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Drugs & Diseases > Emergency Medicine
Spinal Cord Injuries Questions & Answers
Author: Lawrence S Chin, MD, FACS, FAANS; Chief Editor: Brian H Kopell, MD more...
Sections Spinal Cord Injuries
Approach Considerations
Plain Radiography
Computed Tomography Scanning
Prehospital Management
Emergency Department Management
Steroid Therapy in SCI and Controversies
Treatment of Pulmonary Complications and Injury
Analgesics, Other
What is the focus of care for spinal cord injury (SCI)?
What are the categories of the American Spinal Injury Association (ASIA) Impairment Scale of spinal cord injury (SCI)?
What are the ASIA definitions for complete and incomplete spinal cord injury (SCI)?
What are signs of respiratory dysfunction in spinal cord injury (SCI)?
How does the level of spinal cord injury (SCI) affect the degree of respiratory dysfunction?
Which lab tests are performed in the workup of spinal cord injury (SCI)?
Which imaging studies are performed in the workup of spinal cord injury (SCI)?
What is included in emergency department (ED) care for spinal cord injury (SCI)?
How are pulmonary complications managed in spinal cord injury (SCI)?
When is surgical decompression indicated in the treatment of spinal cord injury (SCI)?
What is spinal cord injury (SCI)?
What is the ISNCSCI classification of spinal cord injuries?
What is the American Spinal Injury Association (ASIA) method for classifying spinal cord injury (SCI)?
What is the anatomy relevant to spinal cord injury (SCI)?
What is the neuropathway anatomy relevant to spinal cord injury (SCI)?
What is the vascular supply anatomy relevant to spinal cord injury (SCI)?
What is the pathophysiology of spinal cord injury (SCI)?
What is the role of neurogenic shock in the pathophysiology of spinal cord injury (SCI)?
What is the role of spinal shock in the pathophysiology of spinal cord injury (SCI)?
What is the pathophysiology of primary spinal cord injury (SCI)?
What is the pathophysiology of spinal cord injury without radiologic abnormality (SCIWORA)?
What is the pathophysiology of secondary spinal cord injury (SCI)?
What is the difference between a complete and incomplete spinal cord injury (PCI)?
What are the types of incomplete spinal cord injury (SCI)?
What is the pathophysiology of conus medullaris syndrome?
What is the pathophysiology of cauda equina syndrome?
What is the pathophysiology of a spinal cord concussion?
What causes spinal cord injury (SCI)?
What is the prevalence of spinal cord injury (SCI)?
Which patient groups are at highest risk for spinal cord injury (SCI)?
What is the prevalence of pediatric spinal cord injury (SCI)?
What are the most common causes of pediatric spinal cord injury (SCI)?
How does spinal cord injury (SCI) affect marital status?
What is the prevalence of spinal cord injury (SCI) according to educational status?
What is the effect of spinal cord injury (SCI) on employment status?
What is the prognosis of spinal cord injury (SCI)?
What is the life expectancy and mortality of spinal cord injury (SCI)?
How does pain management effect spinal cord injury (SCI) prognosis?
Which patient group is most likely to be indoor walkers after spinal cord injury (SCI)?
What is the role of a brain-computer interface (BCI) in spinal cord injury (SCI) management?
What is the role of walking assistance systems in spinal cord injury (SCI) management?
What is included in the impatient therapy for spinal cord injury (SCI)?
How is spinal cord injury (SCI) prevented?
What is included in the initial clinical evaluation of spinal cord injury (SCI)?
What is included in the clinical assessment of pulmonary function in acute spinal cord injury (SCI)?
Which determinants of pulmonary function may be impaired in spinal cord injury (SCI)?
Which findings of respiratory dysfunction are characteristic of spinal cord injury (SCI)?
Which physical findings are characteristic of hemorrhagic shock in spinal cord injury (SCI)?
Which physical findings are characteristic of autonomic dysfunction in spinal cord injury (SCI)?
How is hemorrhagic shock differentiated from neurogenic shock in spinal cord injury (SCI)?
How is nerve root injury differentiated from spinal cord injury (SCI)?
How is sensory function testing performed in the evaluation of spinal cord injury (SCI)?
How is a sensory function test scored in the evaluation of spinal cord injury (SCI)?
How is motor strength assessed in spinal cord injury (SCI)?
How is the neurologic level of spinal cord injury (SCI) assessed?
How are sacral roots assessed in spinal cord injury (SCI)?
How are the American Spinal Injury Association (ASIA) Impairment Scale categories defined?
Which conditions should be included in the differential diagnoses of spinal cord injury (SCI)?
What are the differential diagnoses for Spinal Cord Injuries?
What is the role of lab testing in the workup of spinal cord injury (SCI)?
What is the role of imaging studies in the diagnosis of spinal cord injury (SCI)?
What is the role of plain radiography in the workup of spinal cord injury (SCI)?
What is the role of CT scanning in the workup of spinal cord injury (SCI)?
What is the role of MRI in the workup of spinal cord injury (SCI)?
What is the initial approach to spinal cord injury (SCI) treatment?
When is patient transfer indicated in the treatment of spinal cord injury (SCI)?
Which specialist consultations are beneficial to patients with spinal cord injury (SCI)?
What is included in prehospital care for spinal cord injury (SCI)?
How should patient be positioned for the initial evaluation of spinal cord injury (SCI)?
What is the role of airway management in the ED treatment of spinal cord injury (SCI)?
How are hypotension, hemorrhage, and shock in spinal cord injury (SCI) assessed?
How is neurogenic shock managed in the treatment of spinal cord injury (SCI)?
How are head injuries assessed in patients with spinal cord injury (SCI)?
What is the ED treatment for ileus in spinal cord injury (SCI)?
How are pressure sores prevented during the ED treatment of spinal cord injury (SCI)?
What is the role of steroid therapy in the treatment of spinal cord injury (SCI)?
What is the efficacy of high dose steroids for the initial treatment of spinal cord injury (SCI)?
What are the possible adverse effects of steroid treatment for spinal cord injury (SCI)?
What are the guidelines on steroid therapy in the treatment of spinal cord injury (SCI)?
What is the role of GM-1 in the treatment of spinal cord injury (SCI)?
How are steroids administered in the treatment of spinal cord injury (SCI)?
How are the pulmonary complications of spinal cord injury (SCI) treated?
What is the role of surgery in the treatment of spinal cord injury (SCI)?
What are the possible complications of spinal cord injury (SCI)?
What are the signs of neurologic deterioration in spinal cord injury (SCI)?
What causes pressure sores in spinal cord injury (SCI)?
What is the role of a backboard in the initial treatment of spinal cord injury (SCI)?
What are the pulmonary complications relative to spinal cord injury (SCI)?
What causes sepsis in spinal cord injury (SCI)?
How is hypothermia prevented in spinal cord injury (SCI)?
What is the focus of guidelines on spinal cord injury (SCI)?
What are the AANS/CNS guidelines on immobilization of acute spinal cord injury (SCI)?
What are the AANS/CNS guidelines on the initial assessment of acute spinal cord injury (SCI)?
What are the AANS/CNS guidelines on the initial treatment of acute spinal cord injury (SCI)?
What are the goals of medical treatment of spinal cord injury (SCI)?
Which medications in the drug class Analgesics, Other are used in the treatment of Spinal Cord Injuries?
Which medications in the drug class Glucocorticoids are used in the treatment of Spinal Cord Injuries?
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FDA news release. FDA allows marketing of first wearable, motorized device that helps people with certain spinal cord injuries to walk. US Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm402970.htm. Accessed: June 29, 2014.
Harris MB, Sethi RK. The initial assessment and management of the multiple-trauma patient with an associated spine injury. Spine. 2006 May 15. 31(11 Suppl):S9-15; discussion S36. [Medline].
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Claydon VE, Krassioukov AV. Orthostatic hypotension and autonomic pathways after spinal cord injury. J Neurotrauma. 2006 Dec. 23(12):1713-25. [Medline].
Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma. 2005 May. 58(5):890-5; discussion 895-6. [Medline].
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Lawrence S Chin, MD, FACS, FAANS Robert B and Molly G King Endowed Professor and Chair, Department of Neurosurgery, State University of New York Upstate Medical University
Lawrence S Chin, MD, FACS, FAANS is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association for Cancer Research, Children's Oncology Group, Society for Neuro-Oncology, Congress of Neurological Surgeons, American Association of Neurological Surgeons, American College of Surgeons, Phi Beta Kappa
Fassil B Mesfin, MD, PhD, FAANS Assistant Professor of Neurosurgery, Director of Complex Spine and Spine Oncology Program, University of Missouri Health Care
Fassil B Mesfin, MD, PhD, FAANS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American Association of Neurological Surgeons, Congress of Neurological Surgeons
Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM Attending Interventional Physiatrist, Wellspan Health
Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM is a member of the following medical societies: American College of Sports Medicine, American Academy of Physical Medicine and Rehabilitation, Royal College of Surgeons of England, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Medical Informatics Association, Association of Academic Physiatrists, International Society of Physical and Rehabilitation Medicine
Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai
Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Parkinson and Movement Disorder Society, North American Neuromodulation Society
Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from Abbott Neuromodulation for consulting.
Denise I Campagnolo, MD, MS Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds investigator; Novartis investigator; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator
Daniel J Dire, MD, FACEP, FAAP, FAAEM Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio
Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US
Milton J Klein, DO, MBA Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital and Ohio Valley General Hospital
Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, and Pennsylvania Medical Society
Richard Salcido, MD Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine
Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society
Tom Scaletta, MD Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine
Donald Schreiber, MD, CM Associate Professor of Surgery (Emergency Medicine), Stanford University School of Medicine
Donald Schreiber, MD, CM is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Abbott Point of Care Inc Research Grant and Speakers Bureau Speaking and teaching; Nanosphere Inc Grant/research funds Research; Singulex Inc Grant/research funds Research; Abbott Diagnostics Inc Grant/research funds None

redpajama_set_name: RedPajamaCommonCrawl


completed in 1915. Notice Board at First Dromore Presbyterian Church.
It appears that the earliest minister of Dromore was Mr. Henry Hunter, a Scotsman (lic. Down), who was ordained circa May 1660, suspended in 1661 and died in 1674. Rev. William Leggat next settled here. He was licensed by the Presbytery of Down in 1670, and having been ordained in Drum in 1671 he was called to Dromore O.C. and installed in 1675 to the charge of that congregation. At the Revolution he retired for some time to Scotland; but in 1691 he returned here. He was Moderator of the Synod of Ulster in 1693, but absent from it in 1694. The congregation was vacant in 1697, but whether in consequence of the death of Mr. Leggat or his removal to Scotland, is not known. The next minister was Mr. Alexander Colville (lic. Cupar) who was ordained in Newtownards on 26th July 1696 and installed here in 1700. He died on 1st December 1719. In 1724 the majority of the congregation by their commissioners, Messrs. Robert Hamilton and Thomas Ingram, supplicated the Synod to be annexed to the Presbytery of Down; and a minority by their commissioner, Mr. John Magill, supplicated to be continued with the Presbytery of Armagh. The Synod annexed them to Down. The subscription controversy had now commenced and this congregation felt the effects of it. In 1724 Mr. Alexander Colville (or Colvil), son of the preceding minister, being refused ordination by the Presbytery because he refused to subscribe to the Westminster Confession of Faith, repaired to London, and was ordained there in Dr. Calamy's vestry in December 1724. On 25th October 1725 he was irregularly installed in Dromore by the Synod of Munster. For this he was suspended by the Synod of Ulster, and many of the people withdrew from his ministry and formed another congregation in Dromore. Mr. Colvil Jun. became an M.D.(Edin.) in 1728 and joined the Presbytery of Antrim in 1730. He died on 23rd April 1777.
The first minister of the congregation so formed was Mr. James Allen (lic. Armagh) who was ordained here by the Presbytery of Armagh on 18 May 1726. He appears to have demitted this charge about 1752. He was succeeded by Mr. William Henry (lic. Dromore) who was ordained here on 1stMay 1753. Mr. Allen died on 14th January 1764. Mr. Henry, who was grandfather of Dr. P. S. Henry, President of Queen's College, Belfast, resigned this charge and removed to Comber, Co. Down, in 1776. He was succeeded by Mr. John Cochrane (lic. Ballymena) who was ordained here by the Presbytery of Dromore on 5th May 1777. He died on 8th September 1779. He was followed by Mr. James Waddle, (or Waddell), a Dromore licentiate who was ordained on 3rd August 1784. He died in this charge on 12th July 1815 and was succeeded by Mr. James Collins (lic. Tyrone) whose ordination took place on 17th September 1816. After over forty years Mr. Collins obtained an assistant and successor. He was Mr. Jackson Smyth (lic. Route) who was ordained on 20 Jan. 1857. Some time later Mr. Smyth (he received a D.D. afterwards) was called to First Armagh and on 27th March 1860 Mr. James Kirker Strain (lic. Belfast) was ordained in Dromore. Mr. Collins died on 19th December 1863.
The Rev. J. K. Strain was awarded an LL.D. from the Royal University of Ireland in 1885 and after forty active years he died on 28th December 1907. An Ahoghill licentiate, Mr. John Carson Greer, was then settled but only for three years. He then accepted a call to Strand Church, Londonderry, on 1st October 1912. His successor, Mr. Thomas Doey (lic. Tyrone) was ordained on 13th February 1913 and under his guidance the present fine meeting house was built in 1915. He was called to Coleraine, New Row congregation on 2nd September 1918.
The thirteenth minister of First Dromore was Rev. Andrew Thompson, formerly of Tobermore, and he was installed on 6th March 1919. He retired on 30th Nov. 1951 and died on 7th March 1968. During his ministry a new organ was installed. The Rev. Frederick Leslie McConnell of Albert Street Church, Belfast, was then installed on 17th April 1952. He had extensive renovations carried out, a new church hall built and a fine car park provided. Mr. McConnell retired on 31st March 1976 and was succeeded by the Rev. William Donald Patton (lic. Armagh) who had been ordained assistant (5th January 1975) in Trinity congregation, Bangor. He was installed here on 16th February 1977. In August of 1983, Mr. Patton received a call to Greystone Road in Antrim. His successor, the Rev. Roger Crooks was installed in September 1984 and in 1997 he accepted a call to Belvoir congregation. A lengthy vacancy followed during which the Rev. Dr. Roy Magee was appointed stated supply.
The present minister, the Rev. Keith Duddy, was Ordained in Mersey Street Presbyterian Church in 1987 and installed in Clarkesbridge and the Groves in 1989. From 1998 to 1999 he was a Missionay in Nigeria with the Qua Iboe Fellowship. Mr. Duddy was installed in First Dromore Presbyterian Church in March 2000. During his ministry a new manse was officially opened by the Moderator of Presbytery on Saturday 23rd November 2002.
The following brief history was compiled for an article in the Dromore Leader.
In 1660 a Presbyterian congregation was established and the Rev Henry Hunter was ordained in May of that year. Mr Hunter's ministry was shortly to be disrupted as within a year he was deprived of the parish church and tithes by Bishop Jeremy Taylor. For most of the next decade Hunter and his congregation, like most Presbyterians, had no regular Meeting House and met for worship in either private homes or in barns. In about 1670 the congregation built its first Meeting House on the Diamond Road, probably on or about the site of the present church. Alexander Colville, who was installed in July 1700, died in his pulpit on 1stDecember 1719 while conducting public worship. At that time the minister's son, also Alexander Colville was a student at Edinburgh University, with a view to taking up a career in medicine. The congregation wished to have him as their minister and persuaded him to take up the study of theology. Difficulties arose when a formal call was presented to Colville in 1724 because in the interval he had decided that he did not wish to subscribe to the Westminster Confession of Faith. Contrary to Presbyterian discipline, Colville went to London in December 1724 and was ordained by a group of ministers in the vestry of Dr. Calamy's Meeting House, without subscription. On returning to Dromore he took up duties as minister of the congregation and applied to the Presbytery of Armagh for Installation. This was refused and at the following meeting of the General Synod Colville was censured and suspended for disorderly conduct. Once more he took matters into his own hands and requested that he and his congregation might be received into the Southern Association, which was known to hold Non-Subscribing views, and which was outside the jurisdiction of the Synod of Ulster. This was granted and Colville was formally installed in Dromore, by a commission of the Southern Association on 27th October 1725. There then followed a split in the congregation. Colville's Call was signed by 400 persons, which implied upwards of 400 families or two thirds of the congregation. The remaining one third, or 200 families withdrew from his ministry and were established as a separate congregation. The Rev James Allen, first minister of the congregation so formed, was ordained here by the Presbytery of Armagh on 18th May 1726. At first the new congregation held services in an old kiln at the head of Rampart Street, however within a short time Colville and his congregation built a new Meeting House in Pound Street and vacated the old place of worship on the Diamond Road, which was now re-occupied by the new congregation. During the years 1815 to 1837 the church was enlarged and a manse was constructed in about 1878. A record at the Ulster Folk Museum, dated 1837, describes the building as a whitewashed, rough-cast edifice with accommodation for 1,200 and an average attendance of 700. In 1914 the old church building was demolished and the present church, with a seating capacity of 800, was completed in 1915. The old school house (erected in 1860) was demolished in about 1959 and a new church hall built on the same site, was opened in 1960 and extended in 1979. The present minister, the Rev Keith Duddy, was installed in March 2000 and during his ministry a new manse was opened in November 2002.
The above brief history is largely compiled from an article written by the Rev Dr. J. W. Nelson.
The Old School at First Dromore Presbyterian Church, erected in 1860. It was demolished in the late 1950's and a Church Hall built on the same site was opened in 1960. The Rev. F. L. McConnell pictured with Miss Sadie Stronge - Sunday School Teacher at First Dromore for 45 years and John McGrehan - Sunday School Teacher (1934 -1954 and Superintendent (1954 - 1984).


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"We all know that Western Australia's prosperity has been dominated by the agriculture and resources industry. In a globally competitive environment, though, I fear these two industries alone will not maintain our state's economic dominance. In order for WA to continue to go from strength to strength, we must continue to diversify our economic base. With that in mind, I put to this place that we need to enable our state to become a world leader in embracing new technologies.
As at 2017, the global economy is edging ever forward towards the commercialisation of a range of new, disruptive technologies that will prove ever-challenging for governments to address. Emerging technologies like artificial intelligence, autonomous vehicles, diversified energy generation and storage, genetic engineering, memory technology and quantum computing are just some of the areas that we know will have a substantial impact on western societies once commercialised.
Sadly, though, for all of Western Australia's entrepreneurial spirit, governments past and present have not accommodated those emerging industries and ideas as much as I hoped we would.
We cannot expect to be competitive and leaders in the Asia–Pacific region if we still debate whether or not basic concepts like Uber and Airbnb have a place in our society.
As the youngest member of this chamber and, indeed, of the Liberal Party, I hope to frame the discussion that we should embrace, not reject, these emerging technologies.
Our state needs to have openness towards these new and disruptive ideas.
This Parliament should seek to introduce a flexible legislative environment to allow these technological advances to take hold and to flourish right here in WA.
Like every new technology, they will present challenges to the nature of our society but I am certain that with typical Western Australian zeal, we will overcome them and, in so doing, we will build an even better state and continue our dominance in the Asia–Pacific."


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Your customers are getting smarter and they're getting better at self-service. If they have a problem with your product or service they'll look for solutions from their friends, social media or a forum long before they even consider calling your contact centre.
This means that when they do finally call your agents it's about the big issues. Your contact centre is now the escalation point for all those problems your customers couldn't solve online.
But do your agents have the knowledge to solve your customers' biggest problems? Or are you shuffling your customers from one contact point to another, hoping the next person they're transferred to will solve the issue?
Your agents are no longer required to be pleasant and empathetic product specialists, they are required to be pleasant, empathetic whole business specialists; ready for whatever curly question comes their way.
Having a contact centre is no longer enough, you need to transform it into a knowledge centre.
Start at the top. Your company's mission and values say a lot about how you expect them to behave. For instance, Zappos don't classify themselves as a shoe company. They say they're in the customer service business – they just happen to sell shoes. Clearly prioritising service above product.
What is their First Call Resolution rate?
Make sure they are trained in every stage of the customer journey. Customers can call with issues during purchase, during onboarding or even three, 6 or twelve months down the track. At each stage their problems will be different and your staff need to understand the different concerns they have.
When hiring, staff who have an empathetic nature and an aptitude for being-customer centric is a good place to start. And then make sure they have a voice to share ideas, ask for help and tell their success stories. At the end of the day it doesn't matter if they are senior or junior – good ideas and solutions can come from anywhere.
And of course, don't forget to say thank you to staff who are living your knowledge sharing values and providing the customers with excellent support.
There are a lot of tools available that help with the collection and flow of information. For a contact centre the obvious place to start is your call centre software.
Integrates with your CRM so agents have a full customer view.
Allow for charts between agents and their managers or product specialists – if they don't know an answer they can message while still on the call with the customer.
Allows for script wizards so that agents can ask key support questions and be guided, on-screen, to the right solution.
Other knowledge sharing tools include forums, wikis and group chat tools like Yammer and Slack.
Forums such as Whirlpool are common places to take a peek into your customers brains and see what kinds of challenges they're facing. They can also provide call centre staff with unique ways to solve customer problems (customers love to post creative solutions online) as well as showing where the knowledge gaps are in the community.
You can add an extra layer of control by creating your own branded forum. This low cost, low maintenance option gives you direct access to your customers brains. But, as with anything online, without mediation and administration forums can become a pit of off-topic abuse and complaints. To be effective they must be monitored and managed – see our best practices on the following page.
While internal wiki's have traditionally been the domain of technical teams they are a great source of information for call centre staff. Make sure to get call centre staff feedback on ease of use of the information, ensuring it is up to date in plain English and easily searchable.
Whether the information you're providing your call centre staff comes from a wiki, forum or CRM it's important that it is monitored for accuracy. While knowledge sharing is important it is also important to remember that humans are fallible and that a little bit of knowledge can be dangerous. Make sure, whatever the platform, that everyone has personal log in details (so they are accountable) and that an administrator or moderator is appointed to keep everyone on track and the good information flowing freely.
For more detailed information on how to turn your call centre into a knowledge centre, download our eBook Creating problem solvers: how to transform a call centre into a knowledge centre.


Although California does not offer commercial casino gaming, the state contains several Native American tribes that offer varying levels of gaming activity. In addition, the state maintains the California Gambling Control Commission ("Commission"), which establishes licensing and internal control rules, as well as represents the state's interest during the state-tribal compacting process.1 In sum, licensing of suppliers to gaming establishment is regulated both by individual tribes and the state of California. This analysis will provide a general overview of the licensing guidelines for suppliers of goods or services to California gaming establishments and will discuss both Class II and Class III gaming regulation in the state.
Although the NIGC has put forth rules regarding the licensure of key facility management personnel and the establishment of certain management contracts, the rules do not put forth a system for vendor or supplier licensing. These requirements are established solely by the tribe with the approval of the NIGC.
In addition to the tribal process mentioned above, those Gaming Resource Suppliers who must apply for licensure under a tribal gaming compact must also apply for state registration.
For each business entity, there is a $500 application fee and a $20,000 background investigation deposit due when the application is submitted. Unused portions of the background investigation deposit will be refunded to the applicant.22 The duration of the license will depend on the type of business conducted and the agreement between the applicant and the tribal gaming facility.
It should be noted that Principals of Gaming Resource Suppliers must complete the same application as entities. Individuals, however, must also provide two FBI Fingerprint Cards (if a non-California resident) or a Live Scan Service Form (if a California resident).
The Commission regulates manufacturers and distributors of gaming equipment through its regulations.25 The Commission has established two classes of manufacturers and distributors: Class A and Class B.
Class A consists of all manufacturers and distributors not covered by the above definition.29 Because Class A only covers in-state manufacturers and distributors, this analysis will focus primarily on Class B applicants.
Under the California Penal Code, slot machines are defined as follows.
1For a more detailed mission statement, please visit the California Gambling Control Commission's website at: www.cgcc.ca.gov/?pageID=aboutus&pageName=About%20Us.
3California Gambling Control Commission, 'Ratified Tribal-State Compacts.' For a complete listing with links to each individual compact, please visit the Commission's website at: www.cgcc.ca.gov/?pageID=compacts.
4See California Gambling Control Commission, 'Manufacturers and Distributors of Gambling Equipment,' www.cgcc.ca.gov/?pageID=manufacturersDistributors&pageName=Licensees%20and%20Registrants.
5See 25 C.F.R. § 518 et seq.
6See 25 U.S.C. § 2704 et seq.
7See 25 C.F.R. § 522 et seq. Note that this section also applies to all Class III gaming regulations.
8For the language of this section, please follow the following link provided by the NIGC: www.nigc.gov/LinkClick.aspx?link=NIGC+Uploads%2flawsregulations%2fcommissionregulations%2fSEC.547.pdf&tabid=104&mid=761.
10California Gambling Control Commission, Regulation 12492(b).
11California Gambling Control Commission, Regulation 12492(d)(2).
12Note that each individual tribe maintains individual licensing requirements and procedures. For purposes of this analysis, the Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians was used to give general examples of compact provisions.
13Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians, Sec. 6.4.1.
14Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians, Sec. 6.5.6.
15Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians, Sec. 6.4.8.
16Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians, Sec. 6.5.2.
17Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians, Sec. 6.4.5.
18Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians, Sec. 2.11.
19Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians, Sec. 2.4.
20Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians, Sec. 6.4.3.
21Tribal-State Compact Between The State of California And The Barona Band Of Mission Indians, Sec. 6.4.7.
22Application for Finding of Suitability, Gaming Resource Supplier/Financial Sources Provider (Vendor), p. 1.
23Application for Finding of Suitability, Gaming Resource Supplier/Financial Sources Provider (Vendor).
24Application for Finding of Suitability, Gaming Resource Supplier/Financial Sources Provider (Vendor).
25See California Gambling Control Commission, Regulation 12300 et seq.
26California Gambling Control Commission, Regulation 12300(b)(7).
27California Gambling Control Commission Regulation 12301(a).
28California Gambling Control Commission, Regulation 12300(b)(2).
29California Gambling Control Commission, Regulation 12300(b)(2).
30California Gambling Control Commission, Regulation 12300(b)(5).
31Cal. Pen. Code § 330b.
32California Gambling Control Commission, Regulation 12301(b)(1)-(9).
33California Gambling Control Commission, Regulation 12301(b)(10)(A).
34California Gambling Control Commission, Regulation 12303(a)(1).
35California Gambling Control Commission, Regulation 12303(a)(1)(D).
36California Gambling Control Commission, Regulation 12303(a)(2).
37California Gambling Control Commission, Regulation 12303(a)(3)-(5).


If you enjoy drinking an array of coffees from various corners on the planet then you can definitely easily mix good taste with ease by buying coffee online. You need not go to those coffee plantations to obtain your daily dose of delightful caffeine or search high and low in various coffee stores in your town or city.
The internet has resulted in the emergence of numerous businesses and coffee happens to be one such business that's best for both buyers or sellers. It can help sellers to get their coffee beans and flavors in large quantities and highlight them on virtual online showrooms, which in reality is a lot cheaper to accomplish rather than display precisely the same at real huge stores coffeeacidity.com. This results in lower expenses and the resultant savings are given to buyers that could now acquire their roasted coffee or green coffee in a reduced rate. You may thus have an advantage of comparing the already low prices and after that deciding on the web shop that gives the finest coffee at the cheapest rates.
An additional benefit of getting coffee online is you could now select from an array of coffees available on the internet. It is possible to select from light, medium or dark roasts, and may make a choice between Brazilian, Kenyan, Columbian, or any of the other types of coffee beans while remaining seated in your chair. You can also add flavor towards your coffee by choosing among various flavored coffee beans in order to generate new taste and aroma in your coffee cup. It is simple to pay with your debit card and get the coffee beans transported to your own home itself, thus conserving valuable time and fuel that would have been put in traveling to the closest coffee store. In addition you can now shop on a 24/7 basis and may place your order even after returning late from your work area.
You can also purchase coffee machines, coffee roasters, grinders and other coffee accessories just like coffee mugs, filters, etc from online stores after contrasting their features and value. A genuine salesman might not have the time or interest to explain all the features of a coffee maker, whilst you can easily study each of the features and specifications if you are in an online shop. You can also buy coffee flavors from online stores as an excellent alternative to distinctive flavored coffee beans or coffee syrups find this. Not only are these flavors sugar-free but one bottle can certainly flavor about 135 cups of coffee, thus making it very inexpensive at the same time. You're sure to savor drinking delectable flavors such as vanilla, strawberry, melon, hazelnut, etc time and again. Only 2ml of flavor is necessary to turn a typical cup of coffee into coffee with appealingly divine flavor. Such flavors can turn any coffee into gourmet coffee within a few moments.
Just like the mobile cell-phone totally changed the telephone industry, internet shopping has evolved the way people shop and you can easily buy coffee online after browsing through a great deal of coffees, flavors and accessories. You possibly can witness a much better range than any actual shop, whilst getting a good deal on prices too. Now you can drink your preferred coffee drink without moving out of your house to purchase coffee.


When my little sister was married nearly 8 years ago, she decided to go with a colorful and casual wedding involving Gerbera daisies and flip-flops. Sounded like a great idea. Then, I found out the bridesmaid dresses were to match the flowers: yellow and orange. I'm sure by now you know that most people look great in yellow and in orange. Hmph.
Despite what any blissfully naive bride tells you, you will not get to wear your bridesmaid dress again and again. It will go with nothing, if it even "went" in the first place.
Depending on the style of dress, come October, dress up as a princess or Cruella Deville or a fairy or Jackie O. Bonus: Halloween costume!
Cut the top part off. Bam! New skirt! Pair up with kicky boots and a fitted denim top.
Cut the bottom part off. Bonus: new top! Wear with jeans and under a blazer or bolero.
Donate it to the Princess Project or Donate My Dress . Bonus: Tax write-off!
Stretch a large piece of the skirt and paint a masterpiece with fabric paint. Then, frame it. Bonus: one-of-a-kind art!
If you're more inclined, make a table runner, a tablecover for an accent table, a sash, a Christmas tree skirt, a purse, pillow covers, or a little girl's dress.
Bonus: Curtains for the new laundry room!


The Buntzen Lake loop is the most popular trail in the park. This 10 km route can be done as fast as 45 min if you're running and up to 6 hours if you just take your time, enjoy the views and have a picnic.
Buntzen Lake is situated at roughly 130 m above sea level and the highest point on the trail is around 225 m. The single highest elevation gain on the trail is 70 m over 1.1 km.
Before heading out on your hike, make sure you are well prepared. This means, having the TEN ESSENTIALS. It is also important to leave a trip plan (route details and estimated return time) with someone you trust.
Bring your smartphone, fully charged and put it in airplane mode while hiking. I always bring back-up battery packs for extra piece of mind. It is highly recommended that you bring a GPS device; I use my smartphone with a GPS app (Backcountry Navigator). The GPS will work in airplane mode. Learn how to use it before your hike.
For anyone new to hiking, there is a rule to which hikers follow; it is called "Leave No Trace" or LNT. The concept is generally to pack out what you pack in and respect nature, so all future visitors can enjoy what you have enjoyed.
To learn more about LNT, please check out this BLOG by a certified LNT Trainer.
The Buntzen Lake look would be very challenging with a stroller; although I've see the odd person do it. I would suggest the Energy Trail ( http://www.buntzenlake.ca/hiking/#EnergyTrail ).
This site is made and maintained by a hiking enthusiast, who is not affiliated with BC Hydro or Buntzen Lake.
Copyright © 2019 Buntzen Lake. All rights reserved.


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I watched NBC's Meet The Press today and the propaganda scapegoating of Iran was in full force.
It is the USA and Saudi Arabia that are behind the blockade. The blockade is evil, right? That is what is causing the children to starve.
Does your country acknowledge this evil or does your news media condone the evil by omission?
It is the USA and Saudi Arabia that are behind the blockade.
Is that actually true? I know the U.S. has aided SA, therefore making the U.S. partly responsible for the horrors there. But as far as the blockade, has the U.S. actually taken part in setting that up? I haven't read anything where the U.S. was involved in this.
Let me be clear: the question is NOT defense of the US. America's involvement in fighting the rebels is directly responsible for the worst human crisis in history. I'm not disputing that. My question is specifically regarding the U.S. with setting up a blockade.
Let me be clear: the question is NOT defense of the US. America's involvement in fighting the rebels is dire ...[text shortened]... I'm not disputing that. My question is specifically regarding the U.S. with setting up a blockade.
"Western nations, at odds with Tehran over its nuclear program, supported the Saudi-led intervention by helping coordinate airstrikes and refueling Saudi warplanes. The U.N. Security Council effectively supported Riyadh by imposing an arms embargo on the Houthi fighters; it said Yemen-bound vessels could be inspected if there were "reasonable grounds" to suspect they were carrying arms."
Although the US is not officially part of the Saudi led coalition the USA supports it. There is a Washington Post link stating that the US has (or had) 7 Navy ships off the Yemeni coast. I was not able to read the article without a subscription though. Bezos doesn't need my money.
I want to be clear that US support for the blockade started with Obama. He deserves just as much blame as Trump.
Edit: The US was involved in the blockade when it started.
Trump has called for lifting the blockade, but I'm sure it is just lip service now that children are dying from starvation.


text:
Shock shakes the artistic community .. The artist Abeer Shaaban's suicide...
International Sunday 11th October 2020 12:05 AM REPORT
The artistic community was shaken by an unfortunate accident that a young artist committed suicide in her apartment.
The 30-year-old Tunisian artist, Abeer Shaaban, was found dead on Friday in her apartment.
"Bizerte FMN" radio said that Shaban's suicide shook the artistic community in Tunisia, and a security source said that Shaaban was found dead in her home in the city of Korba in the Nabeul Governorate in the northeast, after she committed suicide.
Al-Mustaqbal newspaper said that an investigation had been opened into the circumstances of the death, and the reasons for the suicide of the young artist, under the age of thirty.
It is noteworthy that Shaaban had participated in many dramas and theatrical productions in Tunisia, and she had her own audience, who was greatly shocked by the announcement of the news of her suicide.
The late artist, born in the governorate of Nabeul, the well-known tourist city, aged 30 until 2020, a graduate of the Institute of Dramatic Arts, participated in many cinematic and dramatic works, as well as her fans and followers of her work in the Tunisian state, she was famous through her roles in the theater. He started in this specialty, after that I decided to go to the art scene and present dramatic and cinematic artworks.
These were the details of the news Shock shakes the artistic community .. The artist Abeer Shaaban's suicide... for this day. We hope that we have succeeded by giving you the full details and information. To follow all our news, you can subscribe to the alerts system or to one of our different systems to provide you with all that is new.
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