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Human Factors Review of EMS Ground Ambulance Design
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1 95 Human Factors Review of EMS Ground Ambulance Design Susan Biesbroek, M.Sc. Human Factors Safety Specialist Alberta Health Services Calgary, AB, Canada Elise Teteris, M.Sc. Research Associate Ward of the 21 st Century, University of Calgary Calgary, AB, Canada In 2011, Alberta Health Services (AHS) standardized the design of their new ground ambulances to improve provider safety in the event of a collision. Human Factors methods and design principles were used to examine the new ambulances and provide recommendations to further improve the workspace, functionality, and design for the next generation of ambulances. Human Factors consultants participated in ride-alongs within the urban Calgary area, observing patient care, staff interactions, and workflow. A total of 32 recommendations were suggested for future design iterations of the ambulance. Next steps include utilizing simulations and usability testing to ensure their feasibility and effectiveness. Copyright 2012 Human Factors and Ergonomics Society. All rights reserved /HCS INTRODUCTION Within emergency medical services (EMS) both patient safety and care provider safety are essential requirements. EMS is recognized as a fairly dangerous and unpredictable profession in which vehicle collisions are known to be the most likely factors in fatalities (Macguire, 2003). The National Highway Traffic Safety Administration (NHTSA) analyzed fatal ambulance collision data from a 10 year period ( ) and found approximately 340 ambulance crashes in the United States that contributed to the deaths of 405 people and over 800 injuries to ambulance occupants, with the most fatal and serious injuries occurring with unrestrained passengers and those in the rear patient compartment of the vehicle (Kahn, Pirrallo, & Kuhn, 2001; Becker, Zaloshnja, Levick, Li, & Miller, 2003). Due to these risks, a lot of attention has been focused on improving the crashworthiness of ground ambulance vehicles (Levick, 2007; Levick & Li, 2000; Levick, Shelew, & Blatt, 2001). Poor ambulance design and a lack of restraints for passengers in the rear compartment have been sited to be contributing factors in both injuries and fatalities during ambulance collisions (Sanddal, Alberta & Hansen, 2008). However, even with restraints available in the rear compartment of ambulances findings show that compliance using these safety belt systems is low due to perceptions that they limit patient care, are inconvenient, and restricted movement (Larmon, LeGassick, & Schriger, 1993). There are many standards and regulations that dictate the physical design requirements of ground ambulance vehicles (Alberta Health and Wellness, 2010). But there is very little research on how to organize the required equipment within the interior of the ambulances based on ergonomic evaluations and principles to reduce musculoskeletal injuries and maximize provider efficiency and safety while providing patient care (Ferreira & Hignett, 2005; Gilad & Bryan, 2007). Human Factors considerations of care provider ergonomics, equipment layout and access and evaluating the effectiveness of proposed safety systems would be beneficial to enhance safety within the vehicles (Levick, 2007). Prior to April 2009, Emergency Medical Services within Alberta, Canada were provided by 74 different municipalities and organizations across the province. As part of the transition of healthcare services in Alberta, EMS was brought under the umbrella of Alberta Health Services (AHS), creating a single provider for EMS for the entire province. This has created a unique opportunity to standardize how care is provided (i.e., policies and procedures, equipment, and ambulance design) throughout Alberta. Currently there are over 550 ground ambulances in use across the province. Due to each previous municipality ordering and purchasing their own vehicles, there is a huge variance in the design of these vehicles. One of the major milestones that were undertaken was to begin the standardization of ground ambulance vehicles across the province. In recent years a move toward more crashworthy designed vehicles has occurred, but generally these have
2 96 been one off prototype vehicles that were never fully implemented into the system. The majority of the vehicles in use within AHS include such known risks as bench seats with lap belts, chairs that maintain a sideway facing orientation, lack of child restraints, and equipment storage and securing issues that dramatically increase passenger risk in the event of a collision. Taking into account previous research and design recommendations a safety vehicle was designed to improve EMS provider and passenger safety in the event of a collision. Safety enhancements such as forward facing Captain s chairs in the patient compartment, as well as improved access to controls and supplies, were included to achieve an environment whereby staff could remain seated and belted while delivering patient care during transport. While in theory this seems straight forward, it does require a change in culture and practice for all EMS staff. In an effort to involve users in the design of the new ambulances, staff needs and requirements were recorded at multiple EMS engagement sessions across the province and changes to the design were made based on this information and known safety enhancements. However, user testing in the proposed environment was not completed prior to implementing over 50 of these new vehicles for use on the roads. Immediately staff concerns regarding changes to the design of the vehicles were voiced. A general perception that the new design limited patient care and did not function well for frontline staff requirements was observed. Therefore, Human Factors evaluations were requested to assist in examining the new design and provide recommendations for the next generation ambulances to further improve the ambulance workspace, functionality, and design to maximize compliance and safety within ground ambulances. Human Factors studies how people interact in their surrounding environments, examining the equipment they use, the tasks they perform, and the physical environment in which it all takes place. By examining these interactions changes can be made to the equipment, task, or environment to improve efficiency, safety and reduce frustrations. The main goal is to optimize the design of the product in order to meet the users needs rather than forcing the user to adjust their behaviours to accommodate the product, which in this case was the ambulance design that staff were being forced to work with and felt did not support their behaviours and requirements. METHODS To determine what common tasks were required within the vehicles and gather information on staff workflow and concerns, two Human Factors Consultants participated in eight ride-along sessions in busy urban metro vehicles. During these sessions observations were made on patient care, staff interactions and workflow to highlight any difficulties or inefficiencies encountered while working within the new ambulances. Feedback from both urban and rural EMS personnel was gathered via interview over the course of the evaluations. Figure 1. Patient compartment within the new ground ambulance vehicles RESULTS Based on observation data, Human Factors principles, and staff feedback, over 30 recommendations for changes to the ambulance design were made to the ambulance design committee. To date, 25 of those recommendations have been either included in the most recent design or are in progress for the next round of vehicle purchases. Three main areas of concern were identified: availability of workspace, labeling of supplies and medications, and access to both the patient and required equipment. Workspace The replacement of the large bench seat with the individual Captain s chairs was done with the intention to improve safety. Previous findings have shown that side facing bench seats are less than optimal in the event of a collision (Levick, 2007; Levick & Li, 2000; Levick, Shelew, & Blatt, 2001). In comparison, the Captain s chairs are able to rotate to a forward facing position which reduces injury risk in a crash situation. However, this new seat arrangement reduced both the amount of physical space and available workspace in the new ambulances making it difficult to move around the compartment and deliver patient care, forcing providers to take on awkward working positions.
3 97 These chairs tend to be large and bulky and protrude into the aisle along with the large stretcher wheels that stick out to the side. These issues increase the tripping hazard within the vehicle and reduce provider safety (Figure 2). Furthermore, because of the lack of foot space around the stretcher area EMS personnel were observed to take on sub optimal working positions (Figure 3) to accommodate for the space issues. By reducing the bulkiness of the Captain s chairs and potentially reducing the depth of the supply cabinets, a clear path around the stretcher for care providers to move around the patient compartment safely would be created as well as allow workers to maintain better posture to avoid musculoskeletal injuries. are required for a single patient and these supplies need to be readily available when needed. In previous models of ambulances the providers were accustommed to using the large bench seat as a worksurface to place equipment bags and kits while in use. This allowed them to have the equipment they required conveniently locatedwhile they were treating the patient. On the downside, laying out all necessary equipment also increased the amount of projectiles and risk should a collision occur. Figure 4. Previous bench arrangement used as a worksurface Figure 2. Physical space issues within the vehicle Unfortunately, by replacing the large bench seat with individual Captain s chairs, this previously used flexible workspace is also removed. In addition, an adequate work area replacement has not been provided in the new ambulances and as such, there are very little work surfaces available. The largest work surface provided is a drawer with a plexi-glass lid that when opened and covered, is intended to convert to a work surface. Unfortunately, some design issues impact its usefulness. For example, this surface is too small for the amount of equipment that is required, the drawer does not stay open and supplies tend to then roll onto the floor. Due to these challenges the providers do not use this work drawer and instead place equipment on their Captain s chair (meaning they are no longer seated), on the patient, and on the floor in bins. Figure 3. Suboptimal working postures Workspace is essential in the small confines of ambulances; multiple pieces of equipment and supplies Figure 5. Workspace availability issues
4 98 Recommendations were made to improve the usability of the drawer work surface. Specifically, it was recommended to increase the size of the drawer to enlarge the available work area. In addition, installing a friction locking mechanism on the drawer to keep it open while in use and including a lip around the perimeter to prevent supplies from rolling onto the floor would improve the design and functionality of the workspace. In the next ambulance design, a separate extendible worktable was installed above the drawers with a friction locking mechanism for added workspace beside the attendant s chair. Labeling The location of equipment within the new ambulances is still being determined and standardized. Therefore, the ambulances in use during the observation sessions did not include any labeling to assist users in performing their tasks, forcing staff to open multiple drawers to search for supplies. Figure 6. Current labeling of supplies and medications in the new ambulances There are a number of functions associated with the labeling of supplies. For example, labeling helps reduce search time and uncertainty when trying to locate a particular item, assists in maintaining standardization, and reduces the time required to restock the vehicles. There are two levels of labeling that are required to be functional for the tasks above. Level one labeling is used to locate supplies by providing general labels on the outside of the cabinets and drawers to indicate their contents. Currently all drawers and cabinets are only numbered, there is no indication from the outside of the cabinet or drawer as to what is currently stocked within it. By including general labels (i.e., medications, solutions and sets, cardiac medications, airway supplies) staff know the contents of each drawer or cabinet without having to open it. General labels should be as brief as possible as excessive labeling (i.e., every item housed in that drawer) will actually increase the search time for supplies. The second level of labeling will occur within the cabinets and drawers themselves and are essential in maintaining standardization and assisting during the restocking process. Once staff have opened a drawer or cabinet, they then need to quickly locate the specific item they require. As such detailed labels are needed to ensure equipment is pulled from the appropriate bin, as well as facilitate the restocking of items. Each bin or medication pocket should contain the following pieces of information: the generic name of the item, size or concentration (if needed), and the stocking quantity. All of these will assist in improving standardization of stocking locations and quantities, as well as reduce search time for staff. Ongoing work has occurred with EMS services to finalize the design of their labels and storage of equipment within the new vehicles. Recommendations for labels include avoiding the use of ALL CAPITAL lettering as this increases reading time and takes away word shape cues (MIL-STD-1472F, 1999; Safety signage at hydropower projects, 2001), maximizing contrast between the background and font on the label (i.e., black writing on a white background or vice versa) (NASA-STD-3000, 1995), and using a minimum of 16 point sans-serif font to maximize readability. A color coded bin technique was also suggested as a way to store supplies depending on their function. For example, airway supplies would be located in the blue bins, medications and drug in red bins, IV solutions and oral medications in yellow bins, and general supplies such as band-aids and gauze in green bins. Color coded bins will increase the efficiency of locating items by reducing the amount of bins that need to be searched. Accessibility During the observation sessions a number of accessibility and usability issues were identified that effected the provider s ability to access both the patient, as well as some of the equipment within the ambulance (i.e., sharps containers). These issues impacted care and reduced the safety within the vehicles. Patient access Accessing the patient is essential at all times within transit; however, at times this was difficult due to the physical layout and equipment positioning. For example, EMS personnel were not able to adequately reach the patient to start IV s or hook up lines from the CPR seat on the right side of the patient, as the seat was positioned too close to the patients head. In addition, access to the patient from the right side was compromised as large cabinets to the right of the CPR
5 99 seat impeded patient access and reduced the available work area around the CPR seat. As a result, providers were forced to stand and bend over the patient, or crouch at the side of the stretcher to perform common tasks (Figure 7). Equipment access Other equipment issues involved the usability of the Captain s chairs, as well as the safe disposal of sharps while in transit and when providing patient care. While the majority of staff understands the rationale behind the addition of the Captain s chair in the new vehicles, the acceptance of the chair as a positive change is hindered due to a variety of design deficiencies. As mentioned previously, the chairs tend to be very bulky and impede into the available space around the patient stretcher. These chairs are designed to be flexible in that they will rotate to both a side and forward facing position depending on the nature of the task, allowing providers to better access the patient while still being able to wear their seatbelts while in transit. Specifically, staff are meant to adjust the seat in a forward facing position, for safety, while in transit. This is the key benefit and the most valid equipment design feature to reduce injury in the event of a collision. Unfortunately the chairs are difficult to adjust as the pull knobs for seat adjustment are not easily accessible and are difficult to engage. As a result, rather than adjust the seat to a good working position, the EMS providers were observed turning their torso while seated, taking on a poor working posture. Furthermore, the seatbelt is not height adjustable and tended to dig into the providers necks rather than be located across their shoulders. Figure 7. Difficulties observed while trying to access the patient from the CPR seat To properly access the patient from the CPR seat it was recommended to adjust the positioning of the chair further back in the vehicle, so that providers would have more space to access the patient to start IVs and hook up lines. In order to do so, the equipment cabinets were shortened to allow for adequate space and the CPR seat was repositioned 7 inches further back in the vehicle. These changes have improved patient accessibility and usefulness of the CPR chair. Another recommendation to include a sliding track under this seat for better flexibility is currently under consideration. Figure 8. Poor working posture (left) and seatbelt adjustment issues (right) While in theory the addition of the Captain s chair is suggested to improve safety within the vehicle, design changes are needed to make the chair more functional, improve provider compliance, and make it more user friendly. Doing so may assist in increasing the compliance of seatbelt use within the patient compartment as none of the staff during any ride along sessions were observed using this seatbelt.
6 100 Lastly, the accessibility of the sharps container within the vehicle was identified as a concern. Needlestick injuries can increase the risk of blood borne virus transmission to staff (Needlestick safety and prevention, 2000). To reduce this risk, sharps are disposed of in biohazard containers (i.e., sharps containers); the location of one of the sharps container in the new ambulances negatively impacted this safety risk. Specifically, the opening was often blocked by the attendant s chair requiring the provider to adjust the position of the chair while holding onto the sharp, which tended to be difficult. The sharps container was also positioned too low and required a blind drop when disposing the needle. In addition, the opening was not fully sealed and needles would fall between the container and the outside wall or remain on the lip of the sharps container, increasing the risk of needlestick injuries. Figure 10. New sharps container location CONCLUSIONS Figure 9. Accessibility issues for sharps containers Improving the accessibility of the sharps containers involved relocating the sharps container to an alternate location within the vehicle. Rather than having the sharps container located within the cabinets it is now being placed to the right of the attendant s chair on the back wall (Figure 10). This position optimizes visibility of the opening of the container and is accessible from a seated position on the attendants chair without requiring any adjustments. It is also positioned in a location which does not impede on other equipment and tasks within the vehicle. Optimal healthcare environments are essential in providing the best patient care possible and increasing staff satisfaction. By testing and evaluating equipment and environments prior to implementation, changes can be made in a timely and cost effective manner that will improve patient care and safety and assist in changing the culture within the organization. A great deal of useful information and feedback was gathered throughout this evaluation. Recommendations were implemented where possible to ensure that improvements were made to the functionality, efficiency, and safety of the staff and passengers of these vehicles. These vehicles have been designed to optimize staff safety based on known risks and potential design improvements (Levick, 2007; Levick & Li, 2000; Levick, Shelew, & Blatt, 2001) but have not been designed to optimize workflow or meet care provider needs. Consequently, compliance to the use of these safety enhancements (i.e., seatbelts) was non-existent, nullifying their benefits and increasing the risk to care providers. Such safety aspects such as the occupant restraint net, which would normally catch any unrestrained passengers in the patient compartment, is not required when an individual chair is installed in the place of a squad bench (Alberta Health and Wellness, 2010). As such, the combination of providers not wearing their seatbelts and not having a restraint net installed in the ambulances, there is very little to stop/catch care providers in the event of a collision.
7 101 To improve compliance and further gather useful information on EMS provider workflow, patient care, and equipment requirements, additional Human Factors evaluations are recommended. By using patient simulation and scenario enactments within the new ambulance environment (Caird, et al., 2010; Chisholm et al., 2008) we can achieve a better understanding of EMS behaviours and dispel some of the myths (i.e., the need to stand up while providing patient care in transit) that are impacting safety within these vehicles. These user testing and simulation sessions can be beneficial to increase frontline staff buy-in for future changes by eliciting their feedback and providing behavior based evidence to validate the design, which in turn should improve the compliance rates for safety engineered systems in future generation vehicles. REFERENCES Alberta Health and Wellness (2010). Emergency Health Services Ambulance Vehicle Standards Code January Becker, L.R., Zaloshnja, E., Levick, N., Li, G., & Miller, T.R. (2003). Relative risk of injury and death in ambulances and other emergency vehicles. Accident Analysis and Prevention (35), Caird, J. K., Shultz, J., Mayer, A. K., Chisholm, S. L., & Teteris, E. (2010). Using human factors methods and patient simulation to determine the architectural usability of hospital mock-up rooms. Proceedings of the International Meeting on Simulation in Healthcare, Phoenix, AZ, February Chisholm, S. L., Schultz, J., Caird, J. K., Lord, J., Boiteau, P. & Davies, J. (2008). Identification of intensive care unit (ICU) system integration conflicts: Evaluation of two mock-up rooms using patient simulation. Proceedings of the 52 nd Annual Meeting of the Human Factors and Ergonomics Society (pp ), New York, NY: Human Factors and Ergonomics Society. Ferreira, J., & Hignett, S. (2005). Reviewing ambulance design for clinical efficiency and paramedic safety. Applied Ergonomics, 36(1), Gilad, I., & Bryan, E. (2007). Ergonomic evaluation of the ambulance interior to reduce paramedic discomfort and posture stress. Human Factors, 49(6), Kahn, C.A., Pirrallo, R.G., & Kuhn, E.M. (2001) Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis. Prehospital Emergency Care (5), Larmon, B., LeGassick, T.F., & Schriger, D.L. (1993). Differential front and back seat safety belt use by prehospital care providers. American Journal of Emergency Medicine, 11(6), Levick, N., & Li, G. (2000). Development of a dynamic testing procedure to assess crashworthiness of the rear patient compartment of ambulance vehicles. National Highways Traffic Safety Administration, 454, USA. Levick, N., Shelew, W.B., & Blatt, A. (2001). Occupant injury hazards in ambulance transport, findings from full vehicle crash testing. Academic Emergency Medicine, 8(5), 527 Levick, N., Grzebieta, R. (2007). Crashworthiness analysis of three prototype ambulance vehicles. Objective Safety. MIL-STD-1472F. (1999). Department of defence design criteria standard. Department of Defence. Retrieved October 11, 2005, from NASA-STD (1995, Revision B). Man-system integration standards. Retrieved October 11, 2005, from Needlestick Safety and Prevention Act of Public Law , US Statutes at Large 1901 (2000):114. Safety signage at hydropower projects. (2001, October). Washington, DC: The Federal Energy Commission. Sanddal, N.D., Albert, S., & Hansen, J.D. (2008). Contributing factors and issues associated with rural ambulance crashes: Literature review and annotated bibliography. Prehospital Emergency Care (12)2,
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Monday, March 18, 2013
La Folie Baudelaire
Roberto Calasso's latest book translated into English is La Folie Baudelaire. Here is the author's note at the end of the book – Roberto Calasso, publisher of Adelphi in Milan, is the author of many books, among them The Ruin of Kasch, The Marriage of Cadmus and Harmony, Ka, K., and Tiepolo Pink, all parts of a work in progress of which La Folie Baudelaire is the sixth panel.
An anecdotal bit from Calasso's chapter on Degas –
Until Degas, custom reasonably located the subjects of a portrait in the center. In the same way, there was a tacit rule whereby every figure, even secondary ones, appeared completely. The visual field, with its arbitrary limitations, had to respect the intactness of the characters who came into the picture.
With Degas, this changed. Perhaps not even out of a conscious decision and certainly not to state some new principle. Rather, it was the result of a kind of gestural drift. When did he begin doing this? Not exactly from the start, as the figures in Degas's early portraits are in an irreproachably central position. But we already see a dramatic novelty in The Bellelli Family, a key painting, which the young Degas worked on for seven years. Originally titled Family Portrait – and hence referring to something that is a nucleus par excellence – this painting develops around an empty space in the center. The father has his back to the painter, and the four figures are looking in different directions. All the figures seem to wish to exclude the others from their own visual field, as also happens in a portrait of the Bellelli sisters on their own. They are psychic entities determined not to come even close to one another. The mother's gaze is so fixed and absent as to make her seem blind. The two girls are recalcitrant: the one nearer the center avoids looking at the painter with mischievous determination, so much as to invalidate her axial position. The other gives the artist a bored stare, as if to say, "When is this torment going to stop?" The father ignores the painter; above all he has no gaze. We know from various sources that the Bellelli family was riddled with acrimony, rancor, and fractiousness, an exemplary domestic hell. A southern Strindberg. Group portraits were usually commissioned to emphasize certain features: unity, solidarity, and harmony. Their origins lay in pride and vanity. Instead, Degas wanted to paint – and stubbornly perfected – the portrait of a family united by reciprocal aversions. But it's not the oddness of the spatial arrangement that hints at a psychological state. It is psychological tension used to attain a spatial revelation: the absence of a center. A center that can no longer perform its symbolic function. Here the center is occupied by wallpaper and numerous frames, including that of a mirror.
Of the six books in Calasso's cycle (in progress), two I see that I have not read. But I think the best plan would be to go back and read all six in order, including the ones I haven't read and the ones I have read. To reread Calasso is always to find great flashing swathes of leftover genius that I completely missed the first time through.

subset: commoncrawl


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Facebook Adds New Parent Advice Section to Help Keep Kids Safe Online
Should we be encouraging our kids to use social media? Is restricting them from using social platforms effective?
These are key questions that are likely to get even more focus this year amidst the wider conversation around whether social media, more generally, has been good or bad for society.


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By Gogo Thule Ngane, Wake Up World
Many hours of my day are filled with immense reflections, observation, mental notes and analysis, and just a whole bunch of thoughts! I blame it on my Aquarian imagination and air sign tendencies. So much of what I observe draws me in deeply.
One thing that has always intrigued me is how people express their love and appreciation for God, the divine, or their spiritual deities in the form of constant spiritual practices centered around devotion and appreciation, or bhakti.
Ceremonies, rituals, and all kinds of spiritual events occur around the world where hundreds of candles are beautifully lit, thousands of flower petals nicely adorned on altars, incenses burn strong and sweetly, prayers and empowering words are said, and fruit or carefully prepared foods and dishes are not eaten but offered as a sign of a follower's gratitude — all an energetic exchange that says, 'thank you, i love you'. Continue reading Spirituality: The Path is the Practice


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Getting ready for the royal wedding
With the venue chosen, the guests confirmed and the dress made (yet being kept a closely guarded secret), Prince Harry and Meghan Markle are set to marry on 19 May at St George's Chapel, in Windsor Castle.
It's not just Harry and Meghan who have had to rehearse for their big day. The Household Cavalry Mounted Regiment, which is made up of soldiers Prince Harry served alongside in Afghanistan, have been practising in Hyde Park Barracks, in London. Members of the military will line the street outside the chapel ready to salute when the newlyweds emerge as husband and wife.
Meanwhile, the kitchen in charge of feeding the royal wedding party has been firing up its ovens. On the day, chefs will be preparing delicate chocolate truffles, macaroons, mini crèmes brûlées, and biscuits topped with mango panna cotta.
Even though the wedding will soon be over, the public have the chance to purchase a wide variety of souvenirs to remember the event by. Traditional keepsakes include official Harry and Meghan china mugs, plates and teatowels, while the more unusual items include limited-edition Top Trumps cards, cupcakes and one-of-akind Pez dispensers, which the sweet company will auction for charity.
On 16 May it was revealed that Princess Charlotte and Prince George will be among the ten children chosen to be bridesmaids and pageboys on their uncle's big day.
Harry and Meghan will get married.


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Eggplant Salad
Eggplant — 2-3 pcs.
Chicken Egg — 2 pcs.
Potatoes — 1 pc.
Bulgarian pepper — 1 pc.
Onions — 1 pc.
Garlic cloves — 2-3 pcs.
Green onions — 2-3 pieces.
Fresh dill — 2-3 sprigs
4-5 tablespoons sunflower oil
Salt, black pepper — to taste
1. Eggplant cut into rings 1 cm thick. Eggplant in salted water, I Do not soak. Purchased eggplant from the store does not taste bitter.
2. In a bowl, break the eggs, salt and pepper. Each piece of eggplant dip in the egg mixture and fry in a pan. Spread on a napkin, so that the oil glass. Wait until cool.
3. Potatoes cut into thin strips. Fry until golden color, to fries crunched. And wait until completely cool.
4. pepper cut into strips. Cooled eggplant cut into strips. I cut into four parts. If smaller, then stirring salad vegetable porridge will.
5. Onions cut into half rings. Green chop — and in a bowl. There also squeeze garlic. I love garlic so add 2 large cloves. Add salt and pepper.
6. In a bowl with greens add oil and mix. Filling is ready. Add to the salad and mix.
7. Here is our salad and ready! Can be served immediately or refrigerated hold an hour or two.
Bon Appetit!


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Date: 6/3/09
By: Gee RahadianThe Gear is a recent addition to the techniques of Luffy, and they are another example of his rapid progress in using effectively the powers derived from the fruit of the devil. However, both have their gear a long time to "rest" after their use. These new techniques have been discovered in a completely random Luffy in battle during the adventure of Ratchet Mecha Island in One Piece Movie 7: The Giant Mechanical Soldier of Karakuri Castle (The soldier giant mechanical Karakuri Castle), but because movies are not considered part of the world of One Piece, and some of them are illogical events compared to the regular series, this information is considered unfounded.
Gear 2nd (Second Gear)
After being defeated by Aokiji, Luffy admits to having become stronger if he wants to pursue her dream and protect his friends. The result of his efforts is the 2nd gear, the first time we see the technique in action against Blueno CP9. Increasing vascular pressure in his legs, Luffy sets off an acceleration of its blood flow, thus giving the body more oxygen, increasing his speed and his strength both mentally and physically; Lucci compares this effect to that of a stimulant drug. The effects of the attacks Luffy is so increased (often adds "Jet" to their names to distinguish them), even as warriors by the superior strength of the CP9 agents have difficulties in reaction to the attacks with Gear 2nd.
While in 2nd gear, the metabolism of Luffy is so high that his sweat evaporates almost immediately, thus giving the appearance that it emits smoke, his skin turns red for a color similar to the increase in blood flow. Since all bodies are made of rubber, can expand and allow blood to flow at a higher speed without the risk of internal bleeding.
Luffy Gear developed by the two, this is one of her favorites, since it increases its power, the advantage in combat, giving him the opportunity to confront enemies outside its scope. The 2nd Gear, but can be used only for a short period of time, because the accelerated speed of metabilsmo drastically reduce his energy leaving him exhausted. And 'though able to recover his strength by eating food immediately to restore their nutritional reserves, as seen in the battle against Blueno.
During the battle of Luffy vs. Lucci, we see another negative effect of 2nd gear. Despite the body of Luffy's rubber allows it to make a success of the technique without killing him instantly, the intensity of the flow exerts a tremendous effect on his body shortening its life. Pike argues that this technique is a greasy, but Luffy says that to save his friends would be willing to sacrifice.
3rd Gear (Third Gear)
To use the Gear 3rd Luffy takes his thumb in his mouth, bites and blows hard swelling in the arm. Becomes able to trasfrire air from the bones throughout the entire body, turning the chest in an interface for the various arts. Luffy blows so much air that when the body is concentrated in only one limb increases the size of the latter becoming equivalent to that of a giant.
Used with its strong physiology, this technique gives more mass to his arm capable of covering a large area of attack, sacrificing speed for this immense power. The bones are the key difference compared to its inflated shape is usually used, being soft and elastic like a balloon. The bones are tough enough to repel bullets as demonstrated by Luffy when he was hit by several rounds of marine bouncing without damage. It 'was also capable of doing major damage to Pike when he used one Tekkai Gom Gom Giant Pistol. When he attacks with this technique usually adds the suffix Gigant, describing the nature of the Giant attacks. Among the other attacks, Luffy brings the air back to his chest, and then moved to another part of the body. To exit the form of 3rd Gear exhales heavily pushing back.
The use and activation leading to shrinkage of Gear 3rd Luffy. The time spent in this form is equivalent to time spent in 3rd gear. In this form, Luffy has shown they have no skills and also a substantial loss of strength since his attacks had no effect. The strategy he uses is in fact to run away and hide for the time of shrinking.
The effects of 3rd gear were shown for the first time when Luffy, and Robin chasing Spandam, had to stop in front of a heavy metal door, while the first use was seen in the battle between him and Lucci to Enies Lobby.


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The Government has launched a pound;450,000 project to investigate teacher assessment in schools, which could lead to an alternative to national curriculum tests.
Teachers in 74 schools in 13 local authorities are piloting a key stage 3 scheme backed by the Department for Education and Skills and the Qualifications and Curriculum Authority.
Two teachers in each school are using a new system of assessment called the "monitoring pupil progress" project.
It has started in KS3 English but is likely to be extended. Twenty to 25 borderline pupils in Years 7 and 9 have been selected to take part.
They are being taken out of lessons once a term for set-piece reading and writing exercises, laid down in minute detail by the QCA, which their teachers then mark.
The mark scheme, also devised by the exams watchdog, is complex. In Year 7 writing, for example, there are eight categories ranging from the use of vocabulary to spelling that teachers use to decide whether pupils qualify for a lower or higher national curriculum level.
They then have to tick boxes in an "assessment grid" to give a level to the child in each category. Teachers will also use the system to give levels to the routine work that pupils do in lessons.
The aim is for the mark scheme to be used to identify a pupil's strengths and weaknesses, which can be given to parents and used to identify future teaching priorities.
Some teachers fear the marking grid could increase their workloads and some have reservations about being told what constitutes good work by the QCA and about making the marking of English an exact science.
But the National Association of the Teaching of English is involved in the project and John Johnson, its chairman, believes the scheme could be crucial in convincing ministers to try it as an alternative to tests.
He said it was the "first hesitant step" towards putting more emphasis on teacher assessment.
At NATE's annual conference earlier this month, Sue Hackman, director of the KS3 strategy, told teachers they had to think of possible options if they were serious about objecting to the tests. She denied that the project had originated as an alternative to tests. It was simply about providing better ongoing assessment in schools.
Leading figures at the QCA have privately supported scaling down the testing regime over the years, but replacing the tests could be a tough job. Ministers do not want to be accused of going soft on school accountability.
However, teachers involved in the project are getting behind it (see box).


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Have you ever owed anyone money before? Didn't it place a burden on you? Owing someone money will always bring that cloud over your head and keep it there. It is not a good feeling. Who you owe the money to will also make a big difference.
Have you ever borrowed ten or twenty dollars to a friend or family member, you probably didn't feel very obliged to pay it back because you agreed you'd pay it back when you could. If you instead owed them a thousand dollars with a 10 percent agreed upon interest rate, you'd have a bit more of a burden on your shoulders.
The more burdensome debts are not the ones you owe your friends and family. It is usually the larger debts with the higher interest rates. Credit cards are known to charge some of the highest interest rates, anywhere from 12% to 24% or more. This kind of debt can really build fast with such high interest rates.
Should you pay your debt off? Yes. When it comes to financial management, paying off your debt should be top priority. One of your life long goals should always be to pay off all your debt. Debt grows faster and faster the more you have.
Some say it's not important to pay off a mortgage or that you should even always have one because of the tax deduction. You can only deduct the interest you pay on your mortgage, and that's only a percentage. If you had no mortgage, you wouldn't have to pay any of it.
For example, if you paid $2,000 one year in interest on your mortgage and you are in the 15% tax bracket, you only get to save 15% of the $2,000 which is $300, not the whole $2,000. It's a limited amount of savings and you should not prolong mortgage expense beyond what you original set it up for.
You could say that you could invest what you aren't paying for your house at a higher rate than the mortgage rate and make more money. How many people actually have that money now and if they could save it, how many would invest it and not just go and spend it?
All other debt you should pay off as soon as you can. Credit cards, car loans, and other loans have high interest rates that you must pay down. Better yet, don't accumulate this debt to begin with. You don't need a brand new car, you can buy used, and you never need to use a credit card, but if you do, always pay off the balance at the end of every month.
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Very good location, just a few minutes by car from Tarifa (very nice place) and from the beach. Near the beautiful dunes of Bolonia. Rooms are clean, shower is good, you can park for free at the hostal, very good value for money. We didn't...More
"You really do need a vechicle to stay here. Tarifa town is a long way to walk and the hotel is located on a..."
"Judging by the food, the cleanliness and the price this is definitely a great place."


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The album, which is available now on the music licensing website, features ten well known Christmas carols with original arrangements featuring violin, guitar and mandolin.
Los Angeles, CA (PRWEB) October 22, 2012
With Christmas fast approaching, RoyaltyFreeKings.com announced this week a new addition to their royalty free Christmas music catalog - Acoustic Christmas. The album, which is available now on the music licensing website, features ten well known Christmas carols with original arrangements featuring violin, guitar and mandolin. Customers who buy the album on RoyaltyFreeKings.com can also purchase an extensive 'extras' package, consisting of sub-mixes and individual instrument 'stems' for each track. These extra files give producers greater options and mileage out of the ten tracks featured on the royalty free holiday music album.
Tracks on the Acoustic Christmas album include: Deck the Halls, Joy to the World, The First Noel and Hark! The Herald Angels Sing.
RoyaltyFreeKings.com is still busy working on a collection of Christmas themed albums, with two other albums currently in production: Epic Christmas - traditional Christmas carols set to massive modern orchestral arrangements and a solo piano collection of Christmas carols. These albums will compliment recently released albums - Pop Rock Christmas - featuring instrumental modern pop rock renditions of ten well known carols, and Jazz Christmas - ten carols performed by authentic jazz musicians.
In recent months RoyaltyFreeKings.com also added dozens of tracks to their free background music download section. Available to anyone working on a project with a budget of less than US$250,000, each free track is available for immediate download. The range of styles and genres include: epic dramatic orchestral, ambient piano, jazz, comedy, rock and suspense tension. The selection of royalty free music for free covers full length tracks and music loops.
Tracks featured in the free section are aimed at people who need legal clearance for the music they use, but don't necessarily have the resources to pay for it. Owners of YouTube ''partner' accounts fall into this category - where using unauthorized music runs the risk of getting an account suspended, or worse: getting sued by the owners of the music.
RoyaltyFreeKings.com's collection not only covers the most used styles and genres of music, such as: pop rock, acoustic and romantic, suspense tension and heroic inspiring, but also a growing list of unique 'hybrid' albums. Some of these include 'Epic Patriotic' - US patriotic songs in an epic trailer music setting, 'Patriotic Punk Rock' - American patriotic songs set to edgy punk rock arrangements, 'Jazz Patriotic' - featuring live saxophone, piano, drums and bass, and the upcoming releases 'Acoustic Christmas' and 'Epic Christmas'.
The goal of RoyaltyFreeKings.com since launching in early 2012, has been to make searching for background music for video production easy and streamlined. The main benefit of a crowd-sourcing business model, like that used by many royalty free websites, is a rapid expansion of content. The downside is inevitable - with so many tracks being uploaded, the catalog easily gets bloated with mediocre music that does little to enhance a project, whether it's a commercial, wedding video, film or webisode. Producers looking through websites licensing stock music (also known as 'library music' or 'production music') have to either waste time sifting through such huge collections of music to find something they'd actually want to use, or worse - settle for something inferior just because they don't have the time to continue searching.
By hand picking each piece music, RoyaltyFreeKings.com only allows in music that meets a strict standard of musicality and production value. The result is a streamlined shopping experience where a producer can find, purchase and download the music they need within just a few minutes.


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Red Panda Bistro
30 Visayas Ave., Visayas, Quezon City, Metro Manila
- 6 Reviews
- 0 Recommend
- 6 Reviewers
Primary Details
- Category:
- Fusion
- Phone
- +6326681155
More Info
Most Recent Reviews
Though I've seen the restaurant and pass by it almost everyday, I was only able to dine here a few weeks ago with my family. I was surprised to see that the front wasn't the same as before. The plants and walkway were quite unkempt. I wasn't bothered by it because I'm not the type who judges a book by its cover. BUT it would be great to fix those for safety reasons and because it is a restaurant after all.
For the food, Red Panda offers a wide range of dishes perfect for sharing as well as dimsum and Shabu Shabu Hotpot that will certainly satisfy your tummies. Since there were only a few of us, we tried the following: Tausi Spareribs, Beancurd Roll, Asparagus Oyster Sauce, Chinese Cold Cuts Platter, Cucumber Lemonade and Red Panda Iced Tea.
All the dishes were great but my favorite would be the Beancurd Roll, Chinese Cold Cuts Platter and Cucumber Lemonade. The dimsum classic Beancurd Roll is soft, juicy and stuffed with a delicious meat filling. The Chinese Cold Cuts Platter was also a perfect choice. For drinks, I suggest going for the refreshing Cucumber Lemonade.
Our overall Red Panda experience was okay. Will I visit them again? Of course.
- No. of Comments: 2
- No. of Likes: 5 Likes
Attended a birthday slash graduation celebration here last Sunday.
And... it was just okay? Usual Chinese restaurant.
The place is spacious, lot's of tables and they have function rooms available for big groups. The set up and feel of the place is like a typical old Chinese restaurant. Hmmm, but the whole place felt/looked old... like it needs a lot of cleaning and renovating!
Anywayy. Since we're a big group. I think they ordered the set meals. We were served a lot of dishes but I only got to taste just a few.
- started with a hot bowl of nido soup? which tasted like the powdered kind.
- The beef w broccoli was just okay, crunchy broccoli and the beef was tender but not as tasty and flavorful.
- The sweet and sour lapu lapu was good but it was too small. Payatot yung fish. Hence, bitin!
- Birthday noodles was good. Generous serving size and toppings (lot's of veggies!!! Carrots, cabbage, and meat!!!!) But nothing extra special, just your usual pancit canton.
- lumpiang shanghai was good, too. Not as siksik but still yummy!
- The sweet and sour? spareribs was yummy! Loved how tender the meat was and how it was evenly coated with the tasty sauce! This was my favorite.
- almond coffee jelly something for dessert and it was good? Sakto lang.
Service was good. The staffs were all helpful, very attentive, and friendly! 🏼
- No. of Comments: 0
- No. of Likes: 2 Likes
This was the former david's tea house. Now i have a feeling that they're just the same. Because i also know that there's another david's tea house that became red panda (at dasmariñas). Another thing is that the interior of this restaurant was just the same as the interior of its former david tea house.
The food... Is chinese as well.. I was just amazed that they have caesar's salad.
The service btw, kinda soso. Not so fast. Not so slow. There was a fly and i asked them to do something about it, they were able to provide a candle. The buzzer thing was quite ineffective unless you also raise your hand.
ますます for me.
- No. of Comments: 0
- No. of Likes: 2 Likes
Their shabu-shabu is a must try dish! Specially their satay soup and beef that soo tender! Did I mention you dont need to raise your hand to call the attention of their staffs,yes!! Just push a button like a door bell and their staff will come to u asap.
- No. of Comments: 0
- No. of Likes: 1 Like
Formerly David's Tea House ....
- No. of Comments: 0
- No. of Likes: 1 Like
I got invited to Red Panda for dinner tonight...
The place was very spacious, but parking is definitely a problem... When you enter, you would immediately know that it's a Chinese restaurant...
We used the function room at the second floor of the restaurant-- private, big, with good acoustics... Good for meetings...
We were served soup, shrimps, 2 kinds of fish, beef with broccoli, sweet and sour pork, noodles, and fried rice... Can I just say that I absolutely love fried rice? I base my ratings of Chinese restos on their fried rice... So, it was a fried rice fail tonight... It didn't make me want to keep eating rice... Chowking's YCF rice is actually better... So sorry, it's just an okay rating for me...
- No. of Comments: 0
- No. of Likes: 10 Likes


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