Robert Vroman, M.Ed., BS NREMT-P

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EMS1 Daily News

4 killed in Ohio apartment fire

The bodies of two adult men, an adult woman, and a 5-year-old boy were discovered as crews investigated the 12-unit apartment building

MedStar settles Medicare fraud suit for $12.7

A former employee claimed the company falsified bills for ambulance services to qualify for higher Medicare reimbursements

Kyrgyzstan: Cargo plane crash kills 37, destroys village

Footage from the scene showed the plane's nose stuck inside a brick house and large chunks of debris scattered around

Mich. Gov. signs law requiring CPR to be taught in schools

Michigan students will learn and practice hands-only CPR and how to use an AED

NM EMTs, firefighters practice rope rescues

Participants rotated between being a rescuer, acting as a rigging guy, working the belay rope and between the haul team

Tensions flare over Calif. ambulance response to calls

The firefighters union claimed ambulances from AMR are frequently unavailable to cover their response area

More freezing rain hits portion of central US

Authorities say ice contributed to a southwestern Kansas wreck that killed an Oklahoma man and injured several others

Grief in Baltimore community after fire kills 6 children

Friends and members of the community left notes, photographs and teddy bears to remember those who died

Conn. man dies after jumping out of burning building

When emergency workers arrived, they found the badly burned and injured man at the foot of the building

Freezing rain causes accidents, closures in southern Plains

Forecasters issued ice storm warnings from the Oklahoma and Texas panhandles into southern Illinois, with up to 1 inch of ice expected in some locations
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EMS1 Topic Articles

4 killed in Ohio apartment fire

The bodies of two adult men, an adult woman, and a 5-year-old boy were discovered as crews investigated the 12-unit apartment building

MedStar settles Medicare fraud suit for $12.7

A former employee claimed the company falsified bills for ambulance services to qualify for higher Medicare reimbursements

Kyrgyzstan: Cargo plane crash kills 37, destroys village

Footage from the scene showed the plane's nose stuck inside a brick house and large chunks of debris scattered around

Mich. Gov. signs law requiring CPR to be taught in schools

Michigan students will learn and practice hands-only CPR and how to use an AED

NM EMTs, firefighters practice rope rescues

Participants rotated between being a rescuer, acting as a rigging guy, working the belay rope and between the haul team

Tensions flare over Calif. ambulance response to calls

The firefighters union claimed ambulances from AMR are frequently unavailable to cover their response area

More freezing rain hits portion of central US

Authorities say ice contributed to a southwestern Kansas wreck that killed an Oklahoma man and injured several others

Grief in Baltimore community after fire kills 6 children

Friends and members of the community left notes, photographs and teddy bears to remember those who died

Conn. man dies after jumping out of burning building

When emergency workers arrived, they found the badly burned and injured man at the foot of the building

Freezing rain causes accidents, closures in southern Plains

Forecasters issued ice storm warnings from the Oklahoma and Texas panhandles into southern Illinois, with up to 1 inch of ice expected in some locations
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EMS1 Columnist Articles

Quiz: How accurately can you triage 10 MCI patients?

EMS providers learn triage in their certification courses and occasionally review it during continuing education courses. Perhaps fortunately, it is infrequently used in the field. This EMS1.com and Limmer Creative quiz will be a good review for when you are first on scene for "the big one." How accurate will you be on these 10 simulated patients"

The quiz uses the START triage principles, but can be related to common principles used everywhere. Pick the triage category for each patient.

Inside EMS Podcast: Challenges of using ketamine in the field

Download this podcast on iTunes, SoundCloud or via RSS feed

​​In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson are joined by Scot Phelps. They discuss the uses and challenges of using ketamine in the field.

Learn more about ketamine administration and indications:

Treating geriatric patients: 5 tips for EMTs and paramedics

With over 10,000 people retiring every day and the baby boomer population — those born between 1946 and 1964 — representing nearly 13 percent of our population, 911 calls to treat older patients is a frequent occurrence and guaranteed to rise.

When you’re called to help a geriatric patient with a medical emergency or traumatic injury, here are five ways to facilitate a safe and successful patient contact.

1. Expect age-related changes

Since an age-related decline in the function of our organs alters our body’s response to illness and injury, it is important to know what kinds of changes to expect and how it may affect how our patient presents.

After the age of 30, our organ systems lose one percent of function per year, meaning the body is less able to compensate for shock. With depleted calcium levels, our bones can break easier and simple burns, lacerations and abrasions can cause greater harm since our skin dermis thins by 20 percent and perfusion of blood to the extremities decreases. Additionally, as our brain tissue shrinks, a void is created in our cranial vault so head injuries are more lethal and can take days to develop.

These, and other, anatomical and physiological changes means that EMS providers need to increase our index of suspicion with elderly patients. Vague and non-specific complaints and traumatic injuries with a low-energy mechanism of injury can have life-altering effects on an older patient.

2. Pay extra attention to medications

It is quite common that geriatric patients can forget to take their meds or take the wrong dose. Therefore, along with asking patients about medications, it is also important to locate the prescription bottles, perform a pill count (if indicated) and bring the medications to the ER with the patient.

In addition, study up on commonly prescribed medications, their side effects and how drugs may interact, or potentiate, with one another. If a patient is taking blood thinners and has a head injury or blunt trauma to the torso, be extra alert for internal bleeding. Beta blockers, such as propranolol and carvedilol, taken for high blood pressure, can block the body’s response to shock, meaning your patient may not have an elevated heart rate when you take a set of vital signs.

Lastly, since old age causes patients to metabolize medications more slowly, start with a low dose when administering pain medications and titrate up. You can always give your patient more pain medication, but it’s more difficult to manage a patient who is suddenly altered or not breathing due to an inadvertent overdose.

3. Don’t stop at the chief complaint

Since elderly patients often have multiple medical problems and co-morbidities, don’t stop your detective work at what they believe is their chief complaint. This complaint may, or may not, be their most life-threatening condition and it is up to you to form your own informed, provider impression.

For example, you might have been dispatched for a simple "fall" that could’ve been caused by a stroke or syncopal (fainting) episode. An altered patient with low blood sugar who is found outside might also be suffering from hypothermia. Or, you could discover in your assessment that a patient complaining of a urinary tract infection is also in the throes septic shock.

Lastly, it’s not uncommon to be called to an elderly patient who has multiple life-threatening conditions all going on at once. I remember when I worked as a paramedic in Yellowstone where my patient had a major GI bleed and COPD exacerbation and she’d also overdosed on her Valium. On these calls, it’s important to triage your treatment, focusing on the most critical life threat first and then addressing the others.

4. Be alert for elder abuse and depression

As EMS providers, it is our responsibility — and privilege — to be the patient’s best advocate. When you’re called to the home of an elderly patient, pay attention to the condition of the living space and what family members or health care providers are caring for your patient. Are there any signs of abuse or neglect such as an empty fridge; half-eaten food scattered about; a delay in seeking care or bruises in multiple stages of healing" Does the story you’re given match the illness or injury and are the patient’s medications being given at the proper time and dose"

Also, if the patient is living alone, they can easily feel isolated, depressed or suicidal at the loss of loved ones, their decreasing health or financial situation. If you expect elder abuse or depression, it is important to notify proper authorities once you arrive at the hospital.

5. Have the courage to care

Since senses such as sight and hearing can be dulled in an elderly patient, communication can be difficult, but don't let that stop you from making the effort to connect and communicate. In addition, many geriatric patients fear a loss of independence and being moved into a nursing home so they may not want to go to the hospital. However, it is important to explain your assessment findings, treatment plan and why it is in their best interest that they see a doctor.

Lastly, once you’ve stabilized the patient and taken care of the medical side of things, don’t be afraid to engage your elderly patient on a personal level. In many cultures around the world — and I hope in ours as well — elderly people are revered for their life experience and wisdom. Don’t be afraid to ask about their life. Where did they grow up" What did they do for work" Where was the most amazing place they visited"

Suddenly, the person sitting on the gurney next to you is no longer simply a patient, but a person who’s likely lived an amazing life and will be eager to share it with you. As you meet military veterans, teachers, world travelers or former professional athletes, you’ll be amazed at the stories you hear.

How to use SALT to triage MCI patients

When needs outstrip resources it is appropriate to call for help, but rather than to wait for the resources to come to you, EMS providers can use SALT to move patients forward to resources.

SALT, which stands for Sort, Assess, Lifesaving interventions, Treatment and/or transport is the four step process for responders to manage mass casualty incidents proposed by the National Association of EMS Physicians as part of a Centers for Disease Control and Prevention sponsored project to use the best available science and expert opinion to develop a standard guideline for mass casualty management [2]. SALT, endorsed by more than a dozen national emergency medicine and EMS organizations, along with the Model Uniform Core Criteria for Triage, provides a framework of clear, simple steps that field providers can use to bring order to chaos and help improve patient outcome [2].

Establish command and control

The heart of SALT is the idea that providers focus on the prioritized movement of patients away from the incident that is making more patients and towards safety and the resources to care for them. For SALT to work, a mass casualty incident must first be identified and declared. Because MCI identification differs for every EMS service, each provider must know the MCI threshold for their system.

Regardless of whether they are an MCI officer or a caregiver, each responder must focus on their role in facilitating the movement of patients away from the patient generator, which is the thing that is making more patients or making them sicker. Move patients forward to a casualty collection point, which is a safer place where they can be sorted and prioritized for further forward movement to treatment areas and transport to receiving facilities.

As command and control is established, EMS providers should grab their mass casualty triage tags and any MCI equipment that they intend to use to begin patient triage. Here is how to apply SALT.

Sort the Walkers, the Wavers and the Still

Rapidly prioritize the patients using global sorting. This will help efficiently assess, administer lifesaving interventions and ultimately treat and transport the patients.

Announce to all involved, using a public address system or loudspeaker, "Everyone who can hear me, move to [the safe area you have designated] and we will help you."

Give strong, loud and clear visual and verbal commands. Those who respond first will be the last patients to assess, but they may be able to assist with moving more critical patients forward. These patients are the Walkers.

To the patients who remain in place say, "If you need help, wave your arm or move your leg and we will be there to help you as soon as we can."

These patients who can follow commands but cannot move themselves are the Wavers and the second priority for assessment.

Remember that some patients may be ambulatory, yet opt to stay with another injured patient. Other patients may be able to move and decide to assist a non-ambulatory patient. This is okay. Sorting is simply an easy way for the first arriving EMS units to begin moving patients forward to care.

Those who are Still and have not yet moved or responded to you are the first patients that you need to assess and possibly care for.

Assessment/Lifesaving interventions

With the SALT system, assessment and lifesaving interventions go hand in hand. There is no timing radial pulses or counting respirations in a SALT assessment, only answering simple yes-and-no questions.

When you assess and find a life threat you should provide a lifesaving intervention as long as it does not take longer than a minute and does not require you or another EMS provider to stay with the patient. For example, if you find that a patient has massive hemorrhage, provide rapid bleeding control with a tourniquet.

If a patient’s airway is closed, open it. If that patient is a child or infant, consider giving them two breaths.

If you are an ALS provider, it may be appropriate to provide needle decompression, auto-injector chemical toxin antidotes or other lifesaving interventions that take less than a minute to administer and do not require you to stay with the patient.

Remember, to maintain forward movement of patients, you must also maintain forward movement of EMS providers. That is, if a patient needs lifesaving interventions and you are immediately ready to give them, do so and move on to the next patient. Do not stop during assessment and lifesaving interventions to fetch a piece of equipment or restock supplies. Patients must continue to move forward to the casualty collection point next, then to the treatment area and eventually to transport to receiving facilities.

As you assess and provide lifesaving interventions, categorize or tag patients by priority. SALT and MUCC triage works as follows.

Dead (black triage tape or tag)

Patients with injuries incompatible with life or without spontaneous respirations are triaged as deceased. Assess the following:

  • Adult patient is not breathing after opening airway.
  • Child is not breathing after opening airway and giving 2 breaths.

Patients tagged Dead do not move forward from the point of injury to the casualty collection point.

Immediate (red triage tape or tag)

Patients with severe injuries, but high potential for survival with treatment such as victims of tension pneumothorax, assess the following:

  • Does the patient have a peripheral pulse"
  • Is the patient not in respiratory distress"
  • Is hemorrhage controlled"
  • Does the patient follow commands or make purposeful movements"

A "no" answer to any of these questions and a field provider judgement that the patient is likely to survive given the available resources means the patient should be tagged Immediate.

Immediate patients move forward to the casualty collection point first.

Expectant (gray triage tape or tag)

A "no" response to any of the questions about pulse, breathing, hemorrhage and mental status, but the patient is unlikely to survive given the available resources means the patient should be tagged Expectant. These patients should receive treatment resources only after the Immediate patients have been moved forward.

Examples of expectant patients include head injury with exposed brain matter, carotid artery hemorrhage or burns to 90 percent of the total body surface area.

Delayed (yellow triage tape or tag)

Patients with serious injuries, such as a long bone fracture, that will require eventual forward movement to definitive treatment, but not immediate forward movement and care are tagged Delayed. To determine if a patient is Delayed assess the following:

  • Does the patient have a peripheral pulse"
  • Is the patient not in respiratory distress"
  • Is hemorrhage controlled"
  • Does the patient follow commands or make purposeful movements"

A "yes" response to all of these, but the injuries are still significant, such as a proximal long bone fracture, then the patient should be tagged Delayed.

Minimal (green triage tap or tag)

"Yes" to all of the same questions about pulse, breathing, hemorrhage and mental status, but the patient’s injuries are minor, such as minor abrasions and lacerations and the patient should be tagged Minimal.

Most Minimal patients should have moved forward during the sort of Walkers from the Wavers and the Still. Remaining Minimal patients are the last to move forward and they may help move other patients forward to treatment and transport.

Treatment and Transport

As patients receive their tags from the SALT process, they should move forward to a casualty collection point. Patients continue to move forward from there to a treatment area and eventually to an ambulance for transport to a receiving facility..

The treatment area is the destination for all incoming personnel and equipment from responding EMS agencies. It is also only to temporarily hold patients until they can be transported forward to receiving facilities.

Still a long way to travel

Even though the SALT and MUCC MCI recommendations have been around for years, the change from older triage systems proceeds slowly. As SALT is adopted by additional agencies, more EMS providers will find this simple, straight-forward, easy to learn system helpful to manage mass casualty incidents of all sizes.

References
1. Robertson-Steel, I. Evolution of triage systems. Emergency Medicine Journal 23, 154–155 (2006).

2. Federal Interagency Committee on EMS. National Implementation Of the Model Uniform Core Criteria for Mass Casualty Incident Triage. (2014).

Information sharing will drive EMS growth, improvement

For the typical EMS provider, data may be one of the least sexy topics to discuss around the station dinner table or while sitting at a post. The mention of the word makes most of us imagine spreadsheets, calculators and back office staff entering data into computers — not very relevant to what we do with patients in the field.

In reality, nothing could be further from the truth. Data and information analytics permeates everything that we do as field providers, including better patient care, more targeted services toward the community and increased reimbursement for what do provide. In fact, the National Highway Traffic Safety Administration's Office of EMS has just issued a report on the need to create a culture of information-driven EMS systems to drive future growth and development of the industry. While it's not very likely that you'll be reading this document to your partner in between calls, you should take notice that such reports will impact how you may provide field care.

Data shapes the EMS elephant

There have been concerted efforts to collect data at local, regional and national levels since the mid 1990s. However we still define EMS by what we do locally, on the unit every day. As a result, each of us has a specific opinion as to what we feel is "true" regarding the EMS industry.

It's very much like the old story about blind individuals trying to describe what an elephant is. One man touches the trunk and says one thing, while another woman touches the tail and describes the elephant in a totally different way. Given how systems have developed over the past fifty years, the variability in describing the EMS elephant is huge.

Data can remove the mask of blindness and allow us to see EMS for what it is. The more we know about what we do, how we do it, and most critically, the outcomes associated with our care, the better we are able to adapt our operational tactics and plan for better success.

Better outcomes mean better EMS

You would think that it is self-evident, but consider how much we do in EMS that is not grounded in evidence: transporting patients to the hospital with lights and sirens activated; ALS first responders; myriad of medications we administer in the field. Indeed many interventions and tactics in EMS have been driven by best guesses and so-called expert opinion, with little or no understanding of the outcomes of such interventions.

One area that has seen improvement is in cardiac resuscitation. Many EMS systems are reporting better ROSC and discharge from hospital rates due to better chest compressions, increased bystander CPR and public access AEDs. While we may debate about the specifics and nuances of different interventions, the needle is moving in the right direction.

Significant barriers to data collection, sharing

The EMS industry has a problem sharing information. Some of the reluctance to share is warranted — proprietary data influences the bottom line and the potential for litigation exposure. Pretty much everything else can be blinded or otherwise made anonymous, so that the aggregated dataset becomes large enough to establish true benchmarks for quality.

Because EMS systems have developed independently of each other since the beginning, it's no surprise that data collection has also been kept in siloes. It'll take willingness to participate, effort — and money — to create data collection systems that are universal and therefore, applicable to the entire industry.

Moving forward from here

NHTSA has already started the process for the next iteration of field care services in the United States. I suspect that there will be a greater emphasis on evidence-based processes that will underlie the EMS safety net. For those of us coming into the profession, these are the developments to pay attention to, as unsexy as it is; your future is wrapped up within their outcomes.

What part of paramedic training did you find most difficult?

No matter if you're on day one or a veteran paramedic, you'll never forget your paramedic training experiences.

And a task that is hard for some paramedic students may be easier for others.

We asked our Facebook fans what part of paramedic training they found most difficult. Some said they had a difficult time learning how to study and take tests, being confident in themselves, intravenous access training and developing patient rapport.

What did you find difficult" Sound off in the comment section below.

1. "Everyone was so concentrated on the skills, and the almighty cardiology, that we failed to really study the stuff we see more often. Pulmonology, endocrinology, and to an extent neurology weren't explained as much in detail, which lead to difficulties in putting it all together later in school. I felt it important to understand how all the systems were tightly integrated." — Scott Owens

2. "Getting the right calls to complete the course requirements." — Phil Salamone

3. "Learning the national curriculum and being restricted to state protocols. Having a knowledge base and skill set that you are unable to use is tough. My instructor gave a lecture at the end of the program called "living in a world of grey." It was phenomenal and truly represents the unpredictable reality in which we live. No matter how much training we go through during a paramedic program, we can never be fully prepared for everything we will encounter." — Adam O'Neil

4. "For me, after being out of school for almost 15 years and learning how to study, take tests, and manage my time with a full-time and part-time job, husband, kids, house, extended family … it was chaotic. But, I was a late bloomer and was an EMT for quite a while before the timing was right for me to go through medic class. Passed everything the first time, so I must have done something right." — Nicole Nixon Butler

5. "Being confident in yourself, especially being such a young paramedic. I've only been out of school for five months now, and have been struggling until recently to have confidence in my skills and knowledge that I am capable of doing this job." — Mark Sinnwell

6. "IV training was very difficult for me. Going from a basic where you cannot do any advanced procedures to IV was a giant step. Preceptors for me, also. Trying to find one or two that I cliqued with." — Joel Parks Jr.

7. "The point about two-thirds through the program where I realized, if I knew then (before starting the paramedic program) what I know now, then I would have never started. But I have come too far to quit now." — Patrick Gomer Roberson

8. "Pathophysiology, developing patient rapport, looking at the whole picture and understanding that equipment/drugs are just tools in your bag." — Chris Sheldrew

9. "Being an EMT for seven years and then taking on medic school, doing a proper assessment on a rescue randy and verbalize everything was tough." — Chris Marchese

10. "Putting in the time and dedicating myself to finish. It was tough. With the support of my wife and family, I was able to pull it off." — Dennis Martin

11. "The first solo shift as a paramedic. That the first real day of training." — John Shady

12. "Remembering all the different drugs, what they do and their doses and contraindications." — Warren Glass

13. "Pathophysiology had to be the hardest part for me." — Fernando de Leon

14. "Pediatric IVs and dosages." — Tony Ippolito

15. "Bedside manner." — Greg Hogancamp

5 ways the iPhone changed fire, EMS

Ten years ago, Apple CEO Steve Jobs stepped out in his infamous black turtleneck and jeans in front of an eager audience for his now-legendary keynote address.

The release of the first-ever iPhone was "revolutionary." Cellphone users all around the world dumped their Motorola RAZR flip phones for the pinch-and-zoom spectacular. Other mobile phone companies rolled out smartphones and the personal tech arms race was off and running.

And just how the iPhone changed "Average Joe" users' everyday lives, it also changed how fire and EMS departments operate. A lot has changed in 10 years — iOS updates, competing operating systems and technologies, bigger screens, better cameras, apps to make calculating dosages and scheduling easier, and, most of all, it has allowed firefighters and EMS providers to have critical and potentially lifesaving information at their fingertips.

Here's an overview on how the iPhone changed the course for fire and EMS departments.

1. Apps for first responders

There most definitely is an app for everything these days. Need a way to track schedules, learn more about rescue knots or have a ready-to-go resource to deal with hazmat incidents" Or what about an IV drip rate calculator and timer or an easy way to ensure compressions are being performed at the proper rate" The iPhone made all of these apps — and many more — easy to download and pull up at a moment's notice.

Is there a fire or EMS-specific app you can't live without" Let us know in the comments.

2. Search and rescue operations

There's many simple, yet creative, ways you can use your iPhone during rescue operations.

When a 2-year-old Chinese boy fell down a 40-foot well, firefighters had difficulty attaching a rescue harness. Instead of trying to hoist the boy up blindly, they attached a piece of rope around an iPhone and slid it down to film the position of the boy. The boy was rescued and OK.

3. Fire, EMS camera usage

In Santa Barbara, Calif., firefighters are using their iPhone cameras — with the help of an attached infrared device — to see up to 100 yards in the dark. Another creative way to use an iPhone's camera comes out of Hong Kong, where researches used the cellphone's camera and an app to identify irregular heartbeats by looking at a person's face.

And of course not all changes are for the better — the iPhone has given us the selfie. Some bad selfies turn out good, as in the case of the arsonist who couldn’t resist capturing the moment. And while not all selfies are illegal, some, like this Londoner posing with an MVA, are simply done in bad taste. Of course, firefighters are not above making bad selfie decisions while on-duty. Not all selfies are bad, as this firefighter proved when he sent a quick shot to his family to let them know he was OK.

4. Mapping

When you're en route to a fire scene or medical call, there's plenty of technology in your rig that will get you there via the best direction. But what if you're called to a remote location and have to walk to find your victim" iPhone Maps, Google Earth and other app mapping technology allows users to choose drive, walk, transit or ride. If you need to hop out of your rig, but still need your location on-hand, your trusty iPhone may come in handy yet again.

5. Meal recipes

Are you the best cook at your fire or EMS station" Chances are, the rookie probably needs some help in the recipe department. Because, let's be honest, fast-food is quick and convenient, but it gets old pretty fast. Most departments frown upon crews using their phones while eating at the kitchen table. However, opening up a Pinterest recipe or a colleague's great-grandmother's chicken and dumpling recipe online fills not only the crews' stomachs but also encourages camaraderie.

Prove It: Epinephrine may have a role during resuscitation from cardiac arrest

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EMS1 Tips

7 ways to best use, or avoid, capnography in the field

EMS1 readers shared their suggestions on how to get the most out of the method

Active-shooter response: Are you physically ready?

Normally, I am strong believer that paramedics are at their best when they saunter into a scene, slowly walking and looking for clues and risks. But an active-shooter incident is going to require repetitive bursts of significant physical activity.

3 energy-saving tips for your EMS station

Earth Day, or any day, is a good time to see what you can do at your agency and home to save both resources and money.

How this video can "Keep Yourself Safe"

Consider using this PPE safety video in your EMT course or refresher class

CPR class instruction tips: 5 ways to make it great

My most recent healthcare provider recertification was memorable for all of the things the instructors did well.

Patient assessments: How to avoid free-for-alls

Substantial cajoling and adult guidance from mom in a Santa hat was required to initiate an orderly process of taking turns, appreciating a gift after it was opened, and taking occasional pauses for a meal or to welcome additional relatives.

Patient assessment is a non-linear process

On a skill sheet, patient assessment is presented as a linear process: First size up the scene, then complete the primary assessment followed by the secondary assessment.

Blood pressure reading tips and tricks for EMS

One of the things I'm most often asked by students and rookie EMTs is, "Kelly, how am I supposed to hear a blood pressure in the back of the rig?"

How to use Slideshare for EMS education and training

Slideshare is an online community and tool for sharing presentations.

How to get optimal battery life from your devices

The batteries in your wireless cell phone, tablet or laptop are probably not the same old Duracells you used in your childhood walky-talkies.
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