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Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes
C Clay Cothren1 &
Ernest E Moore1
In the past three decades there has been a significant clinical shift in the performance of emergency department thoracotomy (EDT), from a nearly obligatory procedure before declaring any trauma patient to select patients undergoing EDT. The value of EDT in resuscitation of the patient in profound shock but not yet dead is unquestionable. Its indiscriminate use, however, renders it a low-yield and high-cost procedure. Overall analysis of the available literature indicates that the success of EDT approximates 35% in the patient arriving in shock with a penetrating cardiac wound, and 15% for all penetrating wounds. Conversely, patient outcome is relatively poor when EDT is done for blunt trauma; 2% survival in patients in shock and less than 1% survival with no vital signs. Patients undergoing CPR upon arrival to the emergency department should be stratified based upon injury and transport time to determine the utility of EDT. The optimal application of EDT requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences.
The number of patients arriving at hospitals in extremis, rather than expiring in the prehospital setting, has increased due to the maturation of regionalized trauma systems throughout the world. Salvage of individuals with imminent cardiac arrest or those already undergoing cardiopulmonary resuscitation often requires immediate thoracotomy as an integral component of their initial resuscitation in the emergency department. The optimal application of emergency department thoracotomy (EDT) requires a thorough understanding of its physiologic objectives, technical maneuvers, and the cardiovascular and metabolic consequences. This review highlights these features and the specific clinical indications of EDT, all of which are essential for the appropriate use of this potentially life-saving yet costly procedure.
Historical perspective and clinical outcomes
Emergent thoracotomy came into use in the United States for the treatment of heart wounds and anesthesia-induced cardiac arrest in the late 1800's and early 1900's. The concept of a thoracotomy as a resuscitative measure began with Schiff's promulgation of open cardiac massage in 1874 [1] and had expanded indications with treatment of penetrating chest wounds and heart lacerations around the turn of the century [2, 3]. With improvement in patient resuscitation and an ongoing evaluation of patient outcomes, the indications for emergent thoracotomy shifted. Initially, cardiovascular collapse from medical causes was the most common reason for thoracotomy in the early 1900's. The demonstrated efficacy of closed-chest compression by Kouwenhoven and colleagues [4] in 1960 and the introduction of external defibrillation in 1965 by Zoll and colleagues [5] virtually eliminated the practice of open-chest resuscitation for medical cardiac arrest. The use of emergent thoracotomy following trauma also declined as less invasive therapeutics, such as pericardiocentesis for cardiac tamponade, were preferred [6]. In the late 1960s, the pendulum toward emergent thoracotomy swung again, as refinements in cardiothoracic surgical techniques salvaged patients with life-threatening chest wounds [7] and use of temporary thoracic aortic occlusion saved patients with exsanguinating abdominal hemorrhage [8, 9].
In the past three decades there has been a significant clinical shift in the performance of EDT. While the use of EDT in resuscitation of the patient in profound shock but not yet dead is unquestionable, its indiscriminate use, renders it a low-yield and high-cost procedure [10–12]. During this swing of the pendulum, several groups have attempted to elucidate the clinical guidelines for EDT [13, 14]. In 1979, we conducted a critical analysis of 146 consecutive patients undergoing EDT and suggested a selected approach to its use in the moribund trauma patient, based on consideration of the following variables: (1) location and mechanism of injury, (2) signs of life at the scene and on admission to the ED, (3) cardiac electrical activity at thoracotomy, (4) systolic blood pressure response to thoracic aortic cross-clamping [12].
To validate these clinical guidelines, we established a prospective study in which these data were carefully documented in all patients at the time of thoracotomy. In 1982, the first 400 patients were analyzed [11]. A more recent review has summarized the data on 868 patients who have undergone EDT at the Denver Health Medical Center [15]. Of these, 676 (78%) were dead in the ED, 128 (15%) died in the operating room, and 23 (3%) succumbed to multiple organ failure in the surgical intensive care unit. Ultimately, 41 (5%) patients survived, and 34 recovered fully without neurologic sequelae. While this yield may seem low, it is important to emphasize that thoracotomy was done on virtually every trauma patient delivered to the ED. In fact, 624 (72%) were without vital signs in the field, and 708 patients (82%) had no vital signs at the time of presentation to the ED. In contrast, it is equally important to stress that patients without signs of life at the scene but who responded favorably to resuscitation were excluded from this analysis because they did not require EDT; these patients remind the practitioner that prehospital clinical assessments may not always be reliable in triaging these severely injured patients [16]. Indeed, the authors have salvaged a number of individuals sustaining blunt and penetrating trauma who were assessed to have no signs of life at the scene of injury.
The survival rate and percentage of neurologic impairment following EDT varies considerably, due to the heterogeneity of patient populations reported in the literature and the inconsistency of terminology. Clarification of patient physiology and consistency of terms is the first step in standardizing EDT evaluation (Table 1). We have attempted to elucidate the factors affecting survival following EDT by collating data from a number of clinical series reporting on 50 or more patients (Table 2). Objective analysis of these data is limited due to inconsistencies in patient stratification; some reviews provide a specific breakdown of the injury mechanism and clinical status of patients presenting to the ED, while others combine all injury mechanisms. The summarized data confirms EDT has the highest survival rate following isolated cardiac injury; 35% of adult patients presenting in shock, and 20% without vital signs, were salvaged after isolated penetrating injury to the heart if EDT was performed. In contrast, only 1–3% of blunt trauma patients undergoing EDT survive, regardless of clinical status on presentation. Following penetrating torso injuries, 14% of patients requiring EDT are salvaged if they are hypotensive with detectable vital signs, whereas 8% of those who have no vital signs but have signs of life at presentation, and 1% of those without signs of life are salvaged. These findings are reiterated by a recent report incorporating all patients from 24 separate studies undergoing EDT for either blunt or penetrating mechanism [17]; survival rates by mechanism in descending order are 19.4% for isolated cardiac wounds, 16.8% for stab wounds, 4.3% for gunshot wounds, and 1% for blunt trauma.
Table 1 Definitions of Terminology Used in Patients Undergoing EDT
Table 2 Survival Following Emergency Department Thoracotomy in Adults
Emerging data indicates the clinical results in the pediatric population mirror that of the adult experience. One might expect that children would have a more favorable outcome compared to adults; however, this has not been borne out in multiple studies [18–22]. Beaver and colleagues reported no survivors among 27 patients, from 15 months to 14 years of age, undergoing postinjury EDT at Johns Hopkins Hospital [18]. Powell and coworkers, described an overall survival of 20% (3 of 15 patients) in patients ranging from 4 to 18 years [21]. In a study at Denver Health Medical Center, encompassing an 11-year experience with 689 consecutive EDT, we identified 83 patients (12%) who were under 18 years old [19]. Survival by injury mechanism was 9% (1 of 11) for stab wounds, 4% (1 of 25) for gunshot wounds, and 2% (1 of 47 patients) for blunt trauma. Among 69 patients presenting to the ED without vital signs, only 1 patient (1%) survived (with a stab wound). This contrasted to a salvage of 2 (14%) among 14 patients with vital signs. The outcome in blunt trauma, the predominant mechanism of lethal injury in children, was disappointing, with only 2% salvage, and no survivors when vital signs were absent. Thus, as in adults, outcome following EDT in the pediatric population is largely determined by injury mechanism and physiologic status on presentation to the emergency department.
There is disagreement about the use of EDT in the patient population undergoing cardiopulmonary resuscitation prior to arrival in the emergency department. Although there have been multiple reports with low survival rates and dismal outcomes following prehospital CPR, termination of resuscitation in the field should not be performed in all patients [23]. Our most recent evaluation, incorporating 26 years of experience, indicates EDT plays a significant role in the critically injured patient undergoing prehospital CPR [13]. We believe this study provides simple, clear guidelines for the use of EDT as a resuscitative measure to ensure that all potentially salvageable patients are included (Table 3).
Table 3 Current indications and contraindications for EDT
In sum, overall analysis of the available literature indicates that the success of EDT approximates 35% in the patient arriving in shock with a penetrating cardiac wound, and 15% for all penetrating wounds. Patients undergoing CPR upon arrival to the emergency department should be stratified based upon injury and transport time to determine the utility of EDT. Conversely, patient outcome is relatively poor when EDT is done for blunt trauma; 2% survival in patients in shock and less than 1% survival with no vital signs.
Indications for EDT
Based on our 26 successive years of EDT prospective analysis, we propose current indications for EDT [13] (Table 3). Our current decision algorithm for resuscitation of the moribund trauma patient and use of EDT was formulated and implemented as a key clinical pathway in the emergency department (Figure 1). At the scene, patients in extremis without electrical cardiac activity are declared dead. Patients in extremis but with electrical cardiac activity are intubated, supported with cardiac compression, and rapidly transported to the ED.
Algorithm directing the use of EDT in the multiply injured trauma patient.
On arrival to the ED, the time from initiation of CPR is recorded; blunt trauma patient with greater than 5 minutes of prehospital CPR and no signs of life are declared, while penetrating trauma patients with greater than 15 minutes of prehospital CPR and no signs of life are pronounced. Patients within the time guidelines or those with signs of life trigger ongoing resuscitation and EDT. After performing a left anterior thoracotomy and pericardotomy, the patient's intrinsic cardiac activity is evaluated; patients in asystole without associated cardiac injury are declared. Patient's with a cardiac wound, tamponade, and associated asystole are aggressively treated; the cardiac wound is repaired first followed by manual cardiac compressions and intracardiac injection of epinephrine. Following several minutes of such treatment and volume resuscitation, one should reassess salvageability; we define this as the patient's ability to generate a systolic blood pressure > 70 mmHg.
Patients with an intrinsic rhythm following EDT should be treated according to underlying pathology. Those with tamponade should undergo cardiac repair, either in the trauma bay or the operating room. Control of intrathoracic hemorrhage may entail hilar crossclamping, digital occlusion of the direct injury, or even packing of the apices for subclavian injuries. Treatment of bronchovenous air embolism includes crossclamping of the hilum, putting the patient in Trendelenberg's position, aspirating the left ventricle and aortic root, and massaging the coronaries. Finally, aortic crossclamping is performed to decrease the required effective circulating volume, for either thoracic or abdominal sources of hemorrhage, and facilitate resuscitation. In all of these scenarios, reassessment of the patient following intervention and aggressive resuscitation efforts is performed, with the goal systolic pressure of 70 mmHg used to define salvageability.
Physiologic rationale
The primary objectives of EDT are to (a) release pericardial tamponade; (b) control cardiac hemorrhage; (c) control intrathoracic bleeding; (d) evacuate massive air embolism; (e) perform open cardiac massage; and (f) temporarily occlude the descending thoracic aorta. Combined, these objectives attempt to address the primary issue of cardiovascular collapse from mechanical sources or extreme hypovolemia.
Release pericardial tamponade and control cardiac hemorrhage
The highest survival rate following EDT is in patients with penetrating cardiac wounds, especially when associated with pericardial tamponade [7, 17]. Early recognition of cardiac tamponade, prompt pericardial decompression, and control of cardiac hemorrhage are the key components to successful EDT and patient survival following penetrating wounds to the heart [24]. The egress of blood from the injured heart, regardless of mechanism, results in tamponade physiology. The classic description of clinical findings, Beck's triad, is rarely observed in the emergency department; therefore, a high index of suspicion in the at-risk patient sustaining penetrating torso trauma is crucial, with prompt intervention essential. The first two phases of cardiac tamponade – restricted ventricular diastolic filling, compromised stroke volume and coronary perfusion, and diminished cardiac output – may be aggressively managed with definitive airway control, volume resuscitation to increase preload, and pericardiocentesis. The patient in the third phase of tamponade – intrapericardial pressure approaches the ventricular filling pressure with profound hypotension (SBP < 60) – should undergo EDT rather than pericardiocentesis as the management for evacuation of pericardial blood [25, 26]. Following release of tamponade, the source of tamponade can be directly controlled with appropriate interventions based on the underlying injury.
Control intrathoracic hemorrhage and perform open cardiac massage
Life-threatening intrathoracic hemorrhage occurs in less than 5% of patients following penetrating injury presenting to the ED, and in even lower percentage of patients sustaining blunt trauma [27]. The most common injuries include penetrating wounds to the pulmonary hilum and great vessels; less commonly seen are torn descending thoracic aortic injuries with frank rupture or penetrating cardiac wounds exsanguinating into the thorax through a traumatic pericardial window. There is a high mortality rate in injuries to the pulmonary or thoracic great-vessel lacerations due to the lack of hemorrhage containment by adjacent tissue tamponade or vessel spasm. Either hemithorax can rapidly accommodate more than half of a patient's total blood volume before overt physical signs of hemorrhagic shock occur. Patients with exsanguinating wounds require EDT with rapid control of the source of hemorrhage if they are to be salvaged.
In patients with cardiopulmonary arrest, external chest compression provides approximately 20 to 25% of baseline cardiac output, with 10 to 20% of normal cerebral perfusion [28–30]. While this degree of vital organ perfusion can provide reasonable salvage rates for 15 minutes, few normothermic patients survive 30 minutes of closed-chest compression. Moreover, in models of inadequate intravascular volume (hypovolemic shock) or restricted ventricular filling (pericardial tamponade), external chest compression fails to augment arterial pressure or provide adequate systemic perfusion; the associated low diastolic volume and pressure result in inadequate coronary perfusion [31]. Therefore, closed cardiac massage is ineffective for postinjury cardiopulmonary arrest. The only potential to salvage the injured patient with ineffective circulatory status is immediate EDT.
Achieve thoracic aortic cross clamping
The rationale for temporary thoracic aortic occlusion in the patient with massive hemorrhage is two-fold. First, in patients with hemorrhagic shock, aortic cross clamping redistributes the patient's limited blood volume to the myocardium and brain [9]. Second, patients sustaining intraabdominal injury may benefit from aortic cross clamping due to reduction in subdiaphragmatic blood loss [8]. Temporary thoracic aortic occlusion augments aortic diastolic and carotid systolic blood pressure, enhancing coronary as well as cerebral perfusion [32, 33]. Experimental observations suggest that temporary aortic occlusion is valuable in the patient either with shock due to non-thoracic trauma or in patients with continued shock following the repair of cardiac or other exsanguinating wounds [34, 35]. Indeed, occlusion of the descending thoracic aorta appears to increase the return of spontaneous circulation following cardiopulmonary resuscitation [36, 37]. Reports of successful resuscitation using EDT in patients in hemorrhagic shock and even sustaining cardiac arrest following extremity and cervical injuries exist [38]. In these situations, EDT may be a temporizing measure until the patient's circulating blood volume can be replaced by blood product transfusion. In carefully selected patients, aortic cross clamping may effectively redistribute the patient's blood volume until external replacement and control of the hemorrhagic source is possible. However, once the patient's blood volume has been restored, the aortic cross clamp should be removed, as there is substantial metabolic cost and a finite risk of paraplegia associated with the procedure [39–41]. Typically, complete removal of the aortic cross clamp or replacement of the clamp below the renal vessel should be performed within 30 minutes.
Evacuate bronchovenous air embolism
Bronchovenous air embolism can be a subtle entity following thoracic trauma, and is likely to be much more common than is recognized [42–44]. The clinical scenario typically involves a patient sustaining penetrating chest injury who precipitously develops profound hypotension or cardiac arrest following endotracheal intubation and positive-pressure ventilation. Traumatic alveolovenous communications produce air emboli that migrate to the coronary arterial systems; any impedance in coronary blood flow causes global myocardial ischemia and resultant shock. The production of air emboli is enhanced by the underlying physiology – there is relatively low intrinsic pulmonary venous pressure due to associated intrathoracic blood loss and high bronchoalveolar pressure from assisted positive pressure ventilation. This combination increases the gradient for air transfer across bronchovenous channels [45]. Although more often observed in penetrating trauma, a similar process may occur in patients with blunt lacerations of the lung parenchyma.
Immediate thoracotomy with pulmonary hilar cross clamping prevents further propagation of pulmonary venous air embolism. Thoracotomy with opening of the pericardium also provides access to the cardiac ventricles; with the patient in the Trendelenburg's position (done to trap air in the apex of the ventricle), needle aspiration is performed to remove air from the cardiac chambers. Additionally, vigorous cardiac massage may promote dissolution of air already present in the coronary arteries [44]. Aspiration of the aortic root is done to alleviate any accumulated air pocket, and direct needle aspiration of the right coronary artery may be lifesaving.
Technical pearls
The optimal benefit of EDT is achieved by a surgeon experienced in the management of intrathoracic injuries. The emergency physician, however, should not hesitate to perform the procedure in the moribund patient with a penetrating chest wound when thoracotomy is the only means of salvage. The technical skills needed to perform the procedure include the ability to perform a rapid thoracotomy, pericardiotomy, cardiorrhaphy, and thoracic aortic cross clamping; familiarity with vascular repair techniques and control of the pulmonary hilum are advantageous. As the procedure has been described in detail elsewhere, we will briefly touch on some "pearls" which may facilitate one's approach and success in performing EDT.
Thoracic incision
Upon patient arrival and determination of the need for EDT, the patient's left arm should be placed above the head to provide unimpeded access to the left chest. The thoracotomy incision should start on the right side of the sternum; if sternal transection is required, this saves the time consuming step of performing an additional skin incision (Figure 2). As the initial incision is carried transversely across the chest, as one passes beneath the nipple a gentle curve in the incision toward the patient's axilla rather than direct extension to the bed should be performed; this curvature in the skin correlates with the natural curvature of the rib cage. The initial execution of a clamshell thoracotomy should be done in hypotensive patients with penetrating wounds to the right chest. This provides immediate, direct access to a right-sided pulmonary or vascular injury while still allowing access to the pericardium from the left side for open cardiac massage. Clamshell thoracotomy may also be considered in patients with presumed air embolism, providing access to the cardiac chambers for aspiration, coronary vessels for massage, and bilateral lungs for obliteration of the source. Once the right pleural space is opened, the rib retractor should be moved to more of a midline position to enhance separation of the chest wall for maximal exposure. When visualization of penetrating wounds in the aortic arch or major branches is needed, the superior sternum is additionally split in the midline. If the sternum is divided transversely, the internal mammary vessels must be ligated when perfusion is restored; this may be performed using either a figure of eight suture with 2-0 silk or by clamping the vessel with a tonsil and individually ligating it with a 2-0 silk tie.
A generous thoracotomy incision is performed through the fourth or fifth intercostal space; the incision should start to the right of the sternum, and begin curving into the axilla at the level of the left nipple. The Finochiettos' rib retractor should be placed with the handle directed inferiorly toward the bed, in case transverse sternal split is warranted.
Pericardiotomy and cardiac hemorrhage control
If the pericardium is not tense with blood it may be picked up at the apex with toothed forceps and sharply opened with scissors. If tense pericardial tamponade exists, a knife or the sharp point of a scissors is often required to initiate the pericardiotomy incision. Prompt hemorrhage control is paramount for a cardiac injury. In the beating heart, cardiac bleeding sites should be controlled immediately with digital pressure on the surface of the ventricle and partially occluding vascular clamps on the atrium or great vessels. Efforts at definitive cardiorrhaphy may be delayed until initial resuscitative measures have been completed. In the nonbeating heart, cardiac repair is done prior to defibrillation and cardiac massage. Cardiac wounds in the thick walled left ventricle are best repaired with 3-0 non-absorbable running or horizontal mattress sutures. Buttressing the suture repair with Teflon pledgets is ideal for the thinner right ventricle. When suturing a ventricular laceration, care must be taken not to incorporate a coronary vessel into the repair. In these instances, vertical mattress sutures should be used to exclude the coronary and prevent cardiac ischemia (Figure 3). In the more muscular left ventricle, particularly with a linear stab wound, control of bleeding can often be temporized with a skin-stapling device. Low-pressure venous, atrial, and atrial appendage lacerations can be repaired with simple running or pursestring sutures. Use of a foley catheter for temporary occlusion of cardiac injuries has been suggested; in our experience this may inadvertently extend the injury due to traction forces.
Cardiorrhaphy of the right ventricle is buttressed with pledgets; ligation of a coronary artery can be avoided by performing vertical mattress sutures.
Advanced cardiac life support interventions including cardiac massage
The restoration of organ and tissue perfusion may be facilitated by a number of interventions. Dysrhythmias should be treated according to current guidelines [46] and internal defibrillation has similar indications as closed chest CPR. Familiarity with the internal cardiac paddles and appropriate charging dosages in joules is required (Figure 4). In the event of cardiac arrest, bimanual internal massage of the heart should be instituted promptly. We prefer to do this with a hinged clapping motion of the hands, with the wrists apposed, sequentially closing from palms to fingers. The ventricular compression should proceed from the cardiac apex to the base of the heart. The two-handed technique is strongly recommended, as the one-handed massage technique poses the risk of myocardial perforation with the thumb. Pharmocologic adjuncts to increase coronary and cerebral perfusion pressure may be needed; the first agent in resuscitation at this juncture is intracardiac epinephrine. Epinephrine should be administered using a specialized syringe, which resembles a spinal needle, directly into the left ventricle. Typically the heart is lifted up slightly to expose the more posterior left ventricle, and care is taken to avoid the circumflex coronary during injection.
Internal paddles for defibrillation are positioned on the anterior and posterior aspects of the heart.
Thoracic aortic occlusion
If hypotension persists (SBP < 70 mmHg) following thoracotomy and pericardiotomy, the descending thoracic aorta should be occluded to maximize coronary perfusion. We prefer to cross-clamp the thoracic aorta inferior to the left pulmonary hilum (Figure 5). Although some advocate taking down the inferior pulmonary ligament to better mobilize the lung, this is unnecessary and risks injury to the inferior pulmonary vein. Dissection of the thoracic aorta is optimally performed under direct vision by incising the mediastinal pleura and bluntly separating the aorta from the esophagus anteriorly and from the prevertebral fascia posteriorly; if excessive hemorrhage limits direct visualization, which is the more realistic clinical scenario, blunt dissection with one's thumb and fingertips can be done to isolate the descending aorta. If the aorta cannot be easily isolated from the surrounding tissue, digitally occlude the aorta against the spine to affect aortic occlusion. Although occlusion of the thoracic aorta is typically performed after pericardiotomy, this may be the first maneuver upon entry into the chest in patients sustaining extrathoracic injury and associated major blood loss.
Aortic crossclamp is applied with the left lung retracted superiorly, below the inferior pulmonary ligament, just above the diaphragm. The flaccid aorta is identified as the first structure encountered on top of the spine when approached from the left chest.
Physiologic consequences and optimizing oxygen transport
Once life-threatening intrathoracic injuries are controlled or temporized, the major challenge is restoring the patient's hemodynamic integrity and minimizing vital-organ reperfusion injury. Aortic cross clamping may be life saving during acute resuscitation, but there is a cost to the patient. Occlusion of the aorta results in a reduction in abdominal visceral blood flow to 2 to 8% of baseline values [41, 42]; this decrease in visceral blood flow magnifies the metabolic cost of shock, results in tissue acidosis and increased oxygen debt, and may ultimately contribute to post-ischemic multiple organ failure [42]. Additionally, return of aortic flow may not result in normalization of flow to vital organs; in animal models, blood flow to the kidneys remained at 50% of baseline despite a normal cardiac output [42]. The metabolic penalty of aortic cross clamping becomes exponential when the normothermia occlusion time exceeds 30 minutes [47–49]. Hypoxia of distal organs induces the elaboration, expression, and activation of inflammatory cell adhesion molecules and inflammatory mediators; this systemic inflammatory response syndrome (SIRS) has been linked to impaired pulmonary function and multiple organ failure [50]. Consequently, the aortic clamp should be removed as soon as effective cardiac function and adequate systemic arterial pressure have been achieved.
Removal of aortic occlusion may result in further hemodynamic sequelae [51]. Aside from the abrupt reperfusion of the ischemic distal torso, and washout of metabolic products and inflammatory mediators associated with aortic declamping, there are direct effects on the cardiopulmonary system. Thoracic cross clamping in the normovolemic patient may be deleterious because of increased myocardial oxygen demands resulting from the increased systemic vascular resistance [51]. The return of large volumes of blood from the ischemic extremities, with its lower pH, elevated lactate, and other mediators may exert a cardiodepressant activity on myocardial contractility [52]. Overzealous volume loading during aortic occlusion may also result in left ventricular strain, acute atrial and ventricular dilatation and, consequently, precipitous cardiac failure [42]. Following release of aortic occlusion there is impaired left ventricular function, systemic oxygen utilization, and coronary perfusion pressure in the postresuscitation period [51, 53]. The transient fall in coronary perfusion may not be clinically relevant in patients with efficient coronary autoregulation; however, in patients with coronary disease or underlying myocardial hypertrophy, this increase in cardiac work may results in clinically critical ischemia [53].
Following EDT, patients are frequently in a tenuous physiologic state. The combination of direct cardiac injury, ischemic myocardial insult, myocardial depressants, and pulmonary hypertension adversely impact postinjury cardiac function. Additionally, aortic occlusion induces profound anaerobic metabolism, secondary lactic academia, and release of other reperfusion-induced mediators. Consequently, once vital signs return, the resuscitation priorities shift to optimizing cardiac function and maximizing oxygen delivery to the tissues. The ultimate goal of resuscitation is adequate tissue oxygen delivery and cellular oxygen consumption. Circulating blood-volume status is maintained at the optimal level of cardiac filling in order to optimize cardiac contractility, and the oxygen-carrying capacity of the blood is maximized by keeping the hemoglobin above 7–10 g/dL. If these measures fail to meet resuscitative goals [54] (e.g., oxygen delivery ≥500 mL/min/2, resolution of base deficit, or clearance of serum lactate), inotropic agents are added to enhance myocardial function.
Complications of EDT
Technical complications of EDT involve virtually every intrathoracic structure. The list of such misadventures included lacerations of the heart, coronary arteries, aorta, phrenic nerves, esophagus, and lungs, as well as avulsion of aortic branches to components of the mediastinum. Additional postoperative morbidity among ultimate survivors of EDT includes recurrent chest bleeding, infection of the pericardium, pleural spaces, sternum, and chest wall, and post-pericardiotomy syndrome. Previous thoracotomy, typically seen in patients following coronary bypass, virtually assures technical problems from the presence of dense pleural adhesions and is therefore a relative contraindication to EDT.
There is a finite risk to the health care providers and trauma team performing an EDT [55]. The use of EDT by necessity involves the rapid use of sharp surgical instruments and exposure to the patient's blood. Even during elective procedures in the OR, the contact rate of patient's blood with the surgeon's skin can be as high as 50%, and the contact rate of patients' blood with health care workers' blood as high as 60%. The overall seroprevalence rate of human immunodeficiency virus (HIV) among patients admitted to the ED for trauma is around 4%, but is much higher among the subgroup of patients most likely to require an EDT, e.g., 14% of penetrating trauma victims and nearly 30% of intravenous drug abusers. Caplan and colleagues [56] found that 26% of acutely injured patients had evidence of exposure to HIV (4%), hepatitis B (20%), or hepatitisC virus (14%); there was no difference in the incidence comparing blunt to penetrating trauma. Thus, the likelihood of a health care worker sustaining exposure to HIV or hepatitis in the ED is substantial.
As clinicians faced with increasing scrutiny over appropriation of resources, it is critical to identify the patient population who will benefit from EDT. Resuscitative efforts should not be abandoned prematurely in the potentially salvageable patient but field assessment of salvageability is unreliable. The proposed algorithm clearly defines the indications for EDT in the current era. Our clinical pathway attempts to optimize resource utilization, but outcomes must continue to be evaluated, searching for more definitive predictors of neurologic outcome. Use of more advanced monitoring devices in the ED, together with further elucidation of the characteristics of irreversible shock, may permit a more physiologic prediction of outcome for these critically injured patients in the future.
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Dunn EL, Moore EE, Moore JB: "Hemodynamic effects of aortic occlusion during hemorrhagic shock". Ann Emerg Med 1982, 11:238-10.1016/S0196-0644(82)80090-5.
Michel JB, Bardou A, Tedgui A, et al.: "Effect of descending thoracic aortic clamping and unclamping on phasic coronary blood flow". J Surg Res 1984, 36:17-10.1016/0022-4804(84)90063-5.
Gedeborg R, Rubertsson S, Wiklund L: "Improved hemodynamics and restoration of spontaneous circulation with constant aortic occlusion during experimental cardiopulmonary resuscitation". Resuscitation 1999, 40:171-10.1016/S0300-9572(99)00021-0.
Rubertsson S, Bircher NG, Alexander H: "Effects of intra-aortic balloon occlusion on hemodynamics during, and survival after cardiopulmonary resuscitation in dogs". Crit Care Med 1997, 25:1003-10.1097/00003246-199706000-00018.
Sheppard FR, Cothren CC, Moore EE, Orfanakis A, Ciesla DJ, Johnson JL, Burch JM: "Emergency department resuscitative thoracotomy for non-torso injuries". Surgery in press.
Connery C, Geller E, Dulchavsky S, et al.: "Paraparesis following emergency room thoracotomy: Case report". J Trauma 1990, 30:362.
Mitteldorf C, Poggetti RS, Zanoto A, et al.: "Is aortic occlusion advisable in the management of massive hemorrhage? Experimental study in dogs". Shock 1998, 10:141.
Oyama M, McNamara JJ, Suehiro GT, et al.: "The effects of thoracic aortic cross-clamping and declamping on visceralorgan blood flow". Ann Surg 1983, 197:459.
King MW, Aitchison JM, Nel JP: "Fatal air embolism following penetrating lung trauma: An autopsy study". J Trauma 1984, 24:753.
Thomas AN, Stephens BG: "Air embolism: A cause of morbidity and death after penetrating chest trauma". J Trauma 1974, 14:633.
Yee ES, Verrier ED, Thomas AN: "Management of air embolism in blunt and penetrating thoracic trauma". J Thorac Cardiovasc Surg 1983, 85:661.
Graham JM, Beall AC Jr, Mattox KL, et al.: "Systemic air embolism following penetrating trauma to the lung". Chest 1977, 72:449.
American Heart Association: "Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care". Circulation 2000, 102(suppl):.
Fabian TC, Richardson JD, Croce MA, et al.: "Prospective study of blunt aortic injury: Multicenter trial of the American Associationfor the Surgery of Trauma". J Trauma 1997, 42:374.
Gharagozloo F, Larson J, Dausmann MJ, et al.: "Spinal cord protection during surgical procedures on the descending thoracic and thoracoabdominal aorta". Chest 1996, 109:799.
Katz NM, Blackstone EH, Kirklin JW, et al.: "Incremental risk factors for spinal cord injury following operation for acute traumatic aortic transection". J Thorac Cardiovasc Surg 1981, 81:669.
Adembri C, Kastamoniti E, Bertolozzi I, et al.: "Pulmonary injury follows systemic inflammatory reaction in infrarenal aortic surgery". Crit Care Med 2004, 32:1170-10.1097/01.CCM.0000124875.98492.11.
Kralovich KA, Morris DC, Dereczyk BE, et al.: "Hemodynamic effects of aortic occlusion during hemorrhagic shock and cardiac arrest". J Trauma 1997, 42:1023.
Perry MO: "The hemodynamics of temporary abdominal aortic occlusion". Ann Surg 1968, 168:193.
Michel JB, Bardou A, Tedgui A, Levy B: "Effect of descending thoracic aorta clamping and unclamping on phasic coronary blood flow". J Surg Research 1984, 36:17-10.1016/0022-4804(84)90063-5.
McKinley BA, Kozar RA, Cocanour CS, et al.: "Normal versus supranormal oxygen delivery goals in shock resuscitation: the response is the same". J Trauma 2002, 53:825
Sikka R, Millham FH, Feldman JA: "Analysis of occupational exposures associated with emergency department thoracotomy". J Trauma 2004, 56:867.
Caplan ES, Preas MA, Kerns T, et al.: "Seroprevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and rapid plasma reagin in a trauma population". J Trauma 1995, 39:533.
Moreno C, Moore EE, Majure JA, et al.: "Pericardial tamponade: A critical determinant for survival following penetrating cardiac wounds". J Trauma 1986, 26:821.
Tyburski JG, Astra L, Wilson RF, et al.: "Factors affecting prognosiswith penetrating wounds of the heart". J Trauma 2000, 48:587.
Velhamos GC, Degiannis E, Souter I, et al.: "Outcome of a strict policy on emergency department thoracotomies". Arch Surg 1995, 130:774.
Asensio JA, Berne JD, Demetriades D, et al.: "One hundred five penetrating cardiac injuries: A 2-year prospective evaluation". J Trauma 1998, 44:1073.
Rohman M, Ivatury RR, Steichen FM, et al.: "Emergency room thoracotomy for penetrating cardiac injuries". J Trauma 1983, 23:570.
Baker CC, Thomas AN, Trunkey DD: "The role of emergency room thoracotomy in trauma". J Trauma 1980, 20:848.
Rhee PM, Foy H, Kaufmann C, et al.: "Penetrating cardiac injuries: A population-based study". J Trauma 1998, 45:366.
Durham LA, Richardson RJ, Wall MJ, et al.: "Emergency center thoracotomy: Impact of prehospital resuscitation". J Trauma 1992, 32:775.
Brown SE, Gomez GA, Jacobson LE, et al.: "Penetrating chest trauma: Should indications for emergency room thoracotomybe limited?". Am Surg 1996, 62:530.
Ivatury RR, Kazigo J, Rohman M, et al.: "Directed" emergencyroom thoracotomy: A prognostic prerequisite for survival".J Trauma 1991, 31:1076.
Mazzorana V, Smith RS, Morabito DJ, et al.: "Limited utility of emergency department thoracotomy". Am Surg 1994, 60:516.
Danne PD, Finelli F, Champion HR: "Emergency bay thoracotomy". J Trauma 1984, 24:796.
Department of Surgery, Denver Health Medical Center and the University of Colorado Health Sciences Center, Denver, CO, USA
C Clay Cothren & Ernest E Moore
C Clay Cothren
Ernest E Moore
Correspondence to C Clay Cothren.
Cothren, C.C., Moore, E.E. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg 1, 4 (2006). https://doi.org/10.1186/1749-7922-1-4
Blunt Trauma
Stab Wound
Aortic Occlusion
Pericardial Tamponade
Pulmonary Hilum


text:
Sex Seen: The Emergence of Modern Sexuality in America - PDF free download eBook
Sex Seen provides a complex and intriguing account of the changes that have taken place in the social construction of sexuality during the past century. Focusing on Sacramento, California, at the...
Details of Sex Seen: The Emergence of Modern Sexuality in America
Sex Seen: The Emergence of Modern Sexuality in America
Sex Seen provides a complex and intriguing account of the changes that have taken place in the social construction of sexuality during the past century. Focusing on Sacramento, California, at the dawn of the twentieth century, Sharon Ullman juxtaposes early cinema, vaudeville performances, and popular newspapers and magazines with insights drawn from close interpretations Sex Seen provides a complex and intriguing account of the changes that have taken place in the social construction of sexuality during the past century. Focusing on Sacramento, California, at the dawn of the twentieth century, Sharon Ullman juxtaposes early cinema, vaudeville performances, and popular newspapers and magazines with insights drawn from close interpretations of transcripts from Sacramento court cases.
She demonstrates how attitudes that emerged in the popular discourse—ideas about gender roles, female desire, prostitution, divorce, and homosexuality—often found complex and contradictory expression in the courts. As judges, prosecutors, defense attorneys, and juries all weighed in with differing opinions, the courtroom itself became a site of multiple discourses that attempted to make sense of a growing sexual chaos. In tracing the birth of modern sexuality, Ullman chronicles the dynamics of social change during a unique cultural moment and explains the shifts in the sexual ethos of turn-of-the-century America.
Instead of telling the familiar story of steadily increasing liberation of sexual urges, Ullman chronicles the complex confusions and negotiations of an increasingly public sexual discourse. She relates how laws against cross-dressing gained force at the same time that female impersonation became popular in vaudeville acts, how images of prostitutes were changed by the commercialization of the female body in advertising and film, and how visible expression of female desire was submerged in rape and divorce proceedings. Ullman blends social history, textual analysis, and film and performance criticism to explain how sexuality and desire became an essential part of personal identity in this century.
Her keen, accessible account of a community on the brink of the modern era offers a provocative interpretation of the seeds of our sexual present.
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Portrait sketches, and architectural sketches.
These were done over a period of around a month for an upcoming publication to commemorate 50 years of NID's existence.
The publication team preferred hand-drawn portraits over photographs, to support the respective articles, as it gave a certain vintage and timeless appeal.


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Lee Valley Regional Park Authority's Concession pricing
Concessions pricing at Lee Valley Regional Park venues
Find out more about our concessions policy and pricing.
We aim to encourage the use of our venues from disadvantaged groups, by offering below market, or concessionary rates to help treat all people fairly. Based on examples of best practice provided by the Audit Commission, Lee Valley Regional Park Authority (LVRPA) has developed a three-tier approach to identifying who concessions apply to:
People outside the normal working age
People who are on a low income and in receipt of a form a means tested benefit as identified in the table below.
LVRPA's venues and services try to ensure that where feasible concessions are offered to these groups. At many venues concessionary rates are offered in the form of 'off peak charges'. For example at Lee Valley Ice Centre, off-peak sessions before 17:00 are allowed on the ice for three hours per session as opposed to only two hours during peak times.
Evidence for each concessionary category is subject to change dependent on central Government legislation. The table below shows the current forms of evidence that is acceptable. Any changes to the evidence will be updated annually as part of the LVRPA Fees and Charges review process.
People targeted
Examples of evidence
Group 1: People outside the normal working age
Senior Citizens (men and women) who are entitled to receive the state pension only in line with Government policy. Proof of age card, pension book, driving licence, passport or proof of date of birth.
Juniors – Under 16 Proof of age card, passport or proof of date of birth.
People aged 18 and under
Proof of age card, passport or proof of date of birth.
Group 2: People with disabilities, and their carers
Groups of people with special needs who require assistance.
Applications must be made in writing to the manager of the venue. The letter must be on official headed paper from group, organisation, school, club, society etc.
People with a disability who receive Disability Living Allowance benefit, (DLA) and require assistance from a carer. Award letter within the last 12 months from the Department of Works and Pensions (DWP).
Group 3: People who are on a low income and in receipt of one of the benefits identified in column 2
People on Income Support (IS)
Employment Support Allowance (ESA formerly Incapacity Benefit)
Jobseekers Allowance (JSA)
Carers Credit (CC). Award letter within the last 12 months from the Department of Works and Pensions (IS, JSA, ESA, CC).
An entitlement notice from Local Authority/ Council within the last 12 months clearly highlighting a reduced charge owing to any of the above benefit entitlements.
Tweets by @LeeValleyPark


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Where does Merrill do business?
As a global provider, Merrill works with thousands of clients based in a diverse set of locations including the United States, United Kingdom, France, Germany, Argentina, Brazil, Egypt, China, Hong Kong, Singapore and Saudi Arabia. View all of our global locations.
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Renewable energy and the mathematics of popularity
PETER AINSWORTH JUNE 2012 I recently found myself having to judge the table decorations at a Jubilee Street Party. This is a job I would have ducked if I were seeking re-election as a Member of Parliament. Anyone who has ever been made to judge anything – from fancy dress and face painting to prestigious national Awards – knows that, whoever the winner is, there's only one big loser: you. The problem is that all the entrants have made a huge effort, and that only one of them can win. So what might be called "the mathematics of popularity" are dreadful. You know that you will please 1% and piss off 99% of those who have made the effort. In the case of the Street Party, I made a decision and ran away. My cowardly attempt to shift the opprobrium onto my fellow judge didn't really work either; because on this occasion she was my wife. In the case of this week's British Renewable Energy Awards, I couldn't run away. Not only did I chair the judging panel, but I also had to announce the decisions. The same mathematics applied. So for every table I made a bit happy at a packed out Jumeira Carlton Tower Hotel I seriously upset far more. Being cowardly, I took comfort in the combined wisdom of my fellow judges. They were a great help. They included Jonathon Porritt – one of the most influential Green thinkers of modern times; Professor Catherine Mitchell of Exeter University who is hugely engaged with the science of climate change; Tom Heap, writer and broadcaster; and a financier (we all need them) Richard Nourse of Novusmodus. But that's enough name dropping. The point is that, despite the very difficult economic situation, and despite the uncertainties and – shall we say "fluctuations"? – surrounding UK Government policy in the field of green energy, there were lots of really good examples of enterprise and technical ingenuity on show. I won't take you through a list of the winners and losers; you can find them on the REA website www.r-e-a.net; but all the shortlisted projects were seriously impressive. Take, for example, the work of Camphill Community Glencraig – a project based in Northern Ireland and one of our winners. It's a sustainable place for young people and adults with learning difficulties. They applied to the Low Carbon Communities Challenge and were successful. As a result they have installed a groundbreaking wood biomass district heating system and have weaned themselves off 250,000 litres of oil. Or think about Glosfume Ltd, a Gloucester based company which has designed and developed a range of ceramic filters which can remove up to 99% of pollutants from biomass wood fired boilers, enabling them to be used in schools and hospitals – and to benefit from the Renewable Heat Incentive (the RHI is a very good repost to anyone who thinks that the Coalition Government has done nothing for the green agenda, by the way). It takes guts to set up that kind of business and to see it through. And then there are the big companies. Both National Grid and M&S were on our shortlist. As were Tesco. None of them won an award. I'm slightly worried about that. Were our judges unintentionally biased against Big Business? I don't think so. I think that we all recognised that huge companies like these are actually driving the sustainability agenda. By virtue of their size and financial clout, their crucial relationship with public feeling, and their ability to drive change throughout their supply chains, these big companies are the real game-changers. In fact, it's because companies like these are making the change that change will happen. They are far more influential these days than any number of Government White Papers. I don't write off Government White Papers, but I do assert what has always, I think, been true: that the only source of change is human endeavour and innovation. That means capitalism; but it means capitalism as if the world matters. And this is not altruism; it's based on the need for self preservation. So we probably should have given at least one of the big corporate guys an award. Even though they don't need it. I hope that they will apply again next year. I blame the judges. I don't criticise them though. It's hard being a judge. I guess that it's significant that our special Judges Award was shared by a bureaucrat and a banker. Neither profession is fashionable right now. The bureaucrat was Connie Heldegaard, the EU's energetic Climate Action Commissioner; the banker was Chris Matthews of the Co-operative Bank, who has been a leader in the field of sustainable finance for over thirty years. Not all bankers are useless. Those of us who believe in the need for sustainability, and in the absolute requirement to live within the limits of our natural capital, can take heart from all the entries to the British Renewable Energy Awards. All of them. It's not just the winners who did well. We also had to decide on Journalist of the Year. Journalist of the year? That's really quite horribly invidious; given the power of the unsuccessful candidates to kick up in the media. We picked a good one. But how many journalists are sustainable in the end? And it's only the end that counts.
Back To Our Views


I'm awake and I have mixed emotions about this. I have decided to commit to my writing and that means a writing schedule, something I have never done. I want to write every day and the only way I can do that is to get up at least an hour earlier. So here I sit at 7:35 a.m. stumbling through this because I don't have the wherewithal to work on my current WIP.
But this still counts as writing and it still counts as a writing schedule so there you go.


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Malaysia 2-1 Yemen
Shah Alam: Khyril Muhymeen came off the bench to head in a later winner as Malaysia revived their hope of qualifying for the 2015 AFC Asian Cup with a come-from-behind 2-1 win over Yemen at the Shah Alam Stadium on Friday.
The visitors took an early lead in the Group D match after a fine solo effort by Aiman Al Hagri but Azammuddin Akil put the sides back on level terms before the interval with a tap-in.
Norshahrul Idlan missed a number of chances to put the hosts in front but with just 10 minutes left, his cross from the right found an unmarked Khyril, who glanced the ball into the Yemen net to give the home side all three points.
Malaysia coach K. Rajagobal was a relieved man after watching his side pick up their first points in Group D following a 2-0 loss to Qatar in their opening game last month.
"It was not an easy match," said Rajagobal. "We could have settled earlier but we missed few sitters and then fell behind.
"We have to be more aggressive in front of goal. But anyhow I am happy with the fighting spirit my boys showed and proud they kept pushing despite being a goal down."
Malaysia were looking to end a run of four consecutive losses and they began the game brightly only to fall behind to a fine individual goal by Al Hagri in the 13th minute.
The 21-year-old, who plays for Bahraini side Al Najmah, surged past the challenge of two defenders on the left flank before he curled a superb shot from the top corner of the box that gave goalkeeper Khairul Fahmi no chance.
It took a while for the Malaysians to recover from the shock of conceding but they got back into the match through Azammuddin in the 26th minute.
Mahalli's low cross from the right found Amri Yahyah who was tackled by Yemen defender Mohammed Omar before he could get a shot away. However, the ball broke to the far post where an unattended Azammudin had the simple task of tapping it into the net.
The home side had much of the play during the latter stages of the opening half but they were unable to add a second goal before the break as Norshahrul squandered a couple of good openings.
Yemen could have regained the lead in the second half when substitute Mudir Abdurabu got round the back of the Malaysian defence to reach a long ball but stabbed his shot over the crossbar. Al Hagri then made a strong run up the middle, outpacing Asraruddin Putra Omar before seeing his shot stopped by Khairul Fahmi.
Malaysia created a number of good chances only for Norshahrul to be continually denied by Salem Abdullah.
But the Malaysia forward would have the final laugh with 10 minutes left when he received the ball on the right flank and cut back inside a defender before floating in an inviting cross with his left foot which picked out Khyril, who escaped the attentions of his marker to head in the winning goal.
With the win, Malaysia moved up to three points in Group D while Yemen remained in last place without any points so far.
Yemen coach Tom Saintfiet was left to rue his team's failure to make the most of their early opportunities to add to their lead.
"I am disapointed with the result," said the Belgian. "We could have doubled our advantage just after taking the lead but we didn't do it.
"We could have got a point towards the end but my players were not lethal in front of goal."


Spacious 3 bedroom home with side access for a jet-ski. Double carport Fully screened Air conditioning in the main living area and the master bedroom and ceiling fans in the remaining bedrooms.
This home has been refurbished and tastefully decorated so you can relax and enjoy your holiday.
The airconditioned living area offers a large leather modular lounge in front of the TV, the dining setting comfortably seats 8, and the spacious kitchen for your own culinery haven.
Security screened throughout, and the outdoor area is perfect for enjoy alfresco dining. The garden setting adds to the enjoyment of the back yard.
The double carport gives covered accommodation for 2 vehicles and there is the added area to the side of the house where you could park a jetski.
Located close to the Bells Creek boat ramp you don't have far to go to launch your vessel or throw in your fishing line.


Noodle Village has forever spoiled us for noodle soups. Even New Chao Chow, which normally does pretty well by us, just doesn't compare. Today we were the only English speakers in the place. The waiters loafed about, cracking loud incomprehensible jokes and raucously laughing about them. I was transported elsewhere, as we walked back to the office on Mott, surrounded solely by the tones of Cantonese.


How many of you have spent countless hours trying to resolve relationship breakdowns in the workplace, when you could have been spending it on growing your business?
Human beings are naturally social creatures – we crave friendship and positive interactions, just as we do food and water.
So it makes sense that good working relationships result in a happier and more productive environment.
✓ Trust – If you trust the people you work with, you can be open and honest with them and don't waste time and energy "watching your back."
✓ Mutual Respect – You value their input and ideas and they value yours. Working together, you can develop solutions based on your collective insight, wisdom and creativity.
✓ Mindfulness –Those who are mindful are careful and attend to what they say and don't let their own negative emotions impact the people around them.
✓ Welcoming Diversity – People with good relationships not only accept diverse people and opinions, but they welcome them.
✓ Open Communication – My view is that if you are open and honest with others they are more likely to reciprocate with you.
- have a quick chat on a Monday morning about your weekends, or spend time at lunch with people.
– we all enjoy praise! Be Positive - positivity is attractive and contagious and it will help strengthen your relationships.
- it's good to be friendly, but people can sometimes take advantage if you're too friendly which could impact on your job, especially when someone monopolises your time.
- office politics and "gossip" are major relationship killers at work. If you're experiencing conflict with someone in your team, talk to them directly about the problem.
- focus on listening more than you talk, and you'll quickly become known as someone who can be trusted. People respond to those who truly listen to what they have to say.
Difficult Relationships Occasionally, you'll have to work with someone you don't like, or someone you simply can't relate to, as we all know that recruitment methods aren't always an exact science!
However, for the sake of your business, it's essential you maintain a professional relationship with them.
When this happens, make an effort to get to know the person. Try to engage them in a genuine conversation, or invite them out to lunch.
Instead of putting energy into your differences, focus on finding things that you have in common.
And remember – not all relationships will be great, but you can make sure that they are at least workable!


The way I was able to recognize it so fast is that I have used that same argument myself, and I've been hearing that same argument throughout my entire career. Basically, the core of that argument is: "I'm not qualified to make a decision about that. The onus is on you to educate me deeply about this thing that I'm not even interested in." There's no way to overcome that kind of requirement, nobody can win that argument. But it turns out that usually that reasoning is wrong. I've heard that argument about why we shouldn't have to worry about closure. I've heard it about why we shouldn't use recursion. I've heard it about why punch cards are better than timesharing. You can go all the way back to 'it's better for us to be programming with digits, I don't understand why we need compilers'. It's been going on from the beginning. That's why software development is so slow, because basically we have to wait for a generation to die off before we can get critical mass on the next good idea.
Semantics does not always works as we expect. Seemingly, Crockford forgot his friend's context. He should have let his friend buy in his context in the first place. When you try to propose a solution to solve a problem, which your client does not think as a problem, or does not see a need to solve it immediately, then your semantics will not work in your client's context. So here is what you can do.
Think in the context of your client, guide your client to think in your context and make him believe that it is a problem, then propose your solution. Sometimes, this can be very hard, if the contexts collide heavily.
There are lots new technologies coming, like Domain Specific Language, Cloud computing, Service Oriented Architecture etc. How soon they will be adopted will depends on how people can accept the contexts in which their designer think, and how soon people can accept these context will somewhat depend on the result the early adopters achieve.
A friend of mine asked me recently, what versioning control system should be used. I said "Git". He asked why? I said it is distributed versioning control system and it is scalable. Then He said, "We don't need it to be distributed.". You know, I made the same mistake, I lost the context of friend.


The Arkansas congressional delegation has requested a major disaster declaration for Conway, Crittenden, Jackson, Lonoke, Mississippi, Poinsett, Pulaski, Saline and Van Buren counties.
The requests, in the form of letters to President Obama and Federal Emergency Management Agency (FEMA) Administrator Craig Fugate, were sent by Sens. Blanche Lincoln and Mark Pryor and Reps. Marion Berry Vic Snyder, John Boozman, and Mike Ross.
Beginning April 30 the counties experienced severe storms, tornadoes and flooding. Preliminary assessments indicate that the most serious damage was to private homes, businesses and public utilities. The delegation has requested that Arkansas receive a major disaster declaration for the counties due to the assessed damage, and they have specifically requested assistance to provide temporary housing.


text:
Q: How to change the format in which datetime is stored in postgresql with sequelize? I am using Sequelize ORM with the Postgresql database for my node.js application.
In the database, I have a field 'start_time' with type Sequelize.DATE.
In postman, if I run the API for inserting a value '2020-05-30 02:00:00' in that field, it is stored as '2020-05-29 20:30:00+00:00' in the database. What can I do to store it as I am passing in the database?
My locality is India which is GMT+05:30.

redpajama_set_name: RedPajamaStackExchange


text:
Legal Word of the Day (Brought to you by Frances McDormand): Inclusion Rider
Employment Law, Legal Word of the Day
No sooner had I written a blog post on how the Academy Awards relate to estate planning, did one of the award recipients bring up another legal topic that needed to be covered!
Best Actress winner Frances McDormand gave a powerful speech about gender equality in Hollywood. Her words seemed a fitting continuation of the #MeToo movement and Time's Up initiatives that had a clear presence (both spoken and unspoken) in Los Angelas' Dolby Theatre. At the conclusion, Ms. McDormand said, "I have two words for you: inclusion rider."
https://www.facebook.com/ABCNetwork/videos/1880602121983915/
What is a Rider?
You may already know that a "rider" is an addition or extra to the main contract. Riders have special meaning when it comes to the entertainment world.
Perks!
Riders can be used to grant certain perks to an artist (like all of the actors and actresses present at last night's Academy Awards).
Does a principal dancer want a certain kind of water available backstage? Is the guitarist picky about what foods will be available in the green room before and after a concert? If you're an entertainer (dancer, comic, actor, musician, speaker, etc.) with a reasonable amount of bargaining power (i.e. star power!), you would want to be sure that your contracts include all your favorite little extras. These extras, or demands, should be placed in writing in each legal contract so that they must be honored by the other party such as a film production company, concert promotor, performance venue, and the like.
Riders can also cover specific financial elements. If a pop star, for example, wants a percentage of a concert's profits, she might request this through a rider. A television actor could attempt to request something similar from online streaming sales.
Inclusion Rider
Tack the specific word "inclusion" onto rider and you have a contractual clause that actresses/actors can insist be inserted in contracts that requires cast and crew on a film to meet a certain level of diversity (both racial and gendered).
The concept was explored in a TED talk in 2016 by Stacy Smith. Smith, director of USC Annenberg's Media, Diversity & Social Change Initiative, believes that inclusion riders (also called an "equity clause") could be part of the solution for the lack of diversity in films. In a 2014 piece she penned for The Hollywood Reporter, she wrote:
What if A-list actors amended every contract with an equity rider? The clause would state that tertiary speaking characters should match the gender distribution of the setting for the film, as long as it's sensible for the plot. If notable actors working across 25 top films in 2013 had made this change to their contracts, the proportion of balanced films (about half-female) would have jumped from 16 percent to 41 percent. Imagine the possibilities if a few actors exercised their power contractually on behalf of women and girls. It wouldn't necessarily mean more lead roles for females, but it would create a diverse onscreen demography reflecting a population comprised of 50 percent women and girls.
Smith asserts that there's no reason why the majority of the minor roles (on average, 30-ish or so roles) cannot reflect the demographics of the realistic environment where a story is taking place. An A-list actor or actress can use their contract to stipulate that the supporting roles in the film (or show) reflect equitable diversity in terms of both race and gender.
Smith said she's worked with attorneys in the past to craft specific language for the provisions where if the other party failed to meet the inclusion rider requirements, they would need to pay a penalty to a fund or charitable cause that supports underrepresented persons in the industry.
It's a smart, common sense move that could mean a big change in countering the bias (both conscious and unconscious) in auditions and casting. The intended result is for greater representation and opportunities for women, persons of color, the LGBT community, and persons with disabilities in entertainment. Plus, as actress and comedian Whitney Cummings said, this increased pressure for inclusivity "will make movies better."
Tweets by Inclusionists
McDormand on Inclusion Riders
Backstage after the Oscars ceremony, McDormand said of inclusion riders, "I just found out about this last week. There has always been available to all, everybody who does a negotiation on a film, which means you can ask for or demand at least 50 percent diversity in not only the casting and the crew. The fact that I just learned that after 35 years in the film business – we aren't going back."
Inclusion Riders & You
While you may not be nominated for an Academy Award anytime soon, the takeaway is twofold.
First: if you support increased representation of different genders and races in movies you can support the films that respect inclusion riders with your money. You can also spread the word with the tag #EquityRider when tweeting to actors and actresses asking for them to support the concept through their own contract.
Second: this goes to show the power of the contact and negotiation process. Because the contract can dictate how the relationship between employer and employee (or production company and talent, for instance) run, it's important to hire an attorney to help you stand up for your wants and needs in respect to the relationship.
To this point, if you're a nonprofit organization looking to make some new hires or an employee wondering if the contract you're about to sign will actually be in your best interest, don't hesitate to contact me.
March 5, 2018 /by Gordon Fischer
Tags: contract, equity rider, Frances McDormand, inclusion rider, nonprofit
https://www.gordonfischerlawfirm.com/wp-content/uploads/2017/05/GFLF-logo-300x141.png 0 0 Gordon Fischer https://www.gordonfischerlawfirm.com/wp-content/uploads/2017/05/GFLF-logo-300x141.png Gordon Fischer2018-03-05 10:16:502020-05-18 11:28:55Legal Word of the Day (Brought to you by Frances McDormand): Inclusion Rider
Giving Like a Rock Star: Legal Tips for Donors on Giving Tuesday
25 Days of Giving: Charity Auctions & Tax Deductions
6 of the Scariest Things Your Nonprofit Can Do
Nonprofit Events and Opportunities in August & September
Articles of Incorporation: Like a Nonprofit's "Constitution"
Nonprofits & Sarbanes-Oxley Compliance
Read Across America Day: Introducing the GoFisch Book Club Nonprofit Formation: What the Parkland Students Should Do Now


text:
Q: How to obtain detailed compilation error? I migrated a create-react-app to webpack
unfortunately there are some mistake at compilation. But the mistake message is not significant to find where the error is coming from.
Is there a way to improve the log output of webpack compilation ?
My log output is :> webpack-dev-server --mode development --open --hot
<i> [webpack-dev-server] Project is running at:
<i> [webpack-dev-server] Loopback: http://localhost:8080/
<i> [webpack-dev-server] On Your Network (IPv4): http://192.168.0.70:8080/
<i> [webpack-dev-server] Content not from webpack is served from 'E:\WORKSPACE\testpoub\web_simulation\public' directory
i 「atl」: Using typescript@4.8.4 from typescript
i 「atl」: Using tsconfig.json from E:/WORKSPACE/testpoub/web_simulation/tsconfig.json
× 「atl」: Child process failed to process the request: Error: Debug Failure. False expression.
    at resolveNamesWithLocalCache (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:123200:26)
    at Object.resolveModuleNames (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:123244:20)
    at Object.resolveModuleNames (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:125393:134)
    at actualResolveModuleNamesWorker (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:118239:153)
    at resolveModuleNamesWorker (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:118542:26)
    at resolveModuleNamesReusingOldState (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:118640:24)
    at processImportedModules (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:120165:35)
    at findSourceFileWorker (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:119945:17)
    at findSourceFile (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:119791:26)
    at processImportedModules (E:\WORKSPACE\testpoub\web_simulation\node_modules\typescript\lib\typescript.js:120200:25)
× 「atl」: Child process failed to process the request: TypeError: Cannot read property 'updateRootFileNames' of undefined
    at getProgram (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:152:10)
    at getEmitOutput (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:403:19)
    at emit (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:422:24)
    at processEmit (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:458:22)
    at E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:610:6
    at Object.send (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:49:6)
    at Checker.req (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\checker.ts:100:15)
    at Checker.emitFile (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\checker.ts:105:15)
    at transform (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\index.ts:130:26)
    at transformationFunction (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\index.ts:72:40)
(node:345424) UnhandledPromiseRejectionWarning: null
(Use `node --trace-warnings ...` to show where the warning was created)
(node:345424) UnhandledPromiseRejectionWarning: Unhandled promise rejection. This error originated either by throwing inside of an async function without a catch block, or by rejecting a promise which was not handled with .catch(). To terminate the node process on unhandled promise rejection, use the CLI flag `--unhandled-rejections=strict` (see https://nodejs.org/api/cli.html#cli_unhandled_rejections_mode). (rejection id: 1)
(node:345424) [DEP0018] DeprecationWarning: Unhandled promise rejections are deprecated. In the future, promise rejections that are not handled will terminate the Node.js process with a non-zero exit code.
<i> [webpack-dev-middleware] wait until bundle finished: /
× 「atl」: Child process failed to process the request: TypeError: Cannot read property 'getProgram' of undefined
    at getProgram (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:154:16)
    at processFiles (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:468:11)
    at E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:616:6
    at Object.send (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\runtime.ts:49:6)
    at Checker.req (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\checker.ts:100:15)
    at Checker.getFiles (E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\checker\checker.ts:141:15)
    at E:\WORKSPACE\testpoub\web_simulation\node_modules\awesome-typescript-loader\src\instance.ts:483:34
    at Hook.eval [as callAsync] (eval at create (E:\WORKSPACE\testpoub\web_simulation\node_modules\webpack\node_modules\tapable\lib\HookCodeFactory.js:33:10), <anonymous>:7:1)
    at Hook.CALL_ASYNC_DELEGATE [as _callAsync] (E:\WORKSPACE\testpoub\web_simulation\node_modules\webpack\node_modules\tapable\lib\Hook.js:18:14)
    at E:\WORKSPACE\testpoub\web_simulation\node_modules\webpack\lib\Compiler.js:1192:33
asset index_bundle.js 219 KiB [emitted] (name: main) 1 related asset
asset index.html 1.61 KiB [emitted]
runtime modules 27.4 KiB 12 modules
modules by path ./node_modules/ 160 KiB
  modules by path ./node_modules/webpack-dev-server/client/ 55.8 KiB 12 modules
  modules by path ./node_modules/webpack/hot/*.js 4.3 KiB
    ./node_modules/webpack/hot/dev-server.js 1.59 KiB [built] [code generated]
    ./node_modules/webpack/hot/log.js 1.34 KiB [built] [code generated]
    + 2 modules
  modules by path ./node_modules/html-entities/lib/*.js 81.3 KiB
    ./node_modules/html-entities/lib/index.js 7.74 KiB [built] [code generated]
    ./node_modules/html-entities/lib/named-references.js 72.7 KiB [built] [code generated]
    + 2 modules
  ./node_modules/ansi-html-community/index.js 4.16 KiB [built] [code generated]
  ./node_modules/events/events.js 14.5 KiB [built] [code generated]
./src/index.tsx 39 bytes [built] [code generated] [1 error]

ERROR in ./src/index.tsx
Module build failed: Error: Final loader (./node_modules/awesome-typescript-loader/dist/entry.js) didn't return a Buffer or String
    at processResult (E:\WORKSPACE\testpoub\web_simulation\node_modules\webpack\lib\NormalModule.js:774:17)
    at E:\WORKSPACE\testpoub\web_simulation\node_modules\webpack\lib\NormalModule.js:860:5
    at E:\WORKSPACE\testpoub\web_simulation\node_modules\loader-runner\lib\LoaderRunner.js:407:3
    at iterateNormalLoaders (E:\WORKSPACE\testpoub\web_simulation\node_modules\loader-runner\lib\LoaderRunner.js:233:10)
    at iterateNormalLoaders (E:\WORKSPACE\testpoub\web_simulation\node_modules\loader-runner\lib\LoaderRunner.js:240:10)
    at E:\WORKSPACE\testpoub\web_simulation\node_modules\loader-runner\lib\LoaderRunner.js:255:3
    at context.callback (E:\WORKSPACE\testpoub\web_simulation\node_modules\loader-runner\lib\LoaderRunner.js:124:13)
    at processTicksAndRejections (internal/process/task_queues.js:95:5)

webpack 5.74.0 compiled with 1 error in 9115 ms

A: finally, I used npm list to watch my packages and I found there were some missing dependencies.
After fixing these dependencies issues it was right


Don't miss another Jim Carrey movie! Get email reminders before Jim Carrey films come on TV. We won't spam you. We watch the listings so you don't have to!
Welcome to Projects section.Here you can find information about up comming movies of Mr Carrey,it can be rumours.
Funnyman Jim Carrey has gotten the call to make Phone Booth, a Hitchcockian thriller about a man who answers a pay phone on a crowded New York City street, only to be told by the caller that if he hangs up, he dies.
Joel Schumacher, who directed Carrey in the blockbuster Batman Forever, will helm the decidedly low-fanfare project. Since nearly every scene will involve Carrey fighting an invisible sniper (we hope for less than 10 cents a minute), not much production is required.
Since Fox 2000 optioned the script two years ago, Phone Booth has been a buzz project with many top names attached. Earlier this year, Will Smith was rumored to have the lead in Phone Booth, but is now busying himself with the Muhummad Ali biopic Ali. Likewise, director Michael Bay left the project to film the World War II epic Pearl Harbor.
Shooting is expected to take place on an unnamed Manhattan, N.Y., street this summer. Phone Booth should wrap in just a matter of weeks.
plot:A remake of the 1947 Danny Kaye comedy. Walter Mitty is a timid man who repeatedly daydreams of becoming an unbeatable cowboy, a riverboat gambler, or a top surgeon and ends up by finding himself in a true hero-like situation.
plot: The mask floated to Paris where it created chaos. Stanly Ipkiss has to go to straighten things out. This movie will most likely not be made.


I work for NASA with the Launch Services Program (LSP) at Kennedy Space Center. So what does LSP do?
LSP interfaces between the rocket and NASA unmanned spacecraft. The rockets, or launch vehicles, are actually owned by companies, not NASA. So LSP has to be the rocket experts for NASA, making sure that what happens on the launch vehicle side is best for the spacecraft. LSP selects the rocket that is the best value for the spacecraft, manages the schedule/ budget/ contracts, observes testing, performs analyses, and arranges for the spacecraft to be integrated with the rocket. We work launches here in Florida, but also California, Alaska, Virginia, and even Kwajalein Atoll in the middle of the Pacific Ocean. Our nickname is Earth's Bridge to Space.
I often think of the spacecraft as an egg, and LSP is working to make sure that egg doesn't get damaged during launch: the shell doesn't crack, the yolk and the whites don't mix, the egg doesn't end up frozen on one side and cooked on the other. I work as a guidance, navigation, and controls flight analyst, who makes sure the egg is pointing where it needs to, spinning if it needs to, and doesn't hit the carton on the way out. I also work as a trajectory analyst, who makes sure the egg ends up unbroken in the right place, at the right time. Because if something goes wrong during launch, these amazing spacecraft can't collect the data and images they were made for.
Mars Science Laboratory (MSL) was actually my first mission as a trajectory analyst. For those of you going "What! They assigned a newbie to a flagship mission?", let me reassure you. An experienced analyst worked on the mission for the first four years, and I worked as his backup for over a year. He moved to a systems engineering program and I took over the mission at that point. However, I worked closely with my flight design lead on the mission; the rest of the flight design group lent me their expertise throughout the process too. My counterparts at the Jet Propulsion Lab (JPL: MSL spacecraft provider) and United Launch Alliance (ULA: Atlas V launch vehicle provider) also had lots of experience; I was most definitely not out there on my own.
When working on the trajectories, you have to work backwards. You figure out where on Mars and at what time you want to land. For more on planning the spacecraft's trajectory, see my post "Taking a Road Trip to Mars vs. NYC: Tradeoffs and Margin." The spacecraft lets the launch vehicle know where and when it wants to be dropped off, along with how fast it wants to be going in which direction. Using that information along with the mass of the spacecraft, the configuration of the launch vehicle, and the requirements of the spacecraft, the launch vehicle trajectory can be planned.
The configuration of the launch vehicle indicates things like how big the fairing is (the shell that protects the spacecraft at the top of the rocket while going through the atmosphere) and how many solid rocket boosters are attached to the rocket (Atlas V can have anywhere from zero to five). The launch vehicle has different rules it has to follow, based on the configuration. These rules are things like how long after liftoff the rocket has to pitch over and the maximum dynamic pressure allowed (if the rocket goes too fast while there is still atmosphere, the pressure could break the rocket).
The spacecraft requirements are different for each spacecraft. Some spacecraft have instruments that are light sensitive and, once the fairing comes off, they can't be pointed too close to the sun. Just like, as humans, we can't stare directly at the sun without risking damaging our eyes. Some spacecraft have to be rolled if the launch takes longer than a set amount of time; otherwise, one side of the spacecraft will get too hot from the sun and the other side will get too cold. Some spacecraft have to be spinning at a certain speed at separation; others may want a little spin as possible. These are just a few rules spacecraft may want to have during launch.
In planning the trajectory of the launch vehicle, you make sure the trajectory obeys all the "rules" of the launch vehicle and spacecraft. Then you try to optimize the trajectory, usually for having the most propellant leftover. This way, in case something doesn't perform as expected, you have extra gas to get the rocket on the correct course. This is called margin. And it takes lots of number crunching to get that margin as high as possible.
In addition to being a trajectory analyst for MSL, I was also on console as the NASA Winds trainee. In the last few hours prior to launch, we send up several high altitude balloons anywhere from 11 to 19 miles up. We look for too high velocities or wind shears; wind shears are when the wind at different altitudes are opposing or very different speeds. These conditions can be too extreme to control the trajectory or could even break the vehicle, so we make sure we don't launch during those dangerous times. The launch vehicle provider can also use the wind profile to optimize the trajectory for that particular time.
As much as I love to watch rockets launch, it's quite a different experience to hear the countdown on the headset, see the altitude on the screen increase, and then a minute later feel the launch move through you. It's very emotional, and unbelievable when you realize the trajectory hits its target dead on. My counterpart at JPL said "This was among the most accurate interplanetary injections ever." That's the proudest statement of my career so far.


Aurora BayCare's occupational health program is focused on keeping your workforce healthy. From drug screenings to injury rehab and workplace wellness, Aurora BayCare offers a complete package of workplace health services.
By proactively investing in a safe and healthy workforce, you will cut your company's health care costs, increase productivity, and lower worker compensation claims.
Save money for every dollar you invest. Baseline medical tests and pre-placement screening services are designed to ensure employees have the abilities required for the job. Most organizations see a significant reduction in workers' compensation claims after implementing pre-placement tests.
When an injury does occur, early referral to Aurora BayCare rehab services will reduce costs, treatment time, and lost work days. We can provide therapy in our clinics or at your worksite, maximizing an injured employee's productive work time.
After an injury, work conditioning therapy simulates the actual movements required for the employee's job. Functional capacity tests ensure they are ready to go back to work, safely. We also provide total case management support for insurance, FMLA, and worker's compensation.
A successful return work is a key goal for patients in our Work Specialty Rehabilitation Program. In 2015 and first and second quarters of 2016, our program served 53 clients. 100% of our clients had workers' compensation as a payor source.
The average duration in our program is 34 days.
The average number of treatment days is 11.4 visits for therapy.
Workplace wellness programs boost healthy behaviors and are proven to decrease absenteeism and medical costs. Ask about health seminars, smoking cessation, fitness, and weight-loss programming. We also offer targeted worker exercises—a warm-up and stretching program designed specifically for the type of work your employees do.
We offer a complete package of workplace safety and wellness consulting. Ergonomics assessments and cumulative trauma education can help lower the risk for work-related injuries caused by repetitive movements, and poor body mechanics.


text:
CBSA > CBSA Applauds Rep. Jason Crow for Supporting Health Innovation in Our State
CBSA Applauds Rep. Jason Crow for Supporting Health Innovation in Our State
Colorado BioScience Association (CBSA) applauds Representative Jason Crow (D-CO) for re-introducing the Small Business Innovation Voucher Act with Representative Tim Burchett (R-TN). This bipartisan legislation establishes an innovation voucher program at the Small Business Administration (SBA) and would authorize $10 million per year for five years to establish an innovation voucher program at the SBA.
CBSA collaborates with Congressman Crow and his office on legislation critical to life sciences in Colorado, including this Small Business Innovation Voucher Act. This program is an important step for our ecosystem by encouraging more public-private partnerships to advance the development and commercialization of innovative technologies. CBSA is proud to work alongside the University of Colorado Anschutz Medical campus to advocate for early-stage life sciences companies working to bring life-saving breakthroughs to patients.
Jennifer Jones Paton, President & CEO of Colorado BioScience Association, said:
"This program is an important step for our life sciences ecosystem, encouraging more public-private partnerships that are critical in the development and commercialization of innovative technologies. We appreciate Congressman Jason Crow's leadership on this issue and his support for the innovative startups working to commercialize cutting-edge research that improves and saves lives," said Jennifer Jones Paton, CBSA President and CEO."
Don Elliman, Chancellor of the University of Colorado Anschutz Medical Campus, said:
"We at the CU Anschutz Medical Campus ̶ one of a handful of campuses in the country with a university, hospitals and a growing biotech incubator all on one site ̶ have seen firsthand how partnering and collaborating truly advances innovation. We're grateful to Congressman Crow for his efforts to help early-stage innovators get ideas off the ground, which will have a positive impact on economic development and health throughout Colorado."
We appreciate Congressman Jason Crow's leadership and his commitment on this issue and his support for the innovative startups working to commercialize cutting-edge research that improves and saves lives.
Together, we advocate for shared policy objectives to ensure elected officials hear the collective voice of Colorado's ecosystem and understand the ways we save and change lives.
Review the press release and bill text.