text:
What's new?
Take the JIRP Alumni Survey!
As part of our 70th anniversary celebration efforts, we are actively reaching out to alumni for some bits of information. Some items allow us to keep you in the loop with electronic communications, while others help us gather some data that we can use when applying for grants and other funding. All information is kept confidential and is NOT shared with outside agencies.
As a way to say "thank you" for participating, we will send you a limited edition 70th anniversary FGER/JIRP patch! We look forward to hearing from you!
Successful AGU Fall Meeting!
JIRP staff and students attended the week-long American Geophysical Union (AGU) fall meeting, December 13-18 in San Francisco. Thank you to everyone who stopped by our booth in the Exhibit Hall to ask questions, learn about the program, and talk to JIRPers. We met lots of alumni and many more interested participants- who we hope to meet again!
We are very proud of our JIRP 2015 students and faculty who presented posters and gave talks during the conference. Most importantly, our students were able to present their research through a number of posters, listed here. Click on the links to read the full abstract.
A Survey of Spatial and Seasonal Water Isotope Variability on the Juneau Icefield
Reflectance Spectra of the Juneau Icefield
Estimating Temporal Redistribution of Surface Melt Water into Upper Stratigraphy of the Juneau Icefield
Spatial and Temporal Variability of Winter Accumulation on the Taku Glacier, Southeast Alaska, between 2012-2015
Taku Glacier Dynamics in Response to Regional Climate Variability and Predicted Change
Bed Properties of the Taku Glacier from Flowline Modeling Inversion
Book: Memories of Maynard M. Miller
In 2011, then-JIRP Director Jay Fleisher spearheaded an effort to create a book for Dr. Miller. We are happy to announce that Memories of Maynard M. Miller and Other Juneau Icefield Lore is now available in a revised, spiral-bound 2nd edition. Total cost, including shipping and handling, is $35. All proceeds go directly to JIRP. Order your copy today!
Preview the first 13 pages here
Orders can also be made with a check (made out to FGER) sent to: FGER, 4616 25th Avenue NE, PMB 302, Seattle, Washington 98105
Remembering Maynard M. Miller (1921-2014)
Explore and contribute to the memory of Dr. Miller's legacy at the JIRP blog. Help us remember and honor his life.
Joan W. Miller JIRP Scholarship Fund
Announcing the Joan W. Miller JIRP Scholarship Fund - Your donation directly helps cover tuition costs of selected participants so that the JIRP experience can be accessible to all prospective students.
Maynard M. Miller JIRP Legacy Fund
Help us build a bright JIRP future! Please consider supporting JIRP through a donation to the Maynard M. Miller JIRP Legacy Fund.
The priority consideration period for applications to JIRP 2016 has now closed. Applicants who submitted complete application packets by February 15th have been reviewed and notified of their admission status. Please contact us at firstname.lastname@example.com if you have questions or would like to inquire about available space for this year.
*Please note that the 2016 field season has been extended by one day. JIRP 2016 will run June 24 - August 20.*
Thank you to everyone for a successful 2015 season!
JIRP Affiliates Continue to Receive Awards for "From Icefield to Oceans" Poster
Designer and JIRP faculty, Kristin Timm, along with her collaborators, JIRP Board member Dr. Shad O'Neel, Dr. Eran Hood and Alison Bidlack (both former JIRP faculty), were recognized at this year's Visualization Challenge competition -The Vizzies. In addition, these researchers have just received the 2015 Eugene M. Shoemaker Communication Award.
Their illustration, entitled "From Icefield to Ocean", was one of 300 entries in the annual "Vizzies" competition and was honored with the People's Choice Award. The Shoemaker Awards for External Communications recognize USGS products that demonstrate extraordinary effectiveness and translating complex scientific concepts and discoveries into words and pictures that capture the interest and imagination of the American public.
The figure they developed depicts the important linkages between glaciers and the ocean. They felt it was particularly important to find a compelling way to communicate these research findings to Alaskans because Alaska's coastal glaciers are among the most rapidly changing on the planet and glacier runoff can influence marine habitats, ocean currents and economic activities.
The figure was published in the March 2015 issue of Popular Science and can be seen along with other contest winners online http://www.popsci.com/icefield-ocean-alaska.
Copyright 2014 Foundation for Glacier and Environmental Research (FGER), unless otherwise noted.


text:
4 of 5 people found the following review helpful
A must read (but very carefully!) if you have interest in banking.,
Verified Purchase(What is this?)
This review is from: The Bankers' New Clothes: What's Wrong with Banking and What to Do about It (Hardcover)
In my view, this is an 80% correct book. It has some very questionable statements (like "more equity has no cost to society", or that Basel II internal models are to blame for the crisis - Basel II was implemented at year-end 2007 and the internal models only a couple of years later). But this book make us think!
The first chapters seem like "debt for dummies" (the notes, very inconveniently placed at the end of the book, are much better!). However, when the authors enter into questioning regulations, the book becomes very interesting. A must read!
I do not agree with most of the conclusions, but it is a pleasure reading the book: I have to rate it with 5 stars.
Review Details
(15 customer reviews)
Top Reviewer Ranking: 743,926

subset: commoncrawl


text:
James spent the eve before what he called, possibly, the biggest game of his career, with his family and friends. His old high school buddies are in town.
He joked about watching SpongeBob SquarePants with his kids the night before the game. But his mind never truly left the arena after Game 6.
He scored 18 points in the fourth quarter and overtime after the Heat trailed by 10 points to begin the final period of regulation.
"I want to go down as one of the greatest," James said. "I want our team to go down as one of the greatest teams.
"And we have an opportunity to do that."
Down to the wire
The Heat hasn't won back-to-back games since Game 1 of the Eastern Conference finals. That's no longer a trend to worry about, says Dwyane Wade, who predicted Wednesday that Game 7 "will be to the very last second.
"The reason this series hasn't had a lot of consistency in the sense of teams winning two games in a row is because there are two good teams," Wade said. "Two great coaches, coaching staffs, and credit to everyone in this series for that.
"So I think — I know that (Game 7) will go down as one of the best final games that's been seen. But I think this series will go down as being one of the most competitive, bizarre series that's been seen.
"So this is what you pay for to watch. You pay to watch two great teams battle to the very, very end, and that's what we'll do."
©2013 The Miami Herald
Visit The Miami Herald at www.miamiherald.com
Distributed by MCT Information Services
PHOTOS (from MCT Photo Service, 202-383-6099):
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text:
Terrorism suspected in crash of Egyptian plane; 66 missing
CAIRO (AP) — An EgyptAir jetliner en route from Paris to Cairo with 66 people aboard swerved wildly in flight and crashed in the Mediterranean Sea early Thursday, authorities said. Egyptian and Russian officials said it may have been brought down by terrorists.
There were no immediate signs of survivors.
- Written by MAGGIE MICHAEL, Associated Press ELENA BECATOROS, Associated Press ANGELA CHARLTON, Associated Press


text:
List all words ending with angsts
Only the word angsts was found, nothing longer.
Some random words: boff mu eryngo aiglet eicosanoid beery amateur
This is not a dictionary, it's a word game wordfinder.
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It's a tee. It's a dress. It's the new Graphic T-shirt Dress.
A few presents from Stan and Ollie- L K Southward- Iconic Art UK.
posed films hardy suits ollie stan laurel bowlers red white gold black green holiday portrait sketch pencil christmas hollywood humour stars comedy cry festive hats season movies
Fantastic as always… your talent never ceases to amaze!!!!!
Thanks Kevin
What a fabulous Christmas Card this makes! Extraordinary image of these two…love it!!
This was used as Christmas cards last year Dyle. Thanks for your comment ;-)
lovely !
Great picture. Love the use of the red and green.
Thankyou Serenity!
Nice One :o)
Thanks Michelle!
Simply brilliant again LK…well done indeed :))
Thanks as always ;-)
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Reading mode: Light Dark
Forum indexNikon SLR Lens TalkChange forum
How to quality check a Nikon lens?
Started Jun 8, 2013 | Questions thread
Shop cameras & lenses ▾
87350iroc • Junior Member • Posts: 43
Re: How to quality check a Nikon lens?
In reply to AJB 1883 • Jun 8, 2013
AJB 1883 wrote:
I just purchased a Nikon 400mm f2.8 lens and it is slated to arrive soon. Can anyone provide a thorough process to assure the lens is 100% functional and tack sharp. The lens will be mated to a Nikon D3. Thanks.
I would go out and start using it like you plan to always use it. Then decide if you are happy with the results.
87350iroc's gear list:87350iroc's gear list
Nikon D600 Tokina AT-X Pro 100mm f/2.8 Macro Tamron AF 28-75mm F/2.8 XR Di LD Aspherical (IF) Nikon AF-S Nikkor 28-300mm f/3.5-5.6G ED VR Nikon AF-Nikkor 80-200mm f/2.8D ED +5 more
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Written on: 08/07/2009 by CarmelitaV (1 review written)
Good Points
Nice and tart and fizzy!
Bad Points
They are so good that I bite them all away too soon.
General Comments
I really like the Bassetts Refreshers fizz factor!
As rated by our community of reviewers
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text: Word of the Day – Hospitalist By Lauren Bigica April 1, 2014 7:37 AM Share on Facebook Share on Twitter Southern Stock\Getty Images Today's word of the day is: Hospitalist Dictionary.com defines hospitalist as: noun a physician who specializes in treating hospitalized patients; a specialist in inpatient medicine. Have you ever had to see a hospitalist while being in an hospital? Filed Under: Definitions | Dictionary | Hospitalist | Word of the Day Category: Bob & Marianne in the Morning | Word of the Day Share on Facebook Share on Twitter More Leave a comment Send to a friend! Print this page Pin it! Reddit This! Share on Tumblr! Best of WOBM-AM 'Street Smart NJ' campaign reaches Jersey Shore Jersey Blueberries turn 100 and is cause for celebration Adult Summer Camps are becoming a popular get away destination Asbury Park police officer, sibling indicted in insurance fraud case Recommended For You ZergNet Best of the Web ZergNet


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10 /PRNewswire/ -- The Government Supplies Department of Hong Kong has awarded a contract to Raytheon Company (NYSE: RTN) to supply a Terminal Doppler Weather Radar (TDWR) system to service the new airport at Chek Lap Kok.
What does GSD stand for?
GSD stands for Government Supplies Department
This definition appears somewhat frequently and is found in the following Acronym Finder categories:
- Military and Government
- Organizations, NGOs, schools, universities, etc.
See other definitions of GSD
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- Good Student Discount (insurance)
- Gorham-Stout Disease
- Gott Sei Dank
- Government Services Directory


text:
John Bercow wrongly outs rugby star Ben Cohen in gay gaffe
Post your comment
Comments on this article are now closed.
Reader comments
I know a few Rugby Players that are gay. Oddly enough one of them keeps getting suspended for violent conduct…..
More clues please. Nationality for starters.
These are LOCAL rugby players. Local to me. I doubt you'd know any of them ;)
Well he does look a bit like the proprietor of Pink News, so easy mistake to make
Bercow is such an irritating little prick.
He should stay out of things that don't concern him. (Ditto his harpy of a wife)
He might be irritating, but his support for equal rights for gay people here and abroad (he's the honorary president of the Kaleidoscope Trust) has been constant and is, I believe, sincere and disinterested, and therefore is very welcome.
Totally agree with that.
He's still a prick.
His wife is waaaaaay worse. She broadcasts stupidity every time she opens that gob of hers.
Her "stupidity", as you put it, includes ardent and constant support for the LGBT community, women's rights and children's rights. I reckon her "gob" is far more useful than yours!
Oh whoopee-do.
You are the sort of person that would support Attila the Hun and his murdering Mongol hordes so long as they waved a rainbow flag as they slaughtered the masses.
Gaffe aside, I can see the humour in it as did Bercow and Cohen.
The point is some people can not even imagine straight guy would fight for LGBT rights. So sad! Thank you Ben for being good sport.
To be fair, it s far harder for bisexual married men to come out as bisexual for obvious reasons than for gay men to come out. And is it not right that someone should once in a while assume someone is gay when a lot of the time the world is assuming people straight who are not?
This is bit of a Non Story, Ben is straight & pro LGBT rights & Bercow made an error, thats all.
I wish Ben was Gay because I think he's simply delicious! Lucky wife.
Get to the back of the queue!
A Jewish rugby player? Aren't most Jewish people supposed to go after… ehem… smarter careers tha rugby?
As for gay, straight, bisexual, gay promoting… people are people and who someone puts into bondage and spanks with a rubber flogger is nobody's businesee (as long as both are over the age of consent).
These comments are un-moderated and do not necessarily represent the views of PinkNews. If you believe that a comment is inappropriate or libellous, please contact us.
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text:
Pathfinder Roleplaying Game: Pathfinder Unchained (OGL)
Ultimate Occult (PFRPG) PDF
Into the Breach: The Rogue (PFRPG) PDF
In The Company of Treants (PFRPG) PDF
Mini-Dungeon #029: Heart of the Sacred Dawn (PFRPG) PDF
TORG RPG: The Character Collection
West End Games
A Storm Knight party is only as good as its members. Now the mysterious Guildmaster has assembled the files on some of the most experienced heroes and most dangerous villains of the Possibility Wars into one volume.
Within these pages, you'll find Ayslish sorcerers, Nile heroes, Orrorshan shapechangers and countless others who might aid - or destroy - your team of adventurers. Each comes complete with a list of accomplishments, an evaluation by the Storm Guild, and a full template. Storm Knights in need of allies, or potential foes, need look no further.
This supplement to Torg: Roleplaying the Possibility Wars features 60 pregenerated character templates, suitable for use as advanced player characters or gamemaster characters. Also included are rules for generating your own advanced characters.
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Paizo Announces the Starfinder Roleplaying Game,
Ancient Lands, Eldritch Secrets, and Vast Riches Await in Pathfinder Adventure Card Game: Mummy's Mask,


text:
Can i sli on the MSI 870a-g54
Last response: in Motherboards
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text:
August 1, 2007
| Article
Denver's Ya Ya Nail & Massage Spa offers a relaxed and casual atmosphere where women can catch up and talk while they enjoy exotic beauty treatments like the Choc-o-lot Razzzberry Pedicure or the Linen Herb Facial.
M&M Nails & Wellness Center wins 2007 Salon of the Year award. Owner Maisie Dunbar calls it "the pinnacle of my nail career."
July 27, 2007
| News
Effective May 11, 2007, American International Industries will be the sole distributor of the ProLinc brand line of products.
July 1, 2007
| Article
Sree Roy travels to Baytown, Texas, for family, and for relaxation.
Deborah Lippmann, nail tech and polish manufacturer. In her other life: jazz singer.
June 1, 2007
| Article
Cindy Wentzel, salon owner. In her other life: show dog owner and handler.
Situated in an upscale Boston suburb, MiniLuxe Nail and Beauty Lounge bridges the gap between the small corner nail salon and the day spa, offering high-quality treatments in a clean, modern environment, while still keeping prices affordable for customers.
May 11, 2007
| News
Regis Schools and Empire Beauty Schools have merged to form Empire Education Group.
The American Association of Cosmetology Schools has designed a website just for educators at www.beautyeducators.org.
May 1, 2007
| Article
Do you sit at your workstation and dream of brighter days when you're on your own? Do you imagine all the things you would do if this were your salon? Five techs who accomplished their dream of salon ownership tell us if it's all they imagined.
For some, being a nail tech isn't just a job; it's a way of life. Meet five families who have a shared passion for their profession. Working together has helped to build a solid foundation for each of their family trees.
Melodie Hand, nail tech. In her other life: chocolatier.
Created to feel like your trendy best friend's home, Honey Nail Salon & Boutique uses some innovative business ideas to show Atlanta just how sweet a little boutique beauty can be.
April 30, 2007
| News
On Friday, April 27th, the NAILS Magazine Editorial and Graphics team were recognized for journalism and design excellence at the 56th annual Western Publications Association (WPA) Maggie awards ceremony.
See the Faces Behind the Online Handles at 2016 Nailtech Networking Event101 photos
InternatioNAILS: Australia Gallery15 photos
A 37-year veteran of the nail industry, Lin Halpern may not be someone whose name you know, but surely you've run across at least one of the...
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text:
Mitsubishi Lancer
Dave Moore takes the Mitsubishi Lancer for a test drive.
Nissan builds drone to race its GT-R
We won't own cars any more - we'll share them, forecasts Toyota NZ boss
Toyota Corolla hybrid - the bridge to whatever the ultimate eco-car will be
Expensive Porsche SUV ruined in teen's parking panic
Wellington's Mt Victoria tunnel upgrade complete
Fiat Chrysler accused of concealing defect in Jeep Grand Cherokee
Special Lamborghini Aventador pays homage to Miura
VW to pay over US$10b for US emissions scandal - sources
Taking flight across the US on a Honda Gold Wing
Who should a driverless car try to protect if a crash is unavoidable?
Behind Tesla carnage, signs of support for Elon Musk's SolarCity deal
Bus breakdown causes delays as new Wellington smart motorway switches on
Palestinian's classic car replica turns heads in Gaza
Man chased by police after driving wrong way through one-way tunnel near Kaikoura
How Australia stripped an Australian of her citizenship
Disgust and worry after 'brutal' attack on elderly man at Hastings home
McDonalds registers 'McDelivery' service trademark in New Zealand
'Bordering on the ridiculous': Hansen says global season can't come soon enough
Awkward family photos around water
World's Ugliest Dog crowned a winner
Modest two-bedroom home in Mangere Bridge fetches $1.7million at auction
Why we should all be attention seekers
Beauden Barrett makes most of opportunity at No 10
Black Power motorcyclist killed in Puhoi on way to tangi
Lions capable of putting bite on All Blacks in 2017: Gatland
McDonalds registers 'McDelivery' service trademark in New Zealand
'Bordering on the ridiculous': Hansen says global season can't come soon enough
Mark Reason: We deserve better analysis from host of former All Blacks in TV rugby commentary
Small number of taxpayers bear the brunt of New Zealand tax bill
Families grieve four killed in horror high-speed crash in Hamilton
Police complaint after hotel manager outs cheating lovers
Young mum among four people killed in high-speed crash near Hamilton
Spidercam incident leaves Wallabies coach Michael Cheika fuming
Mark Reason: We deserve better analysis from host of former All Blacks in TV rugby commentary
More than 2 million sign UK petition for new EU referendum
All Blacks player ratings: Great night for Barrett, Dagg, Retallick as Welsh swept
82-year-old grandmother rejects $27 million offer so she can stay in her home
England complete 3-0 series sweep of Wallabies in Sydney try-fest


text:
Written on: 28/02/2014 by ArmaniHodges (1 review written)
Ordered boots 5 and a half weeks ago and they still haven't arrived. I sent an email to customer services after 3 weeks but never got a reply. Phoned last week and told they would be here this week but they aren't , just phoned again surprise,surprise there is a delay and they won't arrive for another week and a half. That will be 7 weeks in total. They have offered to refund my delivery which £5.95 for 7 weeks delivery that should have been done without making it out as a big gesture.it takes ages to speak to anyone when you phone I was waiting for nearly 10 minutes.I will never buy from them again.
As rated by our community of reviewers
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Written by Beccie28
" 50 mm half-size Figure Foam Tray with base 8 large cut outs " Read More
" Avoid at all Costs " Read More


text:
Last update: Thursday 23 June 2016 [150 news items]
Neo Solar Power nets NT$1.02 per share for 1H14
Stockwatch - Jul 25, 11:42
Crystalline silicon solar cell maker Neo Solar Power on July 24 released its financial report for the second quarter of 2014, posting net EPS of NT$1.02 for the first half of the...
Neo Solar, Gintech, GET see sequential drops in June revenues
Jul 7, 14:42
Crystalline silicon solar cell makers Neo Solar Power and Gintech Energy and solar-grade crystalline silicon wafer maker Green Energy Technology (GET) saw consolidated revenues for...
Neo Solar aims at 95MWp in PV system installations in 2014
Jun 12, 11:54
Solar cell maker Neo Solar Power has set a goal for its subsidiary PV EPC (engineering, procurement, construction) contractor General Energy Solutions (GES) to achieve 95MWp in total...
Neo Solar launches new PV modules
Jun 4, 20:34
Crystalline silicon solar cell and PV module maker Neo Solar Power on June 4 unveiled three new PV modules at the 2014 Intersolar Europe exhibition taking place in Munich, Germany,...
Neo Solar, Gigastorage April revenues hit records
Stockwatch - May 7, 11:06
Taiwan-based crystalline silicon solar cell makers Neo Solar Power, Gintech Energy and Solartech Energy as well as solar wafer makers Gigastorage and Green Energy Technology (GET)...
Neo Solar Power March revenues hit record
Stockwatch - Apr 8, 14:33
Solar cell maker Neo Solar Power has reported consolidated revenues of NT$2.518 billion (US$82.9 million) for March, hitting a monthly company record.
Neo Solar Power to deal out cash dividend for 2013
Stockwatch - Mar 19, 12:08
Solar cell maker Neo Solar Power's board of directors has decided to distribute a cash dividend per share of NT$0.30 (US$0.01) for 2013.
Neo Solar, Gintech, GET see sequential drops in February revenues
Mar 7, 11:13
Solar cell makers Neo Solar Power and Gintech Energy, and solar wafer maker Green Energy Technology (GET) have reported sequential declines in February consolidated revenues: NT$2.335...
Neo Solar, Topcell Solar to procure solar-grade wafers from GCL-Poly
Mar 5, 11:54
Taiwan-based solar cell makers Neo Solar Power and Topcell Solar International will buy high-efficiency polycrystalline silicon wafers from China-based GCL-Poly Energy Holdings, according...
Neo Solar, GET report strong December sales
Jan 7, 11:03
Crystalline silicon solar cell maker Neo Solar Power generated December consolidated revenues of NT$2.406 billion (US$80.2 million), hitting the highest since March 2011 and increasing...
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Global definition: Masks are the interface between the rescuer and the patient with failing breathing - when a more technical solution is desired than mouth to mouth expired air resuscitation. {Other adjuncts may be used instead as an interface, but the essence is a mask or device between the patient and his helper.}
Anatomic & Physiologic Concepts:
The normal support of the natural upper airway is a dynamic neural balance of tone in soft tissues, pharyngeal dilating muscles, and the sensing of the presence and passage of gasses, liquids, or solids in the aerodigestive tract while appropriately activating protective reflexes in the epiglottis and glottis to prevent contamination of the lungs.
The airway is at risk if any of these controls fail and flaccidity occurs or physical blockage by foreign substances occurs. Life is preserved if timely actions are taken to remove obstruction, support an open airway, and support or replace natural breathing.
The quickest and simplest effective means of assistance is with the hands and lungs of the first willing rescuer. If it is desired to have an artificial interface (avoiding close personal contact) or to use adjuncts, oxygen, and mechanically control and monitor breathing, a mask is usually the first such used.
The layman's simple opening of the airway (for rescue breathing) has an air path that is somewhat zigzag; air does go in and out but the visual path for intubation is not the same. The layman will likely only have head-tilt and chin-lift in a supine patient. You can give more effective bag-breathing and also be prepared for laryngoscopy/intubation by ramping the torso to a 25° to 35° angle (or reverse Trendelenburg's Position) with the ear canal level with the manubrium/sternal notch and the face parallel to the ceiling.
This coordinates axes of line of sight and the angle of the glottic vestibule (c.f., K.B. Greenland's two-curve theory); unloads the visceral weight that impedes the diaphragm, thus, increasing functional reserve capacity; and may well minimize silent aspiration of regurgitation. [Frank emesis in an unconscious patient will require tipping the table head-down with aggressive suctioning and mopping of the oropharynx and additional tracheal suctioning to determine if aspiration has occurred.]
#1. The worst: The classic errors are placing a pillow under the head of an unconscious person to "make him comfortable" and pressing the mask downwards on the face. The pillow lifts the head flexing the neck and lowering the chin. Pressing the mask downwards further collapses the airway, and rotates the head forward. Soft tissues are squeezed together and obstruct the air flow; airway pressures increase; air more likely is diverted into the stomach; vomiting is likely. Safar's research found "Flexion of the neck caused complete obstruction in all 80 patients previously studied."
#2. Gasp: Overcompensating for an uncorrected partial airway obstruction by bagging harder, faster, without an adequate expiratory interval, will stack breaths (as the lungs don't deflate, before the next breath is forced in). Great harm such as pneumothorax or migration into other spaces may occur. Little true ventilation occurs. Excess volume is diverted into the stomach and vomiting will ensue.
#3. Grasp: Excessive pressure using the mask fatigues your hands, makes leaks more difficult to seal, can abrade the corneas, injure facial nerves, and leave bruises in the shape of your hands and the mask in those who are over-anticoagulated.
#4. Poor Fit: Choosing (or making do with) the wrong mask size makes controlling leaks more difficult. Some adjustments can be made: sliding the nose of the mask a little farther down; the lower edge can be sealed between the lips; invert the mask to use as a nasal mask while holding the lips shut. A large mask is often easier: spread the mask more widely on the face; or invert the mask using the wide base across the nasion and malar area while cupping the chin by the point of the mask. An oral airway can lengthen the face slightly, while a nasal airway does not.
#5. Poof: Not separating the lips blocks outflow. Obstruction by a floppy soft palate acts like a one-way flutter valve that blocks outflow. Sleep breathing would be inspiratory snoring and expiratory poof or sputtering between the lips. Expiratory obstruction occurs when both palatal obstruction and closed lips happen at the same time: this is about 20% occurrence. Keep the lips apart. Drop the chin from the mask during exhalation. An oral or nasal airway solves it. The nasal airway is less likely to "gag" the patient if level of consciousness varies and is more easily tolerated than the oral airway.
#6. Too Tight: Holding the mask too tightly is the reflexive reaction of the panicked and frustrated person. It can cause injury; may worsen mask fit (especially with an overinflated cuff on the mask); and does not examine or fix actual problems. If this carries over to not noticing regurgitation or vomiting and ventilation efforts continue without clearing the airway, disaster follows as the soiling is blown into the trachea and lung.
#7. Too Loose: Persistent defects in sealing the mask to the face cause leaks that deliver ineffective volumes and dilute any oxygen delivered. Novices and persons with small hands may find it difficult to impossible to adjust the mask in several places simultaneously especially with one-hand bagging. Contributory defects of facial contour (wounds, edentulous, cachexia, scarring) may require filling of the defect, a different rescuer, two or more hands on the mask, or bypassing the problem with airway devices.
Teeth & Leaks; Dentures should be in place to maintain contour (with caution to prevent damage or swallowing); they are removed to make room for intubation efforts. A soft mask cuff helps if dentures are not available. Cheeks can be plumped out with gauzes or towels (with caution to avoid migration into the glottis or "losing" them. Using a two-hand mask hold, one can cup the cheeks upwards from below with the sides of the hands and "bunch" them into the cuff of the mask; the mask is held by the two thumbs in parallel.
Beards: There are two problems with beards when managing the airway.
1). A large bushy beard can cause air leaks and poor seal, especially when compounded with vomitus, blood, etc. The traditional suggestion is to apply surgical lubricant to minimize leaks, although this, too, may be messy. A newer recommendation is to use plastic wrap or an adhesive transparent dressing over the beard, fitted well to the lips and provide an oral slit through which to breathe. This blocks leaks and keeps the mask from slipping. Always remember to bypass this problem by a better interface: a modified nasopharyngeal airway; supraglottic airway; or intubation. 2). Even a tidy beard may conceal the reason for which it might be worn –to disguise a receding chin which may represent a short mandible that can make for difficult intubation, and possibly difficult ventilation if the tongue base is large.
The Triple/Quadruple Airway Maneuver:
©Murphy, MF &Walls, RM2001 Based on Langeron
#11. Not Monitoring Clinical Effect: Whenever possible, pulse oximetry and waveform capnography should be in place. Even a colorimetric CO2 detector, in austere circumstances, should be used to detect obstruction or ventilation. Pulse oximetry is limited in being masked by oxygen supplementation and in delay of detecting decreased saturation. The clinician should continuously "look, listen, and feel" for effectiveness of ventilation.
#12. Cervical Spine Injury? When neck injury is suspected, caution is urged. Maintaining alignment, avoiding flexion or extension, and using a jaw thrust that juts the lower anterior teeth forward of the upper; it then should be reinforced with an oral airway or supraglottic airway. Endotracheal intubation should be done by those with the experience and tools for doing so with the least neck movement.
#13. Why aren't you using an SGA, or ETT? Mask breathing is a transitional and sustaining treatment when breathing efforts are inadequate. If support must persist, the airway should be kept open with an appropriate device. Personnel entrusted with face mask ventilation should also be provided with appropriate devices and skills suitable for longer periods or adverse circumstances.
#14. Why are you bagging at all? Humans are not very consistent with bagging. Ventilators are consistent, untiring, adjustable, and monitors itself for performance. They're better at oxygenating and maintaining the patient. Both hands are free if you're holding the mask, or you can prepare for a more definitive airway.
#15. Have a PEEP valve! A PEEP (Positive End-Expiratory Pressure) valve holds in part of the last breath given allowing the residual pressure to hold open the airway and alveoli like a partially filled balloon; this aids in oxygen penetration and overcoming shunt physiology.
PEEP isn't CPAP without continuous forward flow. CPAP is Continuous Positive Airway Pressure throughout the respiratory cycle. Bag-Valve-Mask units are binary; inflation flow & pressure, and after expiration = zero flow. BVMs vary in how easily a patient can take a spontaneous breath. In the NODESAT method of preoxygenation and apneic oxygenation that additional forward flow is by a nasal cannula at 15+ LPM plus the BVM at 15+ LPM; this is intended to provide a refilling of the "reservoir" effect of the natural dead space so that blood flowing through the lungs can by pressure gradient have oxygen diffuse into the blood stream and allow a longer safe apnea interval.
The flow-inflating bags in various anesthesia circuits classified by Mapleson's system can provide CPAP seamlessly with a good face mask seal, adjusting flow, and monitoring or limiting airway pressures by gauge or a pressure limiting valve; however, those not familiar with these tasks feel think it more difficult and are discouraged that it's too hard. If there's no mask leak, there are no problems; just watch the patient, track flow and pressure, and provide exhalation. #16. The Distressed Patient Hears You. Remember that the "sense of hearing is the last to go." He hears your anxiety; he is comforted by your calming voice directed to him. He may hear what you don't expect or what you hope that he doesn't hear. Speak to him by name, calmly and frequently, to convey assurance and expectation of relief or what is to come. No surprises - for either of you. A soothing voice soothes autonomic change.
DIDACTIC CONSIDERATIONS: Studies show that many levels of health care workers perform better bag ventilation when combined with an SGA than when using a mask. Most HCWs, other than anesthesia, emergency, and critical care staff, or paramedics, are obliged to only use a mask, or a mask/OPA ±NPA. Yet, while entrusted to use a BVM —arguably, the most difficult means of artificial respiration, use of an SGA is seldom permitted. Is it not reasonable that those responsible for and entrusted with BVM should likewise be entrusted with an approved SGA?
Recall that mouth to mouth and mouth to mask consistently outperform bag ventilation; and have an exquisitely sensitive feedback mechanism: the rescuer's own lungs. However, few individuals will actually apply mouth to mouth outside their own family.
Two is better than one: In training sessions, it's probably best to start practice with two-handed mask hold to learn and feel the mechanics of providing a really good airway. A triple or quadruple airway is easily achieved, and eliminating mask leaks is easier. Ideally, practice would occur on live patients or high-fidelity simulator to study the feedback and effectiveness. When this skill is mastered, then the student should learn one-hand masking, after which use of airway adjuncts can be introduced. Controlling the airway is like high-level equitation; the interactions must be continuously sensitive and sympathetic with the response. Which bag to use?
Those with a professional obligation to rescue, including health care settings, should use a self-refilling bag with approved adjuncts.
Those rescuers and health care workers with high frequency exposure to critical patients (and a relatively inexhaustible supply of oxygen) should also be competent with a flow-inflating bag learned with mentored supervision. The elegant versatility of the anesthesia bag will awaken the provider to many subtleties of mask ventilation. It does many things well, better than a self-inflating bag, but it must be in the hands of a skilled provider. In transport situations and others where the supply of compressed oxygen is limited, not only should a spare tank be available, but a self-refilling BVM, also, so that ambient oxygen can be given if failure occurs.
PDF of Article & References
Sincerely, Tom Trimble, RN CEN All opinions are solely those of the author. Readers must verify validity to their own practice.
A Reuters News Service report commenting on the recent "Hartford Consensus" headlines "The Average Bystander Won't Know How to Control Bleeding." This is something that any Boy Scout should know how to do. What has happened?
After World War II, there was a de-emphasis on using tourniquets in the field except as a last resort. Rightly so, for tourniquets are not needed except for rapid massive bleeding, which is seldom encountered in the civilian world. Times have changed, and fortunately, so has the science. Notably, field care and rapid evacuation to forward medical facilities has greatly evolved.
The wars of the Middle East have shown us that the leading cause of avoidable death is exsanguination. Without a sufficient quantity of circulating blood, one dies. If enough remaining blood can be conserved by the patient or his helper, the victim survives. With quick application of an effective tourniquet, the blood stays in. Many "improvised" tourniquets, e.g., belts, scarves, rope, unless applied tightly and secured to stay, will otherwise increase the bleeding.
When there is torrential bleeding, it must be stopped immediately by the patient or others who are there. It's not just "Call 9-1-1!" The "First Responder" is actually the patient or someone already there. For the soldier, it is self-aid, buddy-aid, the Combat Lifesaver in his squad, the Medic in the platoon. With immediate care and prompt evacuation (minutes, instead of the hours or days of yore) and prompt surgical care, they survive.
Having studied the avoidable causes of death, and finding the erstwhile fears of a prolonged tourniquet time in place to be no longer valid, the military has striven that each man has a tested and chosen tourniquet. Victims now survive rapid bleeding if it is stopped. When blood spurts from a large artery with each heartbeat, the body is soon emptied. With such wounds, a tourniquet becomes the FIRST RESORT, not the last resort. Here we give up the usual mantra of "Airway – Breathing – Chest Compressions" and instead keep the hemoglobin from spilling on the ground, as the patient's hearts are still breathing and beating.
Improvised Explosive Devices have come to many places that are not battlefields except in the minds of those who bring them there to assault the enemy in his safest places or homelands. People at the Boston Marathon did not expect a battlefield injury, but they were made victims of battle nonetheless. Survivals occurred because rapid bleeding was stopped immediately with effective tourniquets.
This year's Hartford Consensus (IV) undertook by bilingual telephone survey to sample the knowledge and willingness of the public to successfully intervene against bleeding. Only 47% had any first aid training; about half had it> 5 years ago; only 13% had training within the last two years. Of those who could give first aid, 92% claimed they would try to help in a car crash, but only 75% would try to help in a mass shooting if it was safe to do so. However, 98% would try to help a family member with a leg wound, but only a third would use a tourniquet.
I said that a Boy Scout should know how to stop bleeding. Indeed, he should, as should a Girl Scout, --or anyone else, for that matter. But how often have people refreshed or practiced what they know, or take advantage of learning it from organizations such as the Red Cross. Kids now, so often overscheduled, or with multiple sports commitments and extra-curricular activities, cannot be assumed to have been trained or to use what they once learned. If accustomed to Internet style learning, the knowledge points and skills may not have been fully mastered into active memory.
Does your department have an outreach public education program or a display in the waiting room from the local training organization?
Does your department even have tourniquets ready to go (without improvising) in case of need for a trauma victim? Or, for you or others, if you become the battlefield and yourselves your own First Responders?
Rapaport, Lisa. The Average Bystander Won't Know How to Control Bleeding. Tuesday, April 19th, 2016 4:58pm EDT. Reuters.
Jacobs, L. M., Burns, K. J., Langer, G.,& de Jonge, C. K. (2016). The Hartford Consensus: A National Survey of the Public Regarding Bleeding Control. Journal of the American College of Surgeons. Online March 31, 2016.
Jacobs Jr, L. M. (2015). The Hartford Consensus III: Implementation of Bleeding Control--If you see something do something. Bulletin of the American College of Surgeons, 100(7), 20. PMID: 26248396. Republished, by permission, by The Tourniquet Project. (q.v.)
Kellermann, A. L., & Mabry, L. T. C. (2015). Bringing a Battlefield Lesson Home. Academic Emergency Medicine, 22(9), 1093-1095.
Kragh Jr, J. F., O'Neill, M. L., Walters, T. J., Dubick, M. A., Baer, D. G., Wade, C. E., ... & Blackbourne, L. H. (2011). The military emergency tourniquet program's lessons learned with devices and designs. Military medicine, 176(10), 1144-1152.
Lex, Joseph R., MD. Combat Wounds: Vietnam Perspective, from One on the ground. ppt, (Updated, with Iraq, and newer treatments e.g. Tourniquets, Quick Clot, Asherman Chest Seal, etc.) Presented at DevelopingEM 2013. Presentation slides. Presentation audio.
Alam, H. B., Koustova, E., & Rhee, P. (2005). Combat casualty care research: from bench to the battlefield. World journal of surgery, 29(1), S7-S11.
U.S. Army Medical Department Center and School. Department of Combat Medic Training. COMBAT LIFESAVER COURSE: STUDENT SELF-STUDY. The Army Institute for Professional Development.
Sincerely, Tom Trimble, RN CEN All opinions are solely those of the author.Readers must verify validity to their own practice.
We're all aware of the "graying of nursing", and in the population at large of "the Silver Tsunami" as Baby Boomers withdraw themselves from their working years, whether in whole or in part. Many AENPs are in the maturity of their careers having "worked long and hard" to achieve Practitioner status, and are now, just plain, "working long and hard". AENPs, and Nursing, face a critical shortage of the most experienced members. Yet, each decision to leave is an individual calculation. Can I do the work? Do I enjoy it? Can I afford to go? Can I do a different kind of work? Shall I work at something full-time or part-time?
We encourage the young'uns, —who were able to enter, early in their careers, the programs that we had to wait to see created; to persevere gaining the experience which makes practice more successful and satisfying.
However, I poignantly remember a staff nurse colleague, who left the ED to work in the Post Anesthesia Care Unit, who when pressed for an explanation, said "I just wanted to be able to sit down!" It was true. Our constant succession of shifts were arduous and unrelenting. I wished him luck and envied his gumption in resolving his situation, and resumed work.
At times, it seems as if everyone is looking for a "day job," "a better gig," or just "greener grass." Retention of the wise, older, and skillful, —"OK, OK, I'll say it: —grayer", nurse. IS important. We know, among ourselves, that lower nursing ratios are safer and better for both patient and nurse. We want to be able to help them do that. We know that mentoring, leading, counseling, and giving institutional continuity and memory is beneficial to our workplace. Yet, our institutions know not how to do this nor make it feasible.
The tyranny of numbers in calculated FTEs or "productive" and "non-productive" hours work against us. In California, bedside nursing had the protective influence of a state-mandated Staffing Ratio. For EDs, the minimum ratio is 1 nurse: 4 patients. That ratio was not exceeded unless there was a major community event with likely increased patients and disruption. Hallway patients were staffed for during most likely hours. But the admitted patient 'without a bed" could not go upstairs to a lower ratio unit (Tele or ICUs) until a bed there was available, so the patient remained at 1:4, unless tying up the Code Room at 1:1.
The only options for respite were to take a leave of absence or accept a lower % appointment: i.e, if working 96-100%, one could not drop to 60% hours without resigning the original, and with no guarantee of ever getting it back if needed. Hours worked also militated against accrual of retirement credit if not full-time. Older staff would have to continue a grueling pace in order to maintain expectation of retirement "on time."
One might feel, too, as if there was, perhaps, (am I too paranoid?), perhaps, a benefit to management to replace exhausted older nurses with younger/cheaper nurses just grateful for a job (or two jobs, to pay rent or mortgage, student loans, or travel plans). Out go the Master Nurses, in come the "burger-flippers." Diluted staff would be filled in with "Travelers", migrants from low-paying states, and foreign recruits or migrants.
With aging and graying, most will acquire some combination of lower stamina, sore feet, bad back, vision and hearing changes, bladder problems, slower actions, and problems of short-term recall ("what did I come in here for?"). As these build up, one must modify and overcome workplace difficulties with them, or calculate for oneself what will be the trigger point for changing jobs.
If one is in the Provider hole, or Caregiver hole, the hole is not usually changed for an individual. Thus, some may withdraw to academia (depending on degree pressure), go entrepreneur (usually consulting, lecturing, or CE), go commercial in representing someone's product line, or find some grant or project upon whose bandwagon to ride. Much depends on personal and family resources or needs, and how much income or child care one must provide.
I've known nurses whose hearing was such that they worried of missing a clue at triage, or of not being able to tell a family what were the patient's last words. Nurses wearing back braces or boots and orthotics to be able to stand a while. Or whose hypertension was increasingly hard to control due to work. On it goes. Everyone, it is said, is carrying some burden. We should help support each other, as we will all get to the same point.
I don't know the solutions, but if some can be conceived or found, they should be tried. It's common to endow academic chairs or departments. Perhaps, a way could be found to endow fellowships that reimburse hospitals for so-called "non-productive" hours turned to resourcing directly for nurses and patients in novel ways, without losing work and retirement benefits. 50[50 or 75/25 ratios of direct care and other work to ease the physical burden yet enrich the environment of care. It might be a hard sell: it's hard to put a bronze plaque on a working person!
Sincerely, Tom Trimble, RN All opinions are solely those of the author.Readers must verify validity to their own practice.
I didn't grow up in a rural area with volunteer or mortuary-run ambulances. My metropolitan city had an official third-service ambulance and aid-station system (free!) and professional commercial ambulances for private patients. Still, except for the public hospital, other hospitals did little emergency work and would have unattended first aid or treatment room in which one could meet one's physician or have an intern provide care in the meanwhile.
In fact, one of my surgeon grandfather's ortho buddies (perhaps with the help of some lunchtime martinis) took a look at the x-rays of my Boxer's Fracture and snapped it back into place without any analgesia or procedural sedation, casted me, and sent me home. Still no pain medicine. Things were simple then; not much mandated paperwork, either. Nor any computers. Many doctors used fountain pens.
The latter 1950s and 1960s, quested for nerve gas defense studying expired air resuscitation and modern resuscitology; developing intensive care units. I like to think that this changed outlook and purpose, testing what works, rather than generations of ineffective repetitive manual motions of "artificial respiration" with no clue as to whether the airway was open. To me, it harkens a new scientific renaissance of resuscitation science, emergency care, and creating systems for care. Emerging specializations and sub-specialties in medicine and surgery, led ultimately to widespread interest in developing prehospital care, and emergency rooms.
The 1952 Copenhagen epidemic of Poliomyelitis vastly exceeded the number of "Iron Lung" respirators. Anesthesiologists took the lead in establishing a separate are for concentrating patients needing the most intensive care, and used 1,400 medical students in shifts hand-ventilating intubated patients with an anesthesia breathing bag, soda-lime container to absorb CO2, and 50% oxygen given. [Trimble, BVMs]
Many physicians of this era had experience of WWII and Korean War military medicine; they were joined by younger men who used GI Bill benefits to enter medicine, and then honed their skills in Vietnam. It's not too much of a stretch to think that they had a "can-do" attitude and some confidence in building systems.
Perhaps, not insignificantly, they were accustomed to receiving systematized government-supplied medical and trauma care, with "shock rooms" receiving an influx of victims, as contrasted to those later who opposed "socialized medicine."
A booming post-war population and economy led to more travel and recreation outside urban areas and a realization that effective first aid services did not exist everywhere. [Farrington]
Rebuilding of outdated hospitals put emergency rooms on ground level with nearby X-ray service, and, ideally, sometimes closer to the Blood Bank and the Operating Rooms.
Thus, there is a stew of necessary developments predicating modern emergency care: Younger physicians with experience in war (and the systematized provision of care by government); specialization and intensive care; a method of artificial respiration (mouth-to-mouth) that actually worked and gave continuous, instantaneous feedback as to success, funded research and reinvestment in the hospitals.
Efforts in the 1960s by The Committee on Trauma of The American College of Surgeons in improving ORs, emergency rooms, and "Minimal Equipment for Ambulances" gave impetus to better care and more regulation of ambulance services. The National Academy of Sciences – National Research Council (the Federal Government's official science and medicine advisor, in 1966 produced a landmark paper: "Accidental Death and Disability: The Neglected Disease of Modern Society."
The impact of this paper led to massive government regulation, grants, and reorganization of many local ambulance groups to Emergency Medical Services under administrative authorities and with shifts to contracted operators or public agencies such as fire departments who welcomed additional service justification and operating funds. We applied to "The Golden Hour" the attitudes and abilities that led to a man on the moon.
This led to less reliance upon American Red Cross Standard and Advance First Aid certificates;then to the first official ambulance training manual by the Pennsylvania Department of Health; and ultimately to the federally endorsed 84 hour course for Emergency Medical Technician for which was written the 1971 publication of Emergency Care and Transportation of the Sick and Injured ("Orange Book"} of the American Academy of Orthopædic Surgeons.
Federal Department of Transportation approved "Design Requirements for Ambulances" followed and were standardized, causing a transition from hearse-type vehicles, station wagons, and panel trucks or delivery vans, to purpose-built (rather than adapted vehicles) Mobile Intensive Care Units on van chassis or modular "box" van or pick-up truck chassis. Local vehicle modifiers, unable to afford the high costs of testing and approval, went out of business leaving an industry of larger corporations and national sales.
Other more advanced courses developed locally and established themselves in several states, which became a steamroller for Mobile Intensive Care Units, staffed by Paramedics, with proof-of-concept success in Miami, Philadelphia, Seattle, and Los Angeles. Great public support was engendered by the popular success of the television show "Emergency!" (129 episodes from 1972-79." "Rescue 8" had 74 episodes from 1958 (before paramedics).
The first Emergency Medicine Residency Program began in 1970 at the University of Cincinnati.
As Advanced Practice Nursing grew, at first in family practice, then into other specialties, emergency care became an area of interest. A natural one, and especially suited for increasing capability without regard to physician residency program output of graduates, and in less-well-served rural areas.
Below, are in my view, the essential conditions and turning points for advancing to the level of care that we now know.
Milestones of Modern Progress in Emergency Care:
Tom Trimble, RN CEN All opinions are solely those of the author. Readers must verify validity to their own practice.
I've been very fortunate in that my careers in emergency care have spanned many years, much of which was transitional and transformative so that I have lived (as the fortune cookie might say) "in interesting times."
There is in photojournalism, an apocryphal story of a prize-winning photo of a suicidal jumper snapped dramatically in mid-flight. The photographer is asked "How did you get that shot?" The reply was "It's nothing; just f/11, and be there." To which, one might ascribe a translation:
This, in a sense, is an allegory to the realities of emergency care. Compare the possibilities of cardiac arrest resuscitation survival while in the Cardiac Cath Lab, the witnessed versus unwitnessed cardiac arrest in the ED, or the witnessed versus unwitnessed out-of-hospital cardiac arrest. There are no guarantees, only varying degrees of potential luck related to opportunity.
My odyssey began as a younger brother who would frequently spend long periods reading my brother's "Handbook for Boys". I was able to witness (and be the patrol's practice mannequin for) the transition from Shafer's artificial respiration, the back and forth between Holger-Nielsen's and Sylvester's methods, and ultimately the "Rescue Breathing" of Peter Safar, James O. Elam, and Archer S. Gordon. This ultimately led me through Boy Scout first aid; American Red Cross first aid; teaching first aid; ambulance work in the pre-EMT era; teaching in an early EMT class; Paramedic; and nursing as an Emergency Nurse.
My ambulance service was an early adopter: we were all certified in ACLS when few physicians and practically no nurses were. Have I seen changes? It's said that Sir William Osler remarked to always be sure to use a medication when it's new and still has the power to heal. The joke runs that we're so old that we remember when lidocaine worked. The first drug to go was the
Our city was fairly compact with shorter transport times and each county devised its own drug list, so some drugs were not part of our drug bag. We believed in "priming the pump" first with a round of epinephrine and NAHCO3 before attempting defibrillation. We did uninterrupted cardiac compressions with interposed ventilations (this is trending again with an advanced airway in place to minimize interruptions). It took years to encounter "primary VF" (due to lack of 911 systems and late discovery/responses) but the switch to immediate shock had taken place: it was a clear very fine low voltage VF ("I've got a bad a feeling about this …"). No priming allowed: the shock converted to unresuscitable asystole and the patient died. One really only needed to know Sinus Rhythm, Atrial Fibrillation, and Asystole: there was rarely anything else.
To paraphrase Lincoln Steffens, "I have watched the future come to be, and it's working."
Sincerely, Tom Trimble, RN CEN All opinions are solely those of the author. Readers must verify validity to their own practice.
Tom TrimbleTom Trimble, RN CEN is the Online Editor of AENJ.
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