills (that look like candy to them) on the floor, left on a table or night stand or get into the unlocked medicine cabinet. In the adolescent population, they're usually ingesting medicines in an attempt to get high. Knowing what medicines are in the house, even if it means putting them all in a bag and bringing them to the ED, can be invaluable. Caregivers often forget about medicines that are in their cabinet and deny that the patient could ever have ingested anything. For patients with AMS and vital-sign changes, such as apnea or bradycardia, administering naloxone 0.1mg/kg is appropriate and will not present untoward side effects. If the patient doesn't respond to this, increase the dose to 0.2mg/kg up to a total of 10mg to look for patient effect. Another toxic source that can cause AMS, especially in the winter months, is carbon monoxide (CO). Every patient with suspected CO poisoning should receive 100% oxygen en route to the hospital.
3. StructuralTrauma: Trauma is the number one cause of death in children and is always something to consider in a patient with AMS. Head injuries due to non-accidental trauma (child abuse) should always be in your differential diagnosis, especially for infants and toddlers.4
Healthcare providers are now doing a better job of recognizing head injuries causing concussions in older children and adolescents.5 These injuries aren't apparent on a computerrized axial tomography (CT) scan like a subdural or epidural hematoma, but they should still be considered. Seizure: Pediatric seizures are a common reason for EMS to transport a patient. Whether the patient has epilepsy or is having just a simple febrile seizure, these patients can present with AMS. No matter the cause, all seizure patients should have a glucose checked by EMS (see hypoglycemia above). Not all seizure patients present with generalized tonic clonic activity. Patients with partial seizures may present with AMS and automatisms, such as eye blinking, tongue thrusting or rhythmic movements of just one extremity. This is why it's imperative for the healthcare provider to fully assess all patients with AMS.Stroke: The proper recognition of pediatric stroke patients is on the rise. Although it's much less common than in the adult population, patients with such predisposing risk factors as sickle cell disease or clotting disorders are at risk. Just as in adults, timely recognition of a stroke is the key to minimizing morbidity and mortality. Crews must also consider the possibility of a child involved in a fall having sustained a concussion or multiple concussions over a short time period, which can result in significant damage. Intussusception: In toddlers who have been vomiting or had diarrhea, intussusception can also cause AMS. Intussusception is the telescoping of intestines causing a decreased blood supply to the affected segment. This is usually manifested as intermittent, severe, crampy abdominal pain. Often the child will be seen drawing their legs up to their abdomen in pain. The patient may pass a bloody stool, but this is usually a late finding. In some patients, this condition can cause AMS. Intussusception is treated with an air reduction enema and sometimes requires surgery.4. InfectiousMany infectious causes can lead to AMS in the pediatric patient. The three most common causes are meningitis, encephalitis and overwhelming sepsis. Providing these patients with high-flow oxygen and monitoring vital signs are the key to a successful transport. As with any patient with infectious signs and symptoms, the healthcare provider must protect themselves through the use of gloves and a mask when the situation dictates.
5. PsychiatricAlthough uncommon in most pediatric patients, this is a diagnosis of exclusion and one that shouldn't be routinely entertained in the prehospital environment.
ConclusionThe 8-year-old boy from our opening case is transported from home with AMS after his worsening headache. His physical exam is notable only for a response to deep sternal rub. The patient's mom reports that he hasn't suffered any trauma and has never had a headache like this before. He's placed on 100% oxygen via a non-rebreather mask and is immediately transported to the closest hospital. On arrival, the patient is intubated for airway protection and healthcare providers obtain a CT scan. The CT revealed a mid-brain hemorrhage leading to a stroke. It was later discovered that this was secondary to an arteriovenous malformation.As with every patient, a systematic approach to the pediatric patient with AMS is the key to success and will help the prehospital provider ensure the patient gets the best care possible. JEMS
References1. American Heart Association. Handbook of Emergency Cardiovascular Care for Healthcare Providers. American Heart Association: Dallas. 2010.2. Corey Slovis, MD. Five Causes of Altered Mental Status. Emergency Medicine Lecture Series. Vanderbilt University School of Medicine.3. Tsudei B, Kearney PA. Hypothermia in the trauma patient. Injury. 2004;35(1):7–15.4. Limmer D, O'Keefe M, Grant H, et al. Emergency Care, 10th Edition. Brady: 775, 2005.5. Donofrio C, Campbell R. (2011) Recognizing Concussion and Treating Postconcussion Syndrome. In Rehab Management. Retrieved Nov. 30, 2011, from www.rehabpub.com/issues/articles/2011-09_04.asp.
Read "EMS Providers Can Identify Child Abuse" from October JEMS on jems.com/journal to learn more about signs and symptoms of child abuse.
This article originally appeared in January 2012 JEMS as "Clear the Fog: The challenges of patient who can't explain their condition."
David Lehrfeld, MD, | Ray Fowler, MD, FACEP | From the December 2011 Issue | Thursday, December 1, 2011
This is the greatest era in the history of EMS, the newest subspecialty in the house of medicine. It may be said that EMS can do more now for critically ill or injured patients in the field than ever before. Field treatments are now focused more than ever on directly approaching the now-scientifically understood pathophysiology of the conditions threatening our patients.At this important juncture in the history of EMS, it's a useful time to reach into the minds of some of the great resuscitation researchers in the world to find out what they're thinking about regarding the care of critically ill patients in the prehospital arena. Our approach to crafting a paper as a "grand rounds" on resuscitation has been to ask five prominent thinkers in EMS science to respond to three questions. We first wanted to know what they felt—in the area of greatest interest to each physician—was the greatest accomplishment in the past decade in resuscitating critically ill patients in the field. Next, we asked them what they felt is the most difficult challenge in the care of critically ill patients in the field. Finally, we asked the panelists to look into the future and predict the best place to look to improve the outcomes from resuscitation in the field. In doing so, we wanted to tap each expert's vision to help guide an industry that's eager to continue its growth and improve the quality of care as a subspecialty of medicine.These interviews pose a few questions and provide each panelists' thoughts on that subject, moving from the past to the present and into the future.
Discussion What has been the greatest accomplishment in the past decade for EMS in the area of resuscitation science?
Ahamed Idris, MD, FACEP: We must examine every basic and fundamental thing that we do in interventions in EMS. I lump many things under this need for careful evaluation. For CPR, that includes when do we need to ventilate, and what rate of chest compressions is optimal? One thing we discovered is that BLS is the most important thing for improving survival from cardiac arrest. Advanced cardiac life support (ACLS) doesn't have a lot to offer. The one key thing ACLS offers is hypothermia, but most of the other interventions are not very useful. We're in the process of examining antiarrhythmics, and it may be that placebo is the "ideal antiarrhythmic drug" because it has the best survival advantage. We may even need to examine the use of epinephrine.Another important discovery in the past decade has been the rediscovery of whole blood as the ideal resuscitation fluid for traumatic shock. Up until 1974, whole blood was the resuscitation fluid of choice for traumatic shock. Experience in the military has revealed that whole blood is the best resuscitation fluid of anything that can be given.
Paul E. Pepe, MD, MPH, FCCM, FACEP: There are four areas that come to mind right away. One is the public recognition of the importance of AEDs. Two is the development and validation of courses that have made CPR education simpler, faster to learn, and in turn, better because we've simplified the training process.1–3 The third issue is the recognition by the medical community that we haven't been doing quality CPR and that when we do focus on quality CPR, we improve survival rates. The fourth concern is now that "ventilation should match perfusion," meaning you don't need as many breaths in a low-flow state, particularly in the first few minutes after sudden cardiac arrest.
J. Brent Myers, MD, MPH: I think the greatest accomplishment is the recognition that the resuscitation of the out-of-hospital cardiac arrest patient is owned by EMS. It's become a form of a philosophical thing. The notion that we're going to do something, then take the patient to a hospital, and the in-hospital providers are going to do something else, has been totally debunked. I refer to Art Kellerman's editorial in the October 2010Annals of Emergency Medicine, where he said that, based on his editorial analysis of the literature, the patient who suffers out-of-hospital cardiac arrest is 35-fold more likely to survive if there is return of spontaneous circulation (ROSC) in the field rather than ROSC later in the ED. So, to me, we can talk about sequences of defibrillation and continuous compression and therapeutic hypothermia, but none of these works if EMS considers the cardiac arrest patient in a manner similar to the penetrating trauma patient. EMS is the definitive treatment for medical cardiac arrest patients in the field.Corey Slovis, MD, FACEP, FACP: I'm delighted that I can't pick just one. There are three. Therapeutic hypothermia; the decreased emphasis on immediate hyperventilation and intubation with the advent and increased popularity of continuous chest compressions; and the really strong focus—although not yet completely disseminated through the community—on the use of AEDs.
John Freese, MD, FACEP: I believe the greatest accomplishment is the ability to analyze the quality of CPR being delivered to the patient. The world has spent 50-plus years trying to build a model of ideal resuscitation. Now that we can look at the variables of that quality, we realize that we have been building on a variable platform.One example would be CPR prior to defibrillation. Some research has said that it made no difference, but now that we're controlling the variables, we may have to go back and look at that research again. Intubation is another example. I have been wary of continuing intubation for the cardiac arrest patient. If we could control the interruptions to less than 10 seconds and ensure the quality of CPR being delivered during the intubation, what, then, is the effect of intubation on outcomes?
What is the greatest current challenge in the resuscitation of critical EMS patients in the field?
Dr. Idris: I think one of the biggest challenges is identifying who the critically ill patient is. With people who are really sick, it's pretty obvious. People who are in traumatic shock may have a normal blood pressure, but they're still in shock. Identification of critically ill patients is a challenge in EMS. For example, we know that at least 20% of patients in traumatic shock have a normal blood pressure. These patients are even misidentified in the ED, and it probably does result in a delay of care for patients who look too good to be sick.
Dr. Pepe: Airway management choices: Although endotracheal intubation (ETI) has been considered the "gold standard" for airway control and is immediately used in the hospital, concerns exist in the way EMS systems are organized today. Paramedics may not be as skilled as would be preferred in ETI. Because of infrequent opportunities for individual paramedics to perform ETI, it is less likely to be performed in as facile a manner as one would like. However, in systems that maintain a smaller cadre of medics through tiered dispatch systems and an intensive focus on controlling respiratory rates in low-flow states, outcomes can be improved. Nevertheless, the majority of EMS systems are not set up that way, and this has made ETI a less reliable tool and one that can actually be harmful without all the right factors in place.
Dr. Meyers: I think the biggest challenge now is probably the one that has been there all along: I know that this may be politically insensitive, but my biggest concern is changing the paradigm of bystander education. This notion that we need cards and four-hour courses as opposed to a 20-minute YouTube video to teach somebody how to do CPR. We've got to cross that threshold. It's OK for a bystander to pull out his iPhone and use an app to learn CPR on the spot. All of the card courses are equally guilty; it's everybody.
Dr. Slovis: The great variability of bystander response and EMS response, where some communities have many of their citizens trained in CPR and others have few; where some communities have a tiered response and other communities have response times that don't allow for survival.
Dr. Freese: I believe it's the coordination of the care—both in the field and with the transfer to hospital care. We put an enormous pressure on our providers to do a great number of things in a short amount of time, and I think that leads to some degree of frustration that we expect them to accomplish "A to Z" in such a short amount a time; yet, they may not have providers who have sufficient skill and knowledge in the importance of what they're doing and why they're doing it to assist them.
Where is the best place to look for the next few years to improve resuscitation outcomes for EMS?
Dr. Idris: The challenge, which goes to my second point, is that we can't very well measure the effect of what we're doing, the effect of our interventions. For the patient in cardiac arrest, we can't measure blood flow during CPR. So we don't know what we need to do to improve the patient's condition or what we need to change to improve the way we are doing it. Outcome is our only guide right now. There's no intermediate measurement that can give us feedback on blood flow while we are doing CPR. The same thing applies to trauma. Blood pressure is a crude measurement of traumatic shock: It's a metabolic derangement. If we could measure what is happening at the tissue level, we could resuscitate patients more effectively. My whole thinking about improving outcomes from cardiac arrest is "saving life through metrics." We could save many more lives by better measuring what we are doing.
Dr. Pepe: The best place to look is having the political clout to make our cities safer by ensuring that every man, woman and child—at least of age 12 or above—knows how to perform CPR and is ready to do so in a timely manner. This includes the use of AEDs and perhaps, with cheaper AEDs, they might even be sold as an automobile accessory to be sure one is always available. (JEMS then asked Dr. Pepe if he ever imagines a smartphone app that will somehow serve as an AED, and he replied, "Yes, or something similar.")
Dr. Meyers: Hmmm … that's the most challenging of the questions. For the first time in EMS, we're generating our own data in a robust fashion. Thanks to the Resuscitation Outcomes Consortium, EMS as a subspecialty, and Prehospital Emergency Care as a world-class journal, we can now objectively look at each other. I think we look to each other to do this. We have to give kudos to the AHA for the past set of Guidelines, the 2010 AHA Guidelines for CPR and ECC; they were truly multidisciplinary, a really practical document. Previously, when we had to look at someone's ejection fraction before we gave certain drugs, clearly this did not have prehospital resuscitation in mind. We are at such a different place. For the first time, we have quality data from EMS systems and national bodies acknowledging that data, and we are seeing a measureable and quantifiable change in outcome.Dr. Slovis: EMS has to become one of the leaders in preventive medicine in regard to blood pressure control, smoking cessation and lipids management. Who better to lead our nation in preventive healthcare practices than the very people who save lives on a daily basis? Our fire halls have to become community outreach health centers for specific diseases as they relate to stroke and heart attack: BP checks and referrals for treatment, smoking cessation and referrals to places to get care for this, easy lipid profile testing and firefighter- and EMS-led exercise classes offered free to the public.
Dr. Freese: I think the next big leap is going to come with the further integration of technology into our resuscitation technology that's able to communicate from one device to another. I think proprietary technology is a hurdle. An applied mechanical CPR device, which easily improves resuscitation outcomes, is necessary. But if it's not talking to the monitor and isn't able to analyze underlying rhythms appropriately, then time defibrillation efforts at the proper time in the upstroke, and the appropriate time with respect to ventricular fibrillation quality—if all that doesn't happen, we've missed the boat. I think what you end up with today with some technology is like we have with people—they don't understand what each other is doing. We also need to be able to transfer the information to medical oversight. Dr. Myers tells his crews "if you don't have a pulse after 10 minutes, give him a call." And he includes the receiving facility, so they can see the progress of the patient prior to resuscitation. Then, they can see what has happened in real time rather than having someone explain to them what has been going on for the past 30 minutes. The technology piece has to come along for us to be able to improve outcome. We are transfixed on the depth of compression: We need technology to assess the efficacy of our compressions, to guide us as to how we make compressions effective for this patient.
ConclusionThe diversity of the responses from these great leaders in our field demonstrates the breadth of both the responsibility and the opportunity that we have in EMS. The science is clear: Good BLS works; it's an essential partner in the successes that we've had to date and lies at the heart of the potential for the greatest decrease in morbidity and mortality in our work. From these great leaders we hear that simple, quick training programs in performing citizen CPR, for example, might improve survival from out-of-hospital cardiac arrest of thousands of people each year, a public health imperative that cries out for prompt attention. It is clear, then, that we must use all our experience to optimize training, because lives truly hang in the balance. Concepts as simple as immediate citizen response, de-emphasized early ventilation, appropriate rate of compressions and seeking out EMS response are key factors that will save thousands in our country alone. The opportunity to tease out of the minds of great thinkers the essence of their experiences can help us set our sights on the future. Such leadership will allow us to optimize our care and simultaneously guide an industry to partner with medical providers. Thus, we may together set our paths for developing technologies and maximizing patient outcomes. JEMS
References1. Roppolo LP, Heymann R, Pepe P, et al. A randomized controlled trial comparing traditional training in cardiopulmonary resuscitation (CPR) to self-directed CPR learning in first year medical students: The two-person CPR study. Resuscitation. 2011;82(3):319–325. 2. Roppolo LP, Saunders T, Pepe PE, et al. Layperson training for cardiopulmonary resuscitation: When less is better. Curr Opin Crit Care. 2007; 13(3):256–260. 3. Roppolo LP, Pepe PE, Campbell L, et al. Prospective, randomized trial of the effectiveness and retention of 30-min layperson training for cardiopulmonary resuscitation and automated external defibrillators: The American Airlines Study. Resuscitation. 2007;74(2):276–285. Ahamed Idris, MD, FACEP, is professor of emergency medicine and chief of the section on resuscitation research. He's the principal investigator for the National Institutes of Health Dallas Resuscitation Outcomes Consortium, University of Texas Southwestern Medical Center. He can be reached at
.Paul E. Pepe, MD, MPH, FCCM, FACEP, is a professor of surgery, medicine, pediatrics and public health and is Chairman of emergency medicine at the UT Southwestern Medical Center in Dallas. He's also the director of the City of Dallas Medical Emergency Services for Public Safety, Public Health and Homeland Security. He can be reached through his administrative assistant at
J. Brent Myers, MD, MPH, is director of the Raleigh/Wake County EMS System in Raleigh N.C., and is an adjunct assistant professor of emergency medicine at the University of North Carolina, Chapel Hill, N.C. He can be reached at
.Corey Slovis, MD, FACEP, FACP, is professor and Chairman of emergency medicine at Vanderbilt University School of Medicine, and he's the medical director of the Nashville, Tenn. Fire Department and Nashville International Airport. He can be contacted at
.John Freese, MD, FACEP, is the medical director and director of prehospital research at the Fire Department of New York, and he's the principal investigator for NYC Project Hypothermia.
This article originally appeared in December 2011 JEMS as "Resuscitation Round Table: Five EMS experts offer views on key topic."
"The emergency department at Vanderbilt University Medical Center established a program in which patients are quickly assessed in a triage area by a team consisting of a physician, a nurse, and a paramedic. Patients with urgent problems are promptly moved to a treatment room. Patients with nonurgent problems are tested and/or treated in the team triage area. They are then released or return to the waiting area until test results and a treatment room are available. As a result of the program, most patients see the triage doctor within 10 minutes of arriving, the percentage of patients who leave without treatment has decreased from 5 percent to under 1 percent, and patient satisfaction has increased markedly."
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President Obama Meets With Senate Democrats On Capitol Hill
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A staff member buffs the presidential limousine while it is parked... Fotografía de noticiasArte cultura y espectáculos,Colorado Buffaloes,EE.UU.,Edificio del Capitolio,Encuadre de cuerpo entero,Grupo organizado,Horizontal,Limusina,Oficio,Política,Realeza,Universidad de Colorado en Boulder,Washington DCPhotographer Drew AngererCollection: Getty Images News 2013 Getty ImagesWASHINGTON, DC - MARCH 12: A staff member buffs the presidential limousine while it is parked outside the U.S. Capitol March 12, 2013 in Washington, DC. U.S. President Barack Obama met with the Senate Democratic Caucus today, and is making three trips to Capitol Hill this week to meet with lawmakers. (Photo by Drew Angerer/Getty Images)


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Grace Collection Elk Silhouette 49" H Swivel Bar Stool
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The Elk Silhouette Swivel Bar Stool from Grace Collection is part of the lodge theme with its seat back silhouette design of an elk in the wild. The bar stool features a swivel seat with memory return, which makes the seat return to the center position automatically. Made with a steel frame for durability, the stool is available in an assortment of metal finishes and fabric options. Non-marring foot glides keep tile and hardwood floors safe from scratches. Ships via UPS/FedEx Ground.
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What are the roles of the Holy Ghost?
The Holy Ghost, a member of the Godhead, bears witness of Heavenly Father and Jesus Christ. He is the source of personal testimony and revelation. He can guide us in our decisions and protect us from physical and spiritual danger. He is known as the Comforter, and He can calm our fears and fill us with hope. Through His power, we are sanctified as we repent, receive saving ordinances, and keep our covenants. It is through the influence of the Holy Ghost that we receive knowledge of Heavenly Father and Jesus Christ and feel Their power, goodness, and love.
Prepare yourself spiritually
What scriptures and other resources will help the young women understand the roles of the Holy Ghost?
1 Kings 19:11–12; Helaman 5:30; D&C 85:6 (The Holy Ghost speaks in a still, small voice)
John 14:26 (The Comforter can teach us and bring all things to our remembrance)
Romans 8:16 (The Spirit bears witness that we are children of God)
Galatians 5:22–23 (Paul describes the fruit of the Spirit)
2 Nephi 32:5 (The Holy Ghost will show us what we should do)
3 Nephi 27:20 (The reception of the Holy Ghost sanctifies us)
Moroni 8:26 (The Holy Ghost fills us with hope and love)
Moroni 10:5 (The Holy Ghost teaches us the truth)
D&C 42:17; Moses 1:24 (The Holy Ghost bears record of the Father and the Son)
Boyd K. Packer, "Counsel to Youth," Ensign or Liahona, Nov. 2011, 16–19
Craig C. Christensen, "An Unspeakable Gift from God," Ensign or Liahona, Nov. 2012, 12–15
"Roles of the Holy Ghost," True to the Faith (2004), 82
Video: "Voice of the Spirit"
Share experiences
At the beginning of each class, invite the young women to share, teach, and testify about the experiences they have had applying what they learned in the previous week's lesson. This will encourage personal conversion and help the young women see the relevance of the gospel in their daily lives.
Introduce the doctrine
Choose from these ideas or think of your own to introduce this week's lesson:
- Invite the young women to write about a time when they have felt the influence of the Holy Ghost in their lives. What did they do to receive His influence? What difference did His influence make? If appropriate, have several of them share their experiences.
- Invite the young women to sing "Let the Holy Spirit Guide" (Hymns, no. 143) and to share what the words teach them about the roles of the Holy Ghost.
Learn together
Each of the activities below will help the young women understand the roles of the Holy Ghost. Following the inspiration of the Spirit, select one or more that will work best for your class:
- Invite the young women to look in the hymnbook in the "Topics" index under "Holy Ghost" to find a hymn that teaches about how the Holy Ghost can help us. Ask them to share lines from the hymns they chose. Consider singing one of the hymns as a class.
- Divide the young women into small groups. Ask each group to read a few scriptures about the Holy Ghost (such as those suggested in this outline). Invite one young woman from each group to share with the rest of the class what her group's scriptures teach about the roles of the Holy Ghost. Invite the young women to share personal experiences they have had in which the Holy Ghost has helped them in any of these ways.
- Invite each young woman to study the section titled "What Is the Mission of the Holy Ghost?" from Elder Craig C. Christensen's talk "An Unspeakable Gift from God" and prepare to share with the class what she learns about the Holy Ghost. Invite her to share experiences when the Holy Ghost has helped her in the ways Elder Christensen describes.
- Show the video "Voice of the Spirit," and ask the young women to listen for answers to the following questions: Why do we need the Holy Ghost? How can the Holy Ghost help us? Share appropriate experiences you have had listening to the Holy Ghost, and invite the young women to share any experiences they have had. As a class, make a list of things they can do to better hear the promptings of the Holy Ghost.
- Invite the young women to read "Roles of the Holy Ghost" in True to the Faith (page 82). Ask each young woman to select one of the Holy Ghost's roles and look for scriptures or scriptural stories that teach about that role. Invite the young women to share with each other what they find. Encourage them to share experiences in which the Holy Ghost helped them in these ways. What are some future situations in which they will need the help of the Holy Ghost?
- Find some stories from recent general conference talks that illustrate the various roles of the Holy Ghost (some examples from the May 2012 Ensign or Liahona include the stories about Cheryl A. Esplin's granddaughter Ashley in "Teaching Our Children to Understand," pages 10–11; Elder Larry Y. Wilson's daughter in "Only upon the Principles of Righteousness," pages 104–5; and young Dieter F. Uchtdorf being called as deacons quorum president in "The Why of Priesthood Service," page 58). Invite each young woman to read one of the stories, retell it to the class in her own words, and identify what role the Holy Ghost was playing in that story. Encourage the young women to share their own experiences in which the Holy Ghost has helped them in any of these ways.
Ask the young women to share what they learned today. What feelings or impressions do they have? Do they understand the roles of the Holy Ghost? Do they have any additional questions? Would it be helpful to spend more time on this doctrine?
Live what we are learning
Invite the young women to consider how they will live by what they have learned today. For example, they could:
- Determine one way they can better prepare themselves to hear the still, small voice of the Holy Ghost.
- Write down and act on impressions they receive from the Holy Ghost during the week.


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Have you ever wondered what it would be like to shoot a bow and arrow?
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Dynamic Leadership Institute (DLI)
The Dynamic Leadership Institute, known to many as DLI, is designed to teach students
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on campus, within the community and in their futures.
Each of the four phases allows students to view leadership from different perspectives and provides opportunities to examine and enhance their skills.
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• Phase 1 "Leadership Initiative" --- is designed to enhance participants' basic leadership skills and abilities.
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VIP (Volunteerism In Progress)
Volunteerism In Progress is an organization where students, faculty, and staff work together to make a difference in the community. VIP will organize multiple drives and volunteer opportunities during each semester. Each project will aid a different organization in the Owensboro area, giving students the chance to be involved with numerous community organizations.
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Welcome back to the Scattered Shots. Instead of continuing the So You Want to be a Hunter series, this week I thought it would be good to take a break and review the changes in Patch 3.3. So join me, Eddie "Brigwyn" Carrington from the Hunting Lodge as we explore the ins and out of what's instore for us hunters.Patch 3.3 is on the PTR and as we download the patch we've been busily reviewing the patch notes along with the unofficial information from posted up over on MMO-Champion. Without giving everything away in the first paragraph, let's just say that this is looking to be one awesome patch. Without going on about how good it is, let's take a look at what's being said.
From the PTR Patch notes we got to see some insight where Blizzard's development team is taking our class.
- Misdirection: Redesigned. Instead of having finite charges, it now begins a 4-second timer when the hunter using Misdirection performs a threat-generating attack, during which all threat generated by the hunter goes to the friendly target. In addition, multiple hunters can now misdirect threat to the same friendly target simultaneously.
Giving some thought to Misdirection being on a timer instead of being 3 shots, we won't lose one or possibly more of our shots to Auto Shot. So this means you can fire off 3 of our instant shots (Black Arrow, Explosive Shot, Arcane or Multi-Shot) to generate threat towards the tank.
Another possible use for Misdirect now will be using traps like Explosive Trap or the recently buffed Volley to generate threat on either a single or multiple targets. Laying down a trap, pulling the mob over it and then letting loose a Volley attack could give 4 seconds of constant damage while helping a single tank maintain threat on multiple targets.
(A note for new hunters, don't make a mistake and use Distracting Shot with Misdirect. Distracting Shot has a taunt that will automatically increase your threat and won't work with Misdirect.)
That's not all of the official changes though. Beast Mastery and Pets are getting some more love this patch.
Beast Mastery
- Intimidation: If the hunter's pet is in melee range of its target, the stun from Intimidation will now be applied immediately instead of on the pet's next swing or attack.
- Avoidance: Now reduces the damage your pet takes from area-of-effect damage by 30/60/90%, but no longer applies to area-of-effect damage caused by other players.
The change to Avoidance is an interesting one also, its a definite buff to PvE and a nerf to PvP. Applying only to NPC mobs it will allow the pet to avoid 30/60/90% (up from 25/50/75%) of the damage from area-of-effect attacks by mobs. It is nice, but it won't necessarily mean our pets will survive every area-of-effect attack. It should mean less healing will be needed which will help increase our DPS numbers, but we'll still need to cast a Mend Pet every now and again.
The downside is it no longer applies to attacks caused by other players, so this probably means even more of a blow to those hunters on Arena teams.
Now that's all the official news. However that's not to say that's everything coming down the pike. We've heard from Boubouille over on MMO Champion of even more good things.
It seems that along with some of the other changes to help speed up and improve the leveling experience for lower levels, Mend Pet and Scare Beast both look to have their mana cost reduced at the lower ranks. Now I'm not a huge fan of Scare Beast unless I'm trying to get a pesky feral druid off my back, but anything to help Mend Pet is a plus in my book.
The Marksmanship tree looks to be getting some attention also. First we see a lower levels mana cost reduction for Aimed Shot, Arcane Shot, Multi-Shot, Serpent Sting, Volley and Hunter's Mark. This will benefit pretty much every hunter and not just Marks since we use most of these as we're leveling.
Also, Silencing Shot's tooltip is being modified stating that NPCs will be affected by a 3 second interrupt, but not players.
And just when you think that the developers have made enough changes, we see our Survival brethren getting some developer love also.
First, Wyvern Sting, Mongoose Bite, Raptor Strike, Counterattack, Freezing Trap, Explosive Shot will have their mana cost reduced at lower levels also.
Earlier, I mentioned how Explosive trap might be a good tool for Misdirect. Lay the trap, fire Misdirect with a follow-up shot and you'll see threat being increased while you pew pew away. If Blizzard goes through with the suspected change to Explosive Trap by increasing its damage to all enemies to be Ranged Attack Power + 900 Fire damage over 20 seconds, those first 4 seconds of damage could build up a lot of threat for your tank. I'm thinking this is a strategy we might seriously need to be considering as we move into Icecrown and the new instances and raids.
Also, Point of No Escape will now increase the critical strike chance of all our attacks on targets affected by Frost damage. This is technically a nerf because before it increased the critical strike chance of all our attacks. Time will tell as we run through the Icecrown just how big of a nerf this is.
I remember when Patch 3.2 was announced and everyone was up in arms over Lock and Load getting a cooldown. My argument then was if the number of procs didn't match what Blizzard was estimating, we would probably see the cooldown reduced. Unofficially, it looks like Lock and Load's cooldown will be reduced from 30 to 22 seconds. I'm sure that will be a welcome change to all.
Besides all of the skill and talent changes, some information has also been released on some new Leatherworking patterns that can be used for hunters. Unlike before where a hunter might decide to sacrifice Armor for increased Crit Rating, the new patterns all have the same stats making it advantageous to select Mail instead. For example if we compare the items below from MMO-Champion we can see that it just doesn't make sense to make that choice any longer.
Blessed Cenarion Boots and Footpads of Impending Death
Earthsoul Boots and Rock-steady Treads
An odd observation that many including myself have noticed is the distinct lack of Intellect on these new items. This is leaving some to speculate we might be seeing Focus added to the game sooner rather than later. Considering that this change hasn't been reflected on the PTR and I haven't seen any blue posts responding to this, I can only say it remains idle speculation at this point.
One thing I can say with confidence, Patch 3.3 is one patch that is showing Beast Master hunters some real love as well as setting us up for more fun to be had in Icecrown and then Cataclysm.
You want to be a Hunter, eh? Well then you came to the right place. Scattered Shots is the one column dedicated to helping you learn everything it takes to be a Hunter. Each week Scattered Shots will cover topics to help you Fix Your DPS, Choosing the Right Spec, Gear Selection, Macros and Pet Selection, Pet Specs and Management.