text:
SYMPOSIUM ON TRENDS IN TRAUMA
Advances in prehospital trauma care
Kelvin Williamson1, Ramaiah Ramesh1, Andreas Grabinsky2
1 Department of Anesthesiology and Pain Medicine, University of Washington/Harborview Medical Center, #359724, 325 Ninth Avenue, Seattle, WA 98104, USA
2 Emergency and Trauma Anesthesia and King County Medic One, University of Washington/Harborview Medical Center, #359724, 325 Ninth Avenue, Seattle, WA 98104, USA
Date of Web Publication 12-Apr-2011
Andreas Grabinsky
Assistant Professor, Department of Anesthesiology and Pain Medicine, University of Washington/Harborview Medical Center, #359724, 325 Ninth Avenue, Seattle, WA 98104
Prehospital trauma care developed over the last decades parallel in many countries. Most of the prehospital emergency medical systems relied on input or experiences from military medicine and were often modeled after the existing military procedures. Some systems were initially developed with the trauma patient in mind, while other systems were tailored for medical, especially cardiovascular, emergencies. The key components to successful prehospital trauma care are the well-known ABCs of trauma care: Airway, Breathing, Circulation. Establishing and securing the airway, ventilation, fluid resuscitation, and in addition, the quick transport to the best-suited trauma center represent the pillars of trauma care in the field. While ABC in trauma care has neither been challenged nor changed, new techniques, tools and procedures have been developed to make it easier for the prehospital provider to achieve these goals in the prehospital setting and thus improve the outcome of trauma patients.
Keywords: Anesthesiology, emergency, prehospital, trauma
Williamson K, Ramesh R, Grabinsky A. Advances in prehospital trauma care. Int J Crit Illn Inj Sci 2011;1:44-50
Williamson K, Ramesh R, Grabinsky A. Advances in prehospital trauma care. Int J Crit Illn Inj Sci [serial online] 2011 [cited 2020 Jan 22];1:44-50. Available from: http://www.ijciis.org/text.asp?2011/1/1/44/79281
Trauma is the leading cause of death for patients in their first four decades of life. [1] It is therefore essential to optimize trauma care, not just in the hospital, but also in the field when trauma patients have their first contact with medical providers. The treatment that patients receive in the field can significantly alter their outcome. Prehospital Emergency Medical Service (EMS) systems rely on advances in therapy and management, often developed for patient care in the hospital setting, but over time, has reached prehospital care providers.
The concept of the modern prehospital care system for trauma patients goes back to the introduction of the "flying ambulances" by Napoleon's private surgeon, Dominique-Jean Larrey, in 1792. The "flying ambulances" were horse drawn carriages, bringing physicians or medical supplies to the battlefield and transporting wounded soldiers away from the front line. All modern EMS systems still follow this early idea of either bringing the physician to the patient or bringing the patient to the physician.
Civilian systems were often developed for specific patient groups such as trauma patients or patients with myocardial infarction. Nevertheless, these prehospital systems were responsible for all emergency patients and had to be staffed and equipped accordingly.
In Germany, a surgeon developed the first physician based EMS system in Heidelberg with the idea to bring not just a surgeon, but a whole operating room and its staff to the scene of an accident. [2] The system showed very early the shortcomings of a large truck with an operating room team at the scene. The trauma patients did not require surgery, but rather stabilization, at the scene. In the same year, the city of Cologne introduced a similar system. Using a much smaller vehicle driven by a firefighter, one physician attended the scene of the accident and transported the patient back to the hospital. [3] The latter system was then copied by other cities and counties in Germany with the primary focus around the care and transport of trauma patients. Consistent with this, surgeons played a large role in the initial setup of these systems.
The first ground-based paramedic systems in the US are often attributed to an article from Ireland in 1967 by Frank Pantridge and John Geddes, published in the Lancet. [4] In this article, the authors describe the use of a mobile intensive care unit equipped with routine monitoring, defibrillator, and pacing capability. The unit was staffed with personnel from the cardiac intensive care unit and a junior physician.
Following this article, physician staffed mobile intensive care units were introduced in New York and Charlottesville. [5],[6] Unlike European EMS systems, physician staffed EMS systems in the US did not gain popularity and in the early seventies, paramedic staffed systems were established in Miami, Columbus, Los Angeles, Portland and Seattle. [7],[8],[9],[10],[11],[12]
Most EMS systems utilize some sort of a multi-tier approach, in which basic medical providers rush to the patient, and more skilled and trained personal arrive shortly after. This setup provides first responders with very basic training to perform early simple techniques such as chest compressions, automatic defibrillation or basic airway management until advanced interventions can be performed by either paramedics or emergency physicians at the scene. Some countries like Germany and France are still using EMS systems which are based on the idea of bringing the physician to the patient. The transport to the hospital comes second in this concept, as patients often undergo prolonged treatment at the scene. On the other hand, EMS systems in the US are based on the premise of bringing paramedical providers, who are trained to perform a limited number of medical procedures in the field to the patients. The emphasis is focused on rapid transport to the hospital, after the basic rescue techniques, such as airway management and fluid resuscitation, were performed at the scene.
All EMS systems have been undergoing changes over the years. The care of trauma patients is significantly influenced by military conflicts. While the Korean and Vietnam wars saw the first airborne rescue missions by helicopters at a large scale, the civilian EMS systems quickly implemented this new concept into the rescue of civilian trauma patients. Recent changes in military field medicine, such as low volume resuscitation, the revival of tourniquets, and of blood stopping granules, will clearly influence the care of civilian trauma patients in the future. The aim of this article is to give a brief overview of the advances in military and civilian EMS systems which are currently happening and which will affect the way trauma patients are treated, both in the field and in the emergency rooms receiving these patients.
Despite different trauma patterns in patients, loss of airway or breathing is the most rapid cause of death. The airways of severely injured patients need to be secured as soon as possible. Airway management in the field is often more difficult than intubations in the operating room or the emergency department. This is caused by different provider training and experience, patient location, and coexisting medical or surgical problems. Over the years, different devices used in anesthesiology have been introduced to prehospital care providers. These devices range from laryngoscopes and different laryngoscope blades to oral and nasal airways. More recently introduced devices include the Eschmann elastic bougie, and even more recently, supraglottic devices.
The Eschmann or gum elastic bougie has been used by anesthesiologists, especially in Europe, since its introduction by Macintosh in 1949. [13],[14],[15],[16],[17] The Eschmann gum elastic bougie showed good results when used for airway management, not just in the operating room, but also in the prehospital setting. [18] Beside its traditional use to guide endotracheal intubation (ETI), the gum elastic bougie has also been described to facilitate cricothyrotomy in the field. [19] The gum elastic bougie was further evaluated as a guide for intubation after a laryngeal mask airway (LMA) was placed. In a cadaver study, the bougie was placed through an LMA and an endotracheal tube (ETT) was then placed over the bougie. This procedure was successful in placing the ETT into the trachea in about 50% of the attempts. [20]
In 2005, the European Resuscitation Council (ERC) endorsed the use of supraglottic airway devices. [21] The supraglottic devices such as LMA™ (LMA, the Netherlands Antilles), Combitube™ (Nellcor, Boulder, CO, USA), Rusch EasyTube® (Teleflex Medical Company, Reading, Pennsylvania, USA), and King LT™ (King Systems, Noblesville, IN USA) are easier to insert when compared to ETI by providers after minimal training. [22],[23],[24],[25] While the supraglottic airway devices are not providing a definitive airway compared to a cuffed ETT, the supraglottic devices enable the prehospital provider to establish a rescue airway after failed intubation [26] and prepare for a definitive airway such as a cricothyrotomy or rapid transport to the nearest hospital for definite airway management.
A special version of the LMA is the intubating LMA, which combines the ease of insertion of a supraglottic airway device with the security of an ETT. The intubating LMA has a shorter and wider tube, allowing for easy insertion of an ETT through the previously placed LMA. This technique shows good success rates amongst providers otherwise inefficient in intubation with direct laryngoscopy [27] as a backup intubation tool after the other intubation attempts have failed, [28],[29] or in cases of difficult airways, such as limited access to the patients airway. [30],[31] The LMA is easy and quick to insert and often provides the ability to ventilate when adequate mask ventilation is not possible. [32]
The more recent developments of video-assisted laryngoscopes such as the Glidescope® (Verathon Inc., Bothell, WA, USA), the Ambu® Pentax Airway Scope (AWS) (Ambu, Ballerup, Denmark) the C-MAC® Video Laryngoscope (Karl Storz, Tootling, Germany) or the McGrath® Video Laryngoscope (LMA, the Netherlands Antilles) have already started to be introduced to prehospital care providers. So far, most publications of video-assisted laryngoscopes include case reports in trauma patients [33] and mannequin simulations, [34] but not randomized trials. Nevertheless, these studies have shown that the success rate and speed of intubation with video laryngoscopy is comparable in providers, experienced with direct laryngoscopy, due to a steeper learning curve with the video laryngoscopes. [34] The usage of video-assisted laryngoscopy seems to be especially useful for cases involving suspected spine injury where neck movement needs to be reduced or eliminated. Video-assisted devices have shown to reduce cervical spine movement in comparison to direct laryngoscopy. [35] In the near future, with a paucity of manufacturers positioning their product in this expanding market, we can expect more competitive pricing and aggressive advertising of these products to prehospital care providers. While the video-assisted laryngoscopes offer advantages over direct laryngoscopy for difficult airways and for providers with minimal training or experience, they also provide the disadvantage of providers losing their skills in direct laryngoscopy, therefore giving up a time-honored and proven technique to intubate a patient. Nevertheless, given the low national requirement of intubation for new paramedics, we will very likely see a widespread use of video-assisted devices in the prehospital systems. This will hopefully reverse the current trend of abandoning prehospital intubation due to the lack of intubation skill in some paramedics.
Circulatory Access
Paramedics and other prehospital providers have been placing intravenous access as a standard treatment since the beginning of prehospital care. The need to administer fluids and medication makes circulatory access essential. The "gold standard" in the field has been the peripheral intravenous access. In certain patients such as hypovolemic patients, intravenous drug abusers, burn patients, and children, peripheral intravenous access may not be possible.
While the concept of intraosseous access is quite old and has been used for pediatric patients for a long time, only recently this technique was introduced to the adult patients. The technique is supported by the European Resuscitation Council and has shown comparable plasma concentrations of injected drugs, similar to injection through a central venous catheter. [36],[37] Besides mechanical intraosseous devices, the FDA approved three mechanical devices: The FAST1® (Ping Medical, Vancouver, British Columbia, Canada), the EZ-IO® (Vidacare, San Antonio, TX, USA), and the Bone Injection Gun® (Wayside, Yokneam, Israel). The mechanical devices (Bone Injection Gun, FAST 1) showed to be equivalent in terms of success rates as compared to standard intraosseous needles, but differed in the time required to secure circulatory access. [38],[39]
The downside to intraosseous access is the increased infection risk and, even more, the fact that blood products cannot be given through this access. This means that once at the hospital, the patient still requires intravenous access and the intraosseous needle (or needles) needs to be removed. For this reason, intraosseous access is often used as a last resort when peripheral IV access can not be established and central venous access is not possible either.
Central venous access has been used in some prehospital systems, but has a higher risk of serious side effects and complications compared to peripheral IV access. The most common risks are pneumothorax, vascular injury, and infection. For reasons of infection control, all the lines placed in the field need to be considered contaminated and should be replaced at the earliest possible time.
Tourniquets are experiencing a revival after they were all but eliminated in the early 80s when the fear of extended soft tissue damage, nerve damage and the potential loss of the extremity was feared if the tourniquet was used for too long or was not indicated in the first place. The different injury pattern experienced by the US military in the latest conflicts in Iraq and Afghanistan showed that tourniquets save lives in cases of severe blast injuries to the extremities. These findings even translated into tourniquets built into tactical gear by some manufacturers. While these types of injuries are less frequently encountered in the civilian EMS systems, there has been a change of policy regarding tourniquet use in many civilian EMS systems. The different types of tourniquets (rubber, cloth, and windlass) are successful in eliminating distal pulses when applied above and below the knee or elbow. [40] The location of the tourniquet may allow a lower amputation with preservation of the joint. Accurate documentation regarding time of tourniquet application is necessary with their use.
Other forms of hemorrhage control include advanced hemostatic dressings (where a clotting agent is impregnated into the dressing) and granular agents. Examples of hemostatic dressings are: HemCon® bandages (HemCon Medical Technologies Inc., Portland, OR, USA) and QuickClot® ACS+ (Z-Medica Corperation, Wallingford, CT, USA). Two examples of granular agents are Celox and WoundStat. HemCon is a positively charged chitin-based wafer which bonds strongly with negatively charged blood cells upon contact. QuikClot ACS+ dressings contain zeolite particles which rapidly absorb water upon contact with blood, thereby concentrating platelets and clotting factors at the bleeding site. Celox™ (Medtrade Products Ltd., Crewe, United Kingdom) works like HemCon (chitin based), but the granules are packed in the wound. Lastly, WoundStat is made from smectite, absorbs water (like QuikClot ACS+) and forms a clay-like seal in the wound. Military comparisons of these agents show better control of hemorrhage in swine models. [41]
In recent years, end-tidal capnography or capnometry has been introduced in many EMS systems and the emergency room as a way to verify tracheal position of an ETT. [42] Capnography is also useful in guiding mechanical ventilation, especially when transport ventilators are used in which the minute volume can be better controlled than in manual bag ventilation. But the success is limited in critically ill or unstable patients. A further indication is the assessment of effectiveness of cardio pulmonary resuscitation (CPR), as larger volumes of end-tidal CO 2 indicate not only effective ventilation but also better cardiac output.
End-tidal capnography in the prehospital setting can reduce the incidence of severe inadvertent hyperventilation by over 50%. [43]
In intubated patients with traumatic brain injury, the survival rate was increased twofold when the arrival pCO 2 was between 30 and 49 mm Hg, [44] and in another study patients with severe traumatic brain injury were less likely to die when the pCO 2 on arrival was between 30 and 35 mm Hg. [45]
To take advantage of end-tidal CO 2 monitoring, additional teaching of prehospital providers about the correlation of end-tidal to arterial pCO 2 (PaCO 2 ) and the limitation of end-tidal CO 2 in trauma patients is required. Furthermore, correlation withPaCO 2 should be obtained as soon as possible, which usually occurs shortly after arrival at the receiving hospital. Other devices, such as the single use colorimetric end-tidal CO 2 detectors, are still used frequently. One must remember that these devices are of single use and early exposure to ambient air prior to their use can render them useless. These devices can be removed from the breathing circuit as soon as confirmation of tube placement is made.
A new development in patient monitoring is the transcutaneous measurement of tissue hemoglobin oxygenation. Unlike other monitoring devices, the tissue hemoglobin oxygenation measurement has already found access to the prehospital field and seems to give the prehospital provider a tool to assess hypoperfusion in the field. [46]
The future may see other monitoring modalities being introduced and used, such as a point-of-care lactate monitor (much like a glucometer), but their utility in the field and efficacy must be determined.
Trauma management has a "language" which all providers understand if they participate in a trauma assessment and management course. There are trauma courses for medics (including firefighters), nurses, and physicians. Some trauma courses conducted in North America are as follows: International Trauma Life Support (ITLS) for all-comers, Advanced Trauma Life Support (ATLS) for physicians, and Trauma Nurses Core Courses (TNCC) for nurses. Although different governing bodies provide and teach these courses, the "language" of trauma management remains the same. It is very important in trauma management systems for all participants to be fluent in order to provide the best care for patients.
The use of muscle relaxants in patients undergoing ETI facilities and improves the suc cess rate of intubation. [47] Depolarizing and non-depolarizing muscle relaxants have been used by anesthesiologists as a regular adjunct for ETI. In the prehospital setting, the use of muscle relaxants for rapid sequence intubation (RSI) was first described by Hedges in 1988. [48] The increased success rate of ETI using RSI compared to intubation attempts without medication or without muscle relaxants has been reported [49],[50],[51] although it is still questioned by some if muscle relaxants should be used by paramedics or flight nurses. To safely use these potentially dangerous medications, advanced airway training is needed and has been proven to be effective in improving intubation success and decreasing cricothyroidotomy rates when implemented. [52] Besides additional training, protocols, quality improvement and strong medical oversight are required.
The training of new students or medical residents has been undergoing numerous changes over the last years. The most recent development is the use of simulation programs in which the student is exposed to real-life scenarios and realistic time constrictions. The idea of the simulation is to give the student not just vital parameters or other physiologic data, but also to mimic real scenarios including interaction with patients and other team members. These simulations were first used in the training of anesthesiology residents and first described in 1987. [53]
Since then, these simulations have become more sophisticated. Other medical specialties and paramedic training programs have been using simulation-based learning. Simulation is a means where difficult, and sometimes rare, events can be reproduced in a safe setting. Participants can then get multiple exposures to scenarios which occur infrequently. Studies indicate that simulation-based learning programs improve crisis management skills, especially behavioral skills, necessary in the team approach to injured patients. [54]
Airway management and RSI can safely and effectively be performed in the field when resources for prehospital airway management are focused on a small, highly trained, highly experienced and proficient group of paramedics, thereby maximizing their exposure and experience. [55] In a paramedic training program, the odds of successful ETI increase with each cumulative training exposure to ETI. This training requires substantial resources and clinical opportunities, which may not be available to many training programs. [56],[57]
There have been a number of prehospital scoring systems. The purpose of these scores is to predict and identify the most critical of patients and guide with patient transport to the appropriate hospital. It has been shown that organizing a prehospital advanced live support system in combination with the transport of the patient to the most suitable hospital decreases the mortality of trauma patients. This result is attributed to improved quality of care and reduced time to definite treatment. [58],[59]
The Abbreviated Injury Score (AIS) is an anatomical scoring system introduced in 1971 by the Association for the Advancement of Automotive Medicine (AAAM). [60] It was originally designed to stratify victims of motor vehicle crashes and to provide researchers with a simple numeric scale. The AIS forms the basis of the Injury Severity Score (ISS). The AIS underwent a total of six revisions. The current AIS (2001) dictionary lists approximately 1300 injuries. The AIS is commonly used to assign monetary values to injuries for cost-benefit analysis. [61]
Many of these scoring systems, such as the ISS and New Injury Severity Score (NISS) require knowledge of all injuries, some of which are not identified in the prehospital setting. More current scores such as the Revised Trauma Score (RTS) look at physiologic data, but are often cumbersome to calculate.
Raum et al. developed a scoring system that is fairly easy to calculate using variables, some of which are easily obtainable in the prehospital setting. Their system called Emergency Trauma Score (EMTRAS) identified the following as the major predictors in mortality: age, prehospital Glasgow Coma Scale (GCS), base excess, and prothrombin time. [62]
In Germany, Huber-Wagner developed a similar score called The Sequential Trauma Score (STS) which allows prognosis of patient outcome at several early stages. This scoring system looks at variables in the following settings: patient data, the prehospital phase, early trauma room phase and late trauma room phase. Logistic regression of these variables showed that in the prehospital phase, age, blood pressure (BP), heart rate (HR), GCS, and anisocoria were the significant survival predictors. [63] The authors identified peripheral oxygen saturation, GCS, anisocoria, base excess, and thromboplastin as the major predictors for patients' outcome in the early trauma phase, and cardiac massage, AIS of the head, the maximum AIS, and the need for transfusion or massive transfusion to be the most important predictors of survival in the late trauma phase. Compared to other trauma score systems, the STS is collecting data from numerous data points to predict patient survival at different stages.
Prehospital Provider Support
It is now fairly well known and understood that experiencing stressful situations can be detrimental to a provider's well-being. Sometimes called Post Traumatic Stress Disorder (PTSD), its signs and symptoms vary and each person can be affected differently. Prehospital providers are identified as a group at greater risk of PTSD.
In order to maintain the well-being of its employees, EMS systems have developed Critical Incident Stress Debriefings or Meetings. These meetings are interventions meant to manage stress, mitigate the impact of the traumatic event, and to accelerate the recovery process. [64] As with many other aspects of trauma care, the military has performed investigations into this area and applied treatment guidelines early. The Israeli Defense Forces have been using team discussions conducted by mental health professionals, after treating inured patients for many years and have developed guidelines for conducting these debriefings. [65]
A good support system should be readily available to all providers. During debriefing sessions, open channels of communication are vital and acknowledgement of feelings and fears must be validated. Furthermore, more than one session may be required. It is imperative that workers at risk be identified and treated early. In recent scenarios, support systems for prehospital providers were established at the scene, shortly after the traumatic event. In this particular case, voluntary and employed emergency responders were debriefed on the same day, following a panic in a large crowd during an open air festival where several attendees suffocated or were crushed to death. [66]
Prehospital trauma care is an important component of all trauma care systems and definite care of trauma patients needs to start early in the field. The training of prehospital care providers ranges from minimally trained first responders to attending physicians trained in trauma surgery or trauma anesthesia. Because of these discrepancies in training and experience, the prehospital system needs to carefully review and, if appropriate, adopt new technologies, techniques and tools to improve patient care of trauma patients in the field. Many of these techniques were developed by the military, while other technologies were first established in the operating room or the intensive care units. Besides the use of modern techniques and tools, it has become important to introduce scoring systems in prehospital trauma care. These scoring systems can not only aid in the care of trauma patients, but are also a requirement for many research projects to allow comparative studies of different treatment modalities or the comparison of different prehospital care systems. Last but not the least, the need to help medical providers coping with traumatic experiences and reduce the loss of experienced providers due to burn out or posttraumatic stress is of utmost importance.
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51. Davis DP, Ochs M, Hoyt DB, Bailey D, Marshall LK, Rosen P. Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients. J Trauma 2003;55:713-9.
52. Swanson ER, Fosnocht DE. Effect of an airway education program on prehospital intubation. Air Med J 2002;21:28-31.
53. Gaba DM, Maxwell MS, Deandra A. Anesthestic mishaps: Breaking the chain of accident evolution. Anesthesiology 1987;66:670-6.
54. Knudson MM, Khaw L, Bullard MK, Dicker R, Cohen MJ, Staudenmayer K, et al. Trauma training in simulation: Translating skills from SIM to real time. J Trauma 2008;64:225-64.
55. Fakhry SM, Scanlon JM, Robinson L, Askari R, Watenpaugh RL, Fata P, et al. Prehospital rapid sequence intubation for head trauma: Conditions for a successful program. J Trauma 2006;60:997-1001.
56. Warner KJ, Carlbom D, Cooke CR, Bulger EM, Copass MK, Sharar SR. Paramedic training for prehospital endotracheal intubation. Prehosp Emerg Care 2010;14:103-8.
57. Wang HE, Seitz SR, Hostler D, Yealy DM. Defining the "learning curve" for paramedic student endotracheal intubation. Prehosp Emerg Care 2005;9:156-62.
58. Marson AC, Thomson JC. The influence of prehospital trauma care on motor crash mortality. J Trauma 2001;50:917-21.
59. Association for the Advancement of Automotive Medicine, Committee on Injury Scaling. The Abbreviated Injury Scale - 1990 Revision (AIS-90). Des Plains, IL: Association for the Advancement of Automotive Medicine; 1990.
60. Committee on Medical Aspects of Automotive Safety. Rating the severity of tissue damage. JAMA 1971;215:277-286.
61. Chawda MN, Hildebrand F, Pape HC, Giannoudis PV Predicting outcome after multiple trauma: Which scoring system?; Injury 2004;25:347-58.
62. Raum MR, Nijsten MW, Vogelzang M, Schuring F, Lefering R, Bouillon B, et al. (The Polytrauma Study Group of the German Trauma society). Emergency Trauma Score: An Instrument for early estimation of trauma severity. Crit Care Med 2009;37:1972-7.
63. Huber-Wagner S, Stegmaier J, Mathonia P, Paffrath T, Euler E, Mutschler W. The sequential trauma score: A new instrument for the sequential mortality prediction in major trauma. Europ J Med Res 2010;15:185-95.
64. Mitchell AM, Sakraida TJ, Kameg K. Critical incident stress debriefing: Implications for best practice. Disaster Manag Response 2003;1:46-51.
65. Knobler HY, Nachshoni T, Jaffe E, Peretz G, Yehuda YB. Psychological guidelines for a medical team debriefing after stressful event. Military Medicine 2007;172:581-5.
66. Hauke S. [Einsatz bei der "Loveparade": Erstversorgung bei der Katasprophe] GERMAN. Rettungsdienst 2010;33:56-60.
1 Development and Implementation of Short Courses to Support the Establishment of a Prehospital System in Sub-Saharan Africa: Lessons Learned from Tanzania
Hendry R. Sawe,Juma A. Mfinanga,Samwel Kisakeni,Patrick Shao,Paulina Nkondora,Libby White,Christina Bollinger,Irene B. Kulola,Upendo N. George,Michael S. Runyon,Erin Noste
Emergency Medicine International. 2019; 2019: 1
2 Prehospital infection control and prevention in Denmark: a cross-sectional study on guideline adherence and microbial contamination of surfaces
Heidi Storm Vikke,Matthias Giebner,Hans Jørn Kolmos
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2018; 26(1)
3 A Model for Safe Transport of Critical Patients in Unmanned Drones with a 'Watch' Style Continuous Anesthesia Sensor
Ahmed Hasnain Jalal,Yogeswaran Umasankar,Fraker Christopher,Ernesto A. Pretto,Shekhar Bhansali
Journal of The Electrochemical Society. 2018; 165(8): B3071
4 Major Trauma Outside a Trauma Center
Preston J. Fedor,Brian Burns,Michael Lauria,Clare Richmond
Emergency Medicine Clinics of North America. 2018; 36(1): 203
5 Hospital Mortality Based on the Mode of Emergency Medical Services Transportation
Hassan Al-Thani,Ayman El-Menyar,Yugan Pillay,Monira Mollazehi,Ahammed Mekkodathil,Rafael Consunji
Air Medical Journal. 2017;
6 Are prehospital deaths from trauma and accidental injury preventable? A direct historical comparison to assess what has changed in two decades
G.J. Oliver,D.P. Walter,A.D. Redmond
Injury. 2017; 48(5): 978
7 First Aid and Transportation Course Contents Based on Experience gained in the Iran-Iraq War: a Qualitative Study
Forogh Sarhangi,Hamid Reza Gholami,Morteza Khaghanizade,Soheil NajafiMehri
Trauma Monthly. 2015; 20(1)
8 Prehospital Trauma Care in Singapore
Andrew Fu Wah Ho,David Chew,Ting Hway Wong,Yih Yng Ng,Pin Pin Pek,Swee Han Lim,Venkataraman Anantharaman,Marcus Eng Hock Ong
Prehospital Emergency Care. 2015; 19(3): 409
9 Trauma leagues: an alternative way to teach trauma surgery to medical students
Romeo Lages Simões,Fernando Antônio Martins Bermudes,Hudson Silva Andrade,Filipe Machado Barcelos,Breno Pinheiro Rossoni,Gustavo Peixoto Soares Miguel,Carlos Alberto de Castro Fagundes,Gustavo Pereira Fraga
Revista do Colégio Brasileiro de Cirurgiões. 2014; 41(4): 297
Williamson K
Ramesh R
Grabinsky A
Prehospital Prov...


text:
050 - National Defense (1)
150 - International Affairs (16)
250 - General Science/Space/Tech (1)
300 - Natural Resources/Environ (4)
(-) 500 - Edu/Training/Empl/Soc Servs (2)
(-) 700 - Veterans' Benefits/Services (6)
(-) House Committee on Oversight and Government Reform (1)
(-) Senate Committee on Commerce, Science, and Transportation (1)
(-) Senate Committee on Veterans Affairs (6)
S. 2486, Veterans Benefits Improvement Act of 2004
Estimate of direct spending and revenues effects for the bill as cleared by the Congress on November 17, 2004
S. 2485, Department of Veterans Affairs Real Property Management Improvement Act of 2004
Cost estimate for the bill as ordered reported by the Senate Committee on Veterans' Affairs on July 20, 2004
S. 2484, Department of Veterans Affairs Health Care Peronnel Enhancement Act of 2004
S. 2486, Veterans' Benefits Improvements Act of 2004
Cost estimate for the bill as ordered repored by the Senate Committee on Veterans' Affairs on July 20, 2004
S. 2645, Public Broadcasting Reauthorization Act of 2004
Cost estimate for the bill as ordered reported by the Senate Committee on Commerce, Science, and Transportation on July 21, 2004
S. 2483, Veterans' Compensation Cost-of-Living Adjustment Act of 2004
S. 1153, Veterans Prescription Drugs Assistance Act
Cost estimate for the bill as ordered reported by the Senate Committee on Veterans' Affairs
H.R. 4012, District of Columbia College Access Act of 2004
Cost Estimate April 30, 2004
Cost estimate for the bill as ordered reported by the House Committee on Government Reform on April 1, 2004

redpajama_set_name: RedPajamaCommonCrawl


Real estate made simple is a lightning fast and light weight PHP script, equipped with an API using which you can easily hook to its inner functions. You can launch a real estate website within minutes. The demo has 5000+ listings but loads within 2 seconds. You can also use it to earn passive income by promoting adsense or similar ads.


text:
This is a tiny library to generate file names.

It will give you unique file names based on current git commit, as well as the
time and date.

When `fn` is called from the terminal, the file names look like this:

    20190126-142138-244db3e-5f3a90f9
    20190126-142155-244db3e-42464759

Which currently follows this format:

    yyyymmdd-hhmmss-gitsha-prochash

Where `gitsha` is the prefix of the git commit sha. And `prochash` is a hash of
the time when `Fn()` is called and the corresponding process id.

If you are not in a git repo, it looks like this:

    20190126-142213--cc607dd0

You can use `fn -r [dir]` to list all files with the most recent procsha.

Similarly you can list all files with the most recent gitsha with `fn -l [dir]`.

Use `fn -h` in the terminal to see other options.

## Why?

I have a lot of projects where I make large amounts of files (images, 3D
models, 2D vector files), and I've always wanted a more efficient way of
maintaining unique file names.

I got the idea for this when I saw how Vera Molar names her works in this
Periscope video https://twitter.com/inconvergent/status/700341427344113665

## Dependecies

The code runs on Linux (only, probably) and requires `git` to be installed. It
also uses `docopt`, installed via `setup.py`.

## Install

The easiest is to install with:

    ./setup.py [install | develop] [--user]

Unfortunately the command line support relies on `entry_points`, which is
rather slow. To make it run faster you can (for instance) add a symlink in your
local `bin` folder to `./run.py` in this repo.

## Does it guarantee unique file names in any way?

No. It only uses the current time to make a relatively distinct string—don't
use this for anything remotely important.

## On Use and Contributions

This code is a tool that I have written for my own use. I release it publicly
in case people find it useful. It is not however intended as a
collaboration/Open Source project. As such I am unlikely to accept PRs, reply
to issues, or take requests.

redpajama_set_name: RedPajamaGithub


text:
Q: Hiera lookup of datasource failing on new node I'm trying to set up a new node using puppet, but it fails with an error that leads me to believe that hiera isn't finding the correct datasource:
Server Error: Evaluation Error: Error while evaluating a Function Call, undefined method `empty?' for nil:NilClass at ${line 4 in some selfwritten class}

I also got this error, but I don't remember what I changed (if anything) that resulted in it:
Server Error: Evaluation Error: Error while evaluating a Function Call, Unknown alias: 3B4007E7596ADF847ECA510D57069DBF2B3DB006 at ${line 4 in the same selfwritten class}

The line in the class that puppet complains about looks like this:
$network = hiera("network")

This is the first line in the class. This same lookup works on a different node.
My /etc/puppetlabs/puppet/hiera.yaml looks like this
---
:backends:
  - yaml
:hierarchy:
  - "nodes/%{::trusted.certname}"
  - "customer/%{customer}"
  - "preview/%{preview}"
  - "test/%{test}"
  - common

:yaml:
# datadir is empty here, so hiera uses its defaults:
# - /etc/puppetlabs/code/environments/%{environment}/hieradata on *nix
# - %CommonAppData%\PuppetLabs\code\environments\%{environment}\hieradata on Windows
# When specifying a datadir, make sure the directory exists.
  :datadir:

This new node has in its manifest
$customer='foo'

While the working node has
$customer='bar'

I  have a yaml file for each, and yamllint shows neiter errors nor warnings for hiera.yaml or the two below.
ls /etc/puppetlabs/code/environments/production/hieradata/customer/

foo.yaml    bar.yaml

The first line in their respective yaml file defines a string for this value network:
network: "172.28.11"

I've tried using puppet lookup to debug this issue, so far without success
puppet lookup --environment production --debug --explain --node foo-app1.domain.tld --compile network

<snip lots of unrelated stuff>
Debug: hiera(): Looking for data source customer/foo
Error: Could not run: Evaluation Error: Error while evaluating a Function Call, Unknown alias: 3B4007E7596ADF847ECA510D57069DBF2B3DB006 at {same class and line}

If I run that command without --compile it quits without error, but also without looking up the customer datasource

*

*All nodes are running Debian Jessie (8)

*The Puppetserver is version 2.5.0 from the official Puppetlabs Repo for Jessie

*I've tried the puppet agent version from Jessie (3.7.2) and from Backports (4.8.2) - no difference

So: Why is this node failing the hiera lookup?
How do I fix it?
How do I correctly use puppet lookup to fetch this value from the working node? (to aid in debugging)

redpajama_set_name: RedPajamaStackExchange


Kreitlow, a nationally recognized adult educator, suggests that Extension educators who aren't afraid to test their professional security and who see themselves as leaders and change agents involved in improving the quality of rural and urban life, frequently find themselves in the midst of controversy. He presents a change model that helps us see the alternatives for dealing with controversy in the educational environment and describes controversy as a naturally occuring phenomenon and as an input for rapid change. The model also identifies leadership characteristics for dealing with controversy or for using controversy as a means of bringing about change. The author sees controversy as a positive force and an effective tool for an educator.
Who would you say are the most active participants in voluntary action programs in your community? The authors examine the WHO portion of that question and present data indicating middle- or higher-income status individuals in the middle of their life cycle with adequate personal health, extensive informal interpersonal relationships, and who are exposed to mass media as those likely to join voluntary associations and action programs. Is this true in your community? Having this type of knowledge and information should give you clues on how you can more effectively reach and recruit more volunteers.
The author presents a systematic way of looking at the situations of people with whom we program to enable us to more effectively identify their needs. Using values as the basis for the framework, because "...our values give meaning, perspective, and importance to the needs, new technical ideas, or actions we experience," Forest identifies seven value-type cateories and proceeds to demonstrate how they can be used as a guide for program situation analysis. Perhaps you'll find his matrix model and suggestions for ways of using it helpful to you.
Seaman A. Knapp is recognized as the father of the County Demonstration Agent System and is known for his innovative way of helping people help themselves. The author, unhappy with current attempts in programming in 4-H in the inner cities, quotes from one of Knapp's speeches: "Your mission is to solve the problems of poverty, to increase the measure of happiness, and to harness the forces of all learning to the useful and needful in human society." Westwood raises the question of what Knapp would do were he alive today and faced the crises and dilemma we find in the inner cities.
"Effect of Televised Simulated Instruction on Subsequent Teaching"
Breakthrough: Women into Management. Rosalind Loring and Theodora Wells. New York, New York: Van Nostrand Reinhold Company, 1972. 202 pp. $7.95.
How To Plan Meetings Like a Professional. Coleman Finkel. Philadelphia, Pennsylvania: SM/Sales Meetings Magazine, 1972. 109 pp. $5.00 (paper).
Leadership Development for Public Service. Barry A. Passett. Houston, Texas: Gulf Publishing Company, 1971. 135 pp. $7.95.
Parent Education. Evelyn Pickarts and Jean Fargo. New York, New York: Appleton-Century-Crofts, 1971. 311 pp. No price given.
The People Dynamic: Changing Self and Society Through Growth Groups. Howard J. Clinebell, Jr. New York, New York: Harper & Row, 1972. 176 pp. $4.95.
Career Management. Marion S. Kellog. New York, New York: American Management Association, 1972. 200 pp. $11.50.
Casebook in Publicity and Public Relations. Raymond Simon. Columbus, Ohio: Grid, Inc., 1972. 274 pp. $6.95 (paper).
The Coming of Age. Simone deBeauvoir. New York, New York: Putnam, 1972. 585 pp. $10.00.
Continuing Education As a National Capital Investment. Herbert E. Striner. Kalamazoo, Michigan: The W. E. Upjohn Institute for Employment Research, 1972. 118 pp. $1.25 (paper).
Group Discussion As Learning Process: A Sourcebook. Elizabeth W. Flynn and John F. LaFaso. New York, New York: Paulist Press, Publishers, 1972. 253 pp. $5.95 (paper).
The New Supervisor. Martin M. Broadwell. Reading, Massachusetts: Addison-Wesley Publishing Company, 1972. 152 pp. $4.95 (paper).
A Practical Approach to Organization Development Through MBO: Selected Readings. Arthur C. Beck, Jr., and Ellis D. Hillman, eds. Reading, Massachusetts: Addison-Wesley Publishing Co., Inc., 1972. 356 pp. $5.95.
The Process of Social Influence: Readings in Persuasion. Thomas D. Beisecker and Donn W. Parson, eds. Englefield Cliffs, New Jersey: Prentice-Hall, Inc., 1972. 499 pp. $10.95 (cloth), $6.50 (paper).
Reality Games. Saville Sax and Sandra Hollander. New York, New York: The Macmillan Company, Publisher, 1972. 267 pp. $8.95.
Size, Structure, and Future of Farms. A. Gordon Ball and Earl O. Heady, eds. Ames, Iowa: Iowa State University Press, Publishers, 1972. 404 pp. $9.95.
The Small Meeting Planner. Leslie E. This. Houston, Texas: Gulf Publishing Company, 1972. 234 pp. $7.95.
Student Development Programs in the Community Junior College. Terry O'Banion and Alice Thurston, eds. Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1972. 235 pp. $7.95.
Teacher Effectiveness and Teacher Education: The Search for a Scientific Basis. N. L. Gage. Palo Alto, California: Pacific Books, 1972. 226 pp. $7.95.
Toward Gog and Magog Or? A Critical Review of the Literature of Adult Group Discussion. Franklin W. Osinki, John Ohlinger, and Colleen McCarthy. Syracuse, New York: Syracuse University Publication in Continuing Education, 1972. 82 pp. $3.00 (paper).


text:
Shell akquires Italian Solar-Konzept subsidiary
The Shell energy group has acquired the solar project developer Solar-Konzept Italia (SKI) for an undisclosed sum. SKI was previously a... read more
Indian power producer NTPC plans 900 megawatts of photovoltaics in Cuba
Indian energy company NTPC Ltd. is inviting bids from project developers for photovoltaic plants with a total capacity of 900 megawatts... read more
EIG invests $400 million in 8minute Solar Energy
U.S. developer of solar and storage power projects 8minute Solar Energy has signed a $400 million (€353 million) financing agreement... read more
12 companies agree to jointly purchase power from Better Energy megawatt project
The Danish project developer Better Energy has concluded a power purchase agreement (PPA) with a pool of twelve companies. Better Energy... read more
Vietnam halts solar and wind power expansion for 2022
Vietnam's Ministry of Industry and Trade will no longer include new solar and wind power plants in its plans for the current year »due... read more
The Japanese electronics company Panasonic Corporation has introduced two new module series. The H series with heterojunction cells is... read more
SMA Solar Technology AG has introduced a new three-phase hybrid inverter. The »Sunny Tripower Smart Energy« is to be launched in 5... read more
Axpo signs PPA for 300 MW solar power in Poland
Warsaw-based Axpo Polska, a subsidiary of Swiss energy services provider Axpo Holding AG, has signed a power purchase agreement (PPA)... read more
Global solar investments at $27.8 billion in 2021
The U.S. based market research and consulting firm Mercom Capital has published its report on global investments and company... read more
Trina presents new single-axis tracker for large-scale modules
TrinaTracker, the business unit of Chinese solar group Trina Solar Ltd. specializing in tracking systems for large-scale solar power... read more


text:
Home Business CEC's changing trajectory
CEC's changing trajectory
Cayman Enterprise City is finally taking off. Starting the year with 29 firms, the knowledge-based special economic zone expects to accommodate more than 100 companies by year's end, says CEO Charlie Kirkconnell. He speaks with the Journal about the reasons for the project's growth and CEC's target markets.
Charlie Kirkconnell, who took over as CEO of Cayman Enterprise City in February, says it took a while for the changes in the sales effort to take effect.
One of the reasons the numbers are climbing only now is the six- to nine-month period clients typically need from initial contact to signing up. The larger the clients, the longer the process takes, accounting for internal administrative steps.
"So with the long timeline to get clients through the door, you have to be patient. But what we have done is we have really focused on the business of CEC. None of what we are doing is going to happen overnight," he says. "You have to put the right processes in place, and we have refocused our marketing efforts and our sales efforts with the idea that we are going to see the results of this in six to nine months as opposed to waiting around for the home run."
At the same time, CEC has narrowed the focus of its sales team. While companies from Latin America, Dubai or China that match the industry classification criteria are welcome, the primary target market is North America.
"For us, Silicon Valley is absolutely the low-hanging fruit. It is our ideal target. Toronto as well, not just for the tech companies – there is a huge tech center there – but also for film."
CEC is allowed to bring in film companies, media companies, new media, which includes animation for film and post-production, for which greater Toronto area is known. CEC toured Toronto in September and will be back in Silicon Valley this month.
While the strategic focus on the North American has been successful, CEC is also reaching out to other jurisdictions. The special economic zone maintains partnerships in other regions, such as London, where the company will participate in the joint Ministerial Council business event with the Cayman Islands delegation this month.
In addition, Cayman Enterprise City has adapted its online communication.
Because each client group has different key drivers that would make locating in a special economic zone an attractive proposition, CEC has updated its online presence by launching five new websites with targeted messaging more closely related to a spectrum of clients and their needs.
Now that the zone has started to gain some traction, word of mouth will also be a significant sales factor going forward. With more companies becoming operational and seeing the advantages of locating in the special economic zone, interest will grow, Kirkconnell says. Companies that operate in technology circles, in particular, are expected to spread the word and generate sales leads. "We expect that this knock-on effect will become one of our more effective sales tools."
Multiplier effect
One of the requirements of the special economic zone is a physical presence. Each new CEC client setting up a company must start with a minimum of one employee.
Companies may not start with a full complement of staff from day one, but there must be people on the ground, Kirkconnell explains. This means that with just over 100 people working in the special economic zone, CEC is already delivering the desired economic multiplier effect, he says.
"They are here spending money in the economy. They are buying houses, they are buying cars, they are shopping in the stores, they are eating in the restaurants and that is happening already."
The 100 zone employees are working for just over 60 companies that have operations under way. In total, 89 companies have signed license agreements and will obtain a trade certificate with a two- to three-month lag. CEC expects the numbers to increase rapidly, particularly since two large companies have recently made the decision to locate in the zone. One of the firms is projecting to employ 30 to 40 people.
"So within the next two to three months you should see a significant increase in that figure," Kirkconnell says. With that the zone will help expand the size of the economy and bring foreign direct investment and business to the islands, he says.
cayman enterprise city
kirkconnell


text:
The Nelson Fire Department is called to emergencies as first responders
City of Nelson looks for first responder pay
Nelson along with representatives from the Regional District of Central Kootenay attended the annual UBCM convention in Victoria.
Oct. 5, 2012 5:00 p.m.
Nelson along with representatives from the Regional District of Central Kootenay attended the annual Union of British Columbia Municipalities convention in Victoria.
Mayor John Dooley, city council and staff were busy taking in meetings, panel discussions and debates on topics ranging from libraries, local government spending, tanker traffic off the coast of BC and fire department costs.
While topics like the decriminalization and regulation of marijuana made headlines, other issues caught the interest of Nelson delegates.
A resolution around compensation for fire departments when they are first responders to accidents and other incidents was one Dooley felt addressed concerns facing Nelson.
"It's ironic but most communities especially in rural British Columbia are finding it a real challenge because their fire departments are answering calls that used to be covered by ambulance service," he said.
The recent realignment of the ambulance service and the restructuring of health care has meant there is not always an ambulance available as a first responder.
"Consequently our fire departments are having to respond to these accidents and there is no compensation for the work that we do," said Dooley.
The resolution passed at the convention asked funding come from the provincial government or through ICBC when fire department act as first responders.
Before attending last week's meetings, Dooley predicted resolutions around pipelines would also appear during the convention, and one example of this was a resolution around tanker traffic presented by the District of Saanich on Vancouver Island.
"The resolution was to put a moratorium on tanker traffic on the West Coast," he said.
Dooley felt the resolution would be a "slam dunk" as far as being passed, but instead edged through with narrow margins.
"It passed 51 per cent to 49 per cent," he said. "I think there needs to be a bigger discussion there, but many of the media outlets and pollsters seem to have their finger on the pulse of how people are really thinking as far as the well-being of their communities, employment, economic development and all those pieces are packed into that resolution."
Slocan Valley man arrested after car stolen and crashed
School District working to improve school bus routes


There are many Brainshark users in the UK and Europe and 3-4 times per year we visit to either meet one-on-one with customers, conduct a City Tour event, or hold a User Group meeting. This is going to be an amazing year for London - the city is buzzing with preparations for the Queens 60th year Diamond Jubilee in June and there are only 100 days to the Summer Olympics in July.
On April 17, we held the 7th of 14 Customer User Groups this spring. It took place at a private room in a pub at St. Pancras Station. St. Pancras is stunning and is where the Eurostar train leaves from London.
Every meeting takes on its own persona, and this discussion revolved around presentations. Customers volunteered to show their presentations for the purpose of getting some feedback and learn about best practices. One special request was to schedule some of the webinars so those in Europe could participate live.
One customer came in for the meeting from Amsterdam and our special guests were from Bright Carbon and the British Council. Bright Carbon, a UK based agency and Brainshark partner, gave a talk about making presentations more visual. The British Council is the UK's international cultural relations organization and are holding a global competition for schoolchildren, Languages for the Games. The goal is to show creativity in a second language while carrying out a task about Paralympic sports and values. Brainshark provided the Council with a non-profit grant for the students to create their presentation using PowerPoint and submit them using Brainshark. Paul Sweeney of the Council talked about the competition at the User Group meeting.
Deadline is May 18 and additional details are available here.
Having been to the UK many times for Brainshark, I am starting to recognize some of the cultural differences between Brainshark presentations created in the US vs. the UK / Europe.
1. In the UK, our customers tend to rely more on agencies to create their externally focused presentations, whereas in the US, presentations are created by the person writing the script. Working with an agency tends to make for a longer lead time but the presentations can be better integrated into a larger marketing campaign.
2. Implementation of Customer Relationship Management systems is about 1-2 years behind the US and we are speaking with more and more companies rolling out Salesforce.com and Microsoft Dynamics (which has a greater presence in Europe than the US), both of which are integrated into Brainshark.
3. Pubs in the UK are doing something with PowerPoints and no wonder presentations are outsourced to agencies. This photo was taken in Victoria Station.
We expect to be back in the Fall and look forward to meeting even more UK and European-based customers. Click here to learn about upcoming User Group Meetings in Boston, New York, Chicago, Philadelphia, Washington DC, Columbus and Cincinnati.


Tom joined Malcolm Reading Consultants in 2018 and is responsible for designing all our reports, documents, presentations and exhibition materials. He also advises on branding, image and in-house design-related matters.
Tom has recently returned to London following eight years living in Dublin. While there, he was part of the design team at tech startup &Open where his main client was Airbnb, and he also worked as a freelance designer, illustrator and copywriter for New Shoreditch Theatre, the Gate Theatre, literary magazine the Stinging Fly, design studio Indigo & Cloth and artisanal chocolatiers Bean and Goose.
A relative newcomer to the world of Architecture, Tom has enjoyed learning about where buildings really come from.
Tom holds a B.A. and M.Phil. in English Literature from Trinity College, Dublin as well as a diploma in Fine Art from the Chelsea School of Art.


Acro at Tribal in Tulum- all of my favorites in one place! This 90 minute workshop will use partner conditioning drills to challenge you and keep you smiling!
Following the 90 minute class we will have some time to put all of experience in a pile and play! We can continue working skills practiced in class or the jam time can be an opportunity to try out acroyoga moves we've learned in other classes/communities!
50% discount for monthly Tribal members!


I have a realistic view of the capabilities of pupils and will give a real idea of their capabilities.
I teach mathematics to GCSE level and English to degree level. I also teach History to GCSE. Also tuition for 11+ and general for improvement, particularly with special needs pupils.
I go to pupils homes. CRB registered (see note). Croydon ,Purley, , Caterham and all areas around in South Croydon . I live in Kenley, just South of Purley. .
5-16 +. Specialist in reading and learning difficulties also in Dyscalculia. Have had experience in a school situation 11-16, though have taught primary Special Needs.
GCSE- Maths to foundation level only on the new syllabus from 2017, English, History A level English, History 11+ SATS at KS2. Common entrance and any other exams including ESL exams.
I tutor hard and expect hard work in return. All delivered with humour and a desire to get pupils to learn for learning's sake not just for an exam.Though passing an exam is important it is only ever the beginning of the journey.
Taught English to A level. Mathematics taught to GCSE. History Taught to GCSE. 30 years of tutoring in London many of those within the Hindu and Moslem community. Taught in mainstream and special schools in Lambeth and Croydon.
Current to 2014. Present legislation makes it impossible for an individual to get a DRB, you have to go through an organisation and private tutors are not required to have one(??).There are also no requirement to have one every year. some places have one every year most every 3 years. I teach many pupils whose parents will vouch for my integrity.
Degree was from St Davids University Lampeter. Many courses through the years in English as a second language, Maths and English. I have been involved in professional training of other teachers and support staff.
Have taught for 38 years . Current students are studying for entrance in Wisons school, Wallington county and St Olaves. Have taught for Eton and other major public schools.Also for IGCSE, GCSE Maths and English.Also tutor pupils with Autism and learning difficulties.


Satiya's calm voice, smile and clear guidance is perfect for a class that focuses on relaxation. This is a shorter class that anyone can do at any time of the day, whether you're looking for a peaceful pause in the middle of a busy day, a great way to wake up or an effective way to prepare for sleep.
Great for end of day relaxation!
Relaxing hip movements, soothing guidance.
Thank you Satiya for a beautiful class.
Good video, lots of options for different people although some things seem a bit much for gentle beginner.
Satiya always gives a great, relaxing class.
This worked better for me than Day 9's practice. Thank you.


"A Case Study Of The Walt Disney Company Marketing Essay." UKEssays.com. 11 2018. All Answers Ltd. 04 2019 <https://www.ukessays.com/essays/marketing/a-case-study-of-the-walt-disney-company-marketing-essay.php?vref=1>.
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This is part four of five in a series on Ransomware that will discuss the growth of ransomware, recent WannaCry attacks, tips to safeguard our data and also includes an interview with our VP of Marketing who shares what Asigra's solutions can do to prevent attacks.
In 2017, ransomware attacks have skyrocketed and the bad news is that these numbers are getting worse. Reports from CNBCindicate that there has been a 6000 per cent increase of ransomware infections deriving from email and similar reports show that 92 per cent of surveyed IT firms reported their clients had been attacked by ransomware.
In a recent attack in May 2017 (known as WannaCry), critical information was stolen, and encrypted data from the U.S. National Security Agency affected over 99 countries across a wide range of industries. European authorities estimated that at least 200,000 computers in the public and private sector were infected globally.
Organizations who were most vulnerable had old/outdated software (i.e. operating on Windows XP). The infections were deployed via a worm, which initially asked for $300 (£230) in Bitcoin cryptocurrency to unlock the files for each computer. Fines have now doubled to $600 (£348) Bitcoin, with threats of being permanently locked out of systems after seven days of non-payment. Although the attack affected so many companies, payments to the cyber criminals have still been slow, as organizations either a. don't know where to obtain bitcoin currency and b. know that paying the ransom does not guarantee that the files will actually be retrieved.
Backup, Backup, Backup!! The truth is that disaster recovery solutions (i.e. data protection strategies, backup with snapshots, CDP, replication for different levels of recovery) and effective data protection are the only two things to thoroughly protect your data.
Hear our VP of Marketing, Michael Stephens share his insights on CFRB 1010 on these recent attacks and how our solution can help combat ransomware.


Jeremiah 38:1 Forsothe Safacie, sone of Nathan, and Jedelie, sone of Fassur, and Jothal, sone of Selemye, and Fassour, sone of Melchie, herden the wordis whiche Jeremye spak to al the puple, and seide, Jeremiah 38:2 The Lord seith these thingis, Who euer dwellith in this citee, schal die bi swerd, and hungur, and pestilence; but he that flieth to Caldeis, shal lyue, and his soule schal be hool and lyuynge. Jeremiah 38:3 The Lord seith these thingis, This citee to be bitakun schal be bitakun in to the hond of the oost of the kyng of Babiloyne, and he schal take it. Jeremiah 38:4 And the princes seiden to the kyng, We preien, that this man be slayn; for of bifore castyng he discoumfortith the hondis of men werriours, that dwelliden in this citee, and the hondis of al the puple, and spekith to hem bi alle these wordis. For whi this man sekith not pees to this puple, but yuel. Jeremiah 38:5 And kyng Sedechie seide, Lo! he is in youre hondis, for it is not leueful that the kyng denye ony thing to you. Jeremiah 38:6 Therfor thei token Jeremye, and castiden hym doun in to the lake of Elchie, sone of Amalech, which was in the porche of the prisoun; and thei senten doun Jeremye bi cordis in to the lake, wherynne was no watir, but fen; therfor Jeremye yede doun in to the filthe.
Jeremiah 38:7 Forsothe Abdemalech Ethiopien, a chast man and oneste, herde, that was in the kyngis hous, that thei hadden sent Jeremye in to the lake; sotheli the king sat in the yate of Beniamyn. Jeremiah 38:8 And Abdemalech yede out of the kyngis hous, and spak to the kyng, and seide, Jeremiah 38:9 My lord the kyng, these men diden yuele alle thingis, what euer thingis thei diden ayens Jeremye, the profete, sendynge hym in to the lake, that he die there for hungur; for whi looues ben no more in the citee. Jeremiah 38:10 Therfor the kyng comaundide to Abdemelech Ethiopien, and seide, Take with thee thretti men fro hennus, and reise thou Jeremye, the profete, fro the lake, bifor that he die. Jeremiah 38:11 Therfor whanne Abdemelech hadde take men with hym, he entride in to the hous of the kyng, that was vndur the celer; and he took fro thennus elde clothis, and elde ragges, that weren rotun; and he sente tho doun to Jeremye, in to the lake, bi cordis. Jeremiah 38:12 And Abdemelech Ethiopien seide to Jeremye, Putte thou elde clothis, and these to-rent and rotun thingis vndur the cubit of thin hondis, and on the cordis. Therfor Jeremye dide so. Jeremiah 38:13 And thei drowen out Jeremye with cordis, and ledden hym out of the lake. Forsothe Jeremye dwellide in the porche of the prisoun.
Jeremiah 38:14 And kyng Sedechie sente, and took hym Jeremye, the profete, at the thridde dore that was in the hous of the Lord. And the kyng seide to Jeremye, Y axe of thee a word; hide thou not ony thing fro me. Jeremiah 38:15 Forsothe Jeremye seide to Sedechie, If Y telle to thee, whether thou schalt not sle me? And if Y yyue councel to thee, thou schalt not here me. Jeremiah 38:16 Therfor Sedechie the king swoor to Jeremye priueli, and seide, The Lord lyueth, that maad to vs this soule, Y schal not sle thee, and Y schal not bitake thee in to the hondis of these men, that seken thi lijf. Jeremiah 38:17 And Jeremye seide to Sedechie, The Lord of oostis, God of Israel, seith these thingis, If thou goest forth, and goest out to the princes of the kyng of Babiloyne, thi soule schal lyue, and this citee schal not be brent with fier, and thou schalt be saaf, thou and thin hous. Jeremiah 38:18 Forsothe if thou goest not out to the princes of the kyng of Babiloyne, this citee schal be bitakun in to the hondis of Caldeis; and thei schulen brenne it with fier, and thou schalt not ascape fro the hond of hem. Jeremiah 38:19 And kyng Sedechie seide to Jeremye, Y am angwischid for the Jewis that fledden ouer to Caldeis, lest perauenture Y be bitakun in to the hondis of hem, and thei scorne me. Jeremiah 38:20 Forsothe Jeremye answeride, and seide to hym, Thei schulen not bitake thee; Y biseche, here thou the vois of the Lord, which Y schal speke to thee, and it schal be wel to thee, and thi soule schal lyue. Jeremiah 38:21 That if thou wolt not go out, this is the word which the Lord schewide to me, Lo! Jeremiah 38:22 alle the wymmen, that weren left in the hous of the kyng of Juda, schulen be led out to the princes of the kyng of Babiloyne; and tho wymmen schulen seie, Thi pesible men disseyueden thee, and hadden the maistrye ayens thee; thei drenchiden thee in filthe, and thi feet in slidirnesse, and yeden awei fro thee. Jeremiah 38:23 And alle thi wyues and thi sones schulen be led out to Caldeis, and thou schalt not ascape the hondis of hem; but thou schalt be bitakun in to the hondis of the kyng of Babiloyne, and he schal brenne this citee bi fier.
Jeremiah 38:24 Therfore Sedechie seide to Jeremye, No man wite these wordis, and thou schalt not die. Jeremiah 38:25 Sotheli if the princes heren, that Y spak with thee, and comen to thee, and seien to thee, Schewe thou to vs what thou spakest with the kyng, hide thou not fro vs, and we schulen not sle thee; and what the kyng spak with thee, Jeremiah 38:26 thou schalt seie to hem, Knelyngli Y puttide forth my preiris bifore the kyng, that he schulde not comaunde me to be led ayen in to the hous of Jonathan, and Y schulde die there. Jeremiah 38:27 Therfor alle the princes camen to Jeremye, and axiden hym; and he spak to hem bi alle the wordis whiche the kyng hadde comaundid to hym, and thei ceessiden fro hym; for whi no thing was herd. Jeremiah 38:28 Therfor Jeremye dwellide in the porche of the prisoun, til to the dai wherynne Jerusalem was takun; and it was don, that Jerusalem schulde be takun.


Hi, my lenses were imported yesterday and the lenses that had YouTube videos are not showing the videos on the Hub versions. The original video module title shows on the hub, but no video. I haven't checked all of them yet, but this affects at least 8 of my hubs and I haven't found any yet where the video shows correctly.
This is for specific YouTube video urls, not the search based video issue I saw in another thread.
Below are some of the affected hubs with the title that the video followed in when it was a lens and the specific video url that should be displayed.
title="You Might Be A Fantasy Football Addict If..."
title="Watch How A Tombstone Is Made"
Please investigate and advise. Thanks.
Hi MacPharlain! Thank you for reporting this and for providing those examples.
We have a fix for this in the works and plan to re-import all affected Hubs that have not been edited. Please don't edit your Hubs if you want them to be imported again. We plan to do a re-import (note: only for Hubs affected by *this* bug specifically) later this week. If you prefer to add videos back manually and be excluded from the re-import, you are free to do that! I'll update this thread when the re-import is done.
Thanks Marina! I'll wait for y'all to re-import them.
Will the re-import reset their stats back to zero?
Sorry, can you clarify what you mean by 'reset their stats back to zero'? Thanks!
Will the page view statistics reset to zero when the hub is re-imported?
Thank you! This is great news. I was afraid that I would have to re-do all the youtube videos.
The same thing happened to me with some of my hubs, although others did import the videos. I have no idea what the difference is. I just went ahead and added the missing videos.
My content from Squidoo was imported about 12 hours ago. So far it looks like no YouTube videos were successful in making it to their ultimate destination on HubPages. I intentionally edited any lenses on Squidoo that had multiple videos in one module, so I know that's not the problem. I include at least one video on each article -- so this is literally a problem with every single new Hub. Will this be fixed -- or are these videos lurking in a secret spot that is not visible?
Good news, everyone! Hubs that were affected by this bug (and also that haven't been edited) have been re-imported. I encourage you all to check your Hubs and if you see any new problems, please let us know. If you find new bugs unrelated to missing videos and photo galleries, please open a new thread to report it. Thanks!
The YouTube video problem is most certainly NOT fixed on my hubs. I just check several -- no videos to be found on any.
Thanks for letting me know. Can you confirm that the videos are missing from Hubs that you have not attempted to edit? If so, please provide a couple of URLs to your Hubs so we can investigate further.
Thanks for the speedy attention to this ongoing hiccup (I happen to think it's a pretty big one, though).
Thank you for the quick reply! I will unmark this thread as "Resolved" until we are done investigating.
Many thanks to you and the rest of the HubPages team for your ongoing persistence in getting this right. As of this morning, my video content has miraculously appeared. Everything is looking good! A Bravo Zulu (Well Done) to all!
I'm happy to hear that your videos are back, bushaex!
Mine aren't there either. They are also YouTube and were hand picked.
Thanks, Ann. Can you confirm that the videos are missing from Hubs that you have not attempted to edit? If so, please provide a couple of URLs to your Hubs so we can investigate further.
I'm afraid this hasn't fixed my missing video bugs either, and I can confirm that the hubs haven't been edited as I haven't edited any of my lenses/hubs yet. Here's three of mine that are missing the videos.
Thanks for all the help with this.
Also, I have not attempted to edit any of my lenses.
My videos are missing too, but I'm just adding new ones. I've saved all my 'lenses' as webpages, so I can see which videos I had chosen. For me no need to re-import my hubs.
On lenses I have not edited yet there are still no you tube videos.
On the ones I did edit I manually added them. Would make things easier if they could be imported with video intact.
there are others, but this may be enough to help you locate why the fix hasn't worked.
I gave up on this last week, I only have 10 imports that really relied on videos to tell the story, so I just started over. Was a pretty tedious process too I might add, might be worth waiting for a fix for a prolific user of videos though.
Like chezchazz posted, I had to manually add all the YouTube videos on my pages. If you downloaded your content from Squidoo, the YouTube number will show up, but it was easier for me to just browse YouTube with my keywords and start over fresh. Unlike Squidoo, it appears you can only add 1 video per module.
I'd like to provide a quick update that the fix for this bug is still being worked on and there may be another reimport of Hubs in the next couple of days. Thanks for your patience, everyone.
I am having the same problem, but fortunately only 4 or 5 hubs are affected and I have been re-adding using the html copies of lenses I had saved.
I've been re-adding videos. A reimport would be brilliant, if indeed that is possible.
A reimport is currently in progress and should be done tomorrow. Some users are already reporting that their videos are back!
That's awesome! Thanks for the update, Marina, and for all the hard work you and the team have been doing to make the transfer of lenses as seamless as possible for us.
That's exciting news! Thank you so much for all your hard work!
Thanks for the update on this Marina!
I noticed that some of my videos on hubs, that I've not yet updated or edited, are now showing duplicate videos. I'm not sure if this has to do with the re-import of the videos. I guess, I'll wait for the re-import to complete and check again tomorrow.
My lenses never got updated however I did manage to re-import the missing videos and the finished Hubs are looking great.
I would appreciate readers feedback as to how I might make them even better, although most are now scoring in the 70-90 range so I figure they are not too bad?
I just edited a page that the video did not transfer. I just transferred it manually. Now going back thru other pages that I have edited to see if the videos transferred.
Yippie! I just checked 2 pages that have not been updated yet and the YouTube videos are showing Thank you to the HP staff!
I just went to edit one of my hubs and noticed that none of my embedded youtube videos are showing up. The capsule is clearly there as they still have the titles I have given them, but instead of a video there's just huge white space where the videos should be...Is anyone else experiencing this?


Communications Act 2003, Section 2 is up to date with all changes known to be in force on or before 18 April 2019. There are changes that may be brought into force at a future date. Changes that have been made appear in the content and are referenced with annotations.
2(1)In subsection (3) of section 18 (penalty on revocation of television services licence), for "a financial penalty of the prescribed amount" there shall be substituted " a specified financial penalty ".E+W+S+N.I.
"(3A)The maximum amount which a person may be required to pay by way of a penalty under subsection (3) is the maximum penalty given by subsections (3B) and (3C).
(b)7 per cent. of the amount which OFCOM estimate would have been the qualifying revenue for the first complete accounting period of the licence holder falling within the period for which the licence would have been in force.
(b)7 per cent. of the qualifying revenue for the last complete accounting period of the licence holder falling within the period for which the licence is in force.
is served after the commencement of this paragraph.


text:
HomeLatest NewsEgypt Latest News'Sisi isn't everyone's favorite dictator', the Guardian says amid today's mass protests against Egypt's dictator
'Sisi isn't everyone's favorite dictator', the Guardian says amid today's mass protests against Egypt's dictator
September 27, 2019 MEO Staff Egypt Latest News
At the UN general assembly in New York, Donald Trump lauded Mr Sisi as 'a great leader' when asked about the protests; not a great surprise since he had previously reportedly hailed him as 'my favorite dictator'.
While foreign leaders buddy up to Abdel Fatah al-Sisi, his people endure a brutal crackdown on rights, the Guardian's editorial on Thursday read. Also, the U.S. Working Group on Egypt issued a statement two days ago called on the U.S. administration to restate clearly Washington's support for peaceful protests in Egypt.
Even before Egyptian authorities warned that they would "decisively confront" any protests that take place on Friday, it was evident that it would require extraordinary courage to answer the call to the streets. Abdel Fatah al-Sisi's regime has repeatedly shown its utter ruthlessness since seizing power six years ago in a coup. Security forces killed thousands of people protesting against the takeover. The country has locked up 60,000 political prisoners. Executions have soared this year.
Yet hundreds of people did demonstrate in cities including Cairo, Suez and Alexandria last week. The authorities responded with teargas, rubber bullets, beatings and live ammunition. Almost 2,000 people have since been arrested – more than are thought to have taken part. They include several prominent figures who do not appear to have been involved in any way, including the internationally recognized rights lawyer Mahienour el-Massry, who was defending protesters; the journalist and opposition politician Khaled Dawoud; and Hazem Hosny, a former spokesperson for Sami Anan, the former military chief of staff detained since he tried to challenge Mr. Sisi for the presidency last year.
The demonstrations were triggered by videos posted on social media by an exiled Egyptian called Mohamed Ali, claiming to expose the corruption of top military figures which he says he witnessed as a builder working on their properties. They resonated with a population ground down by relentless repression and the struggle to get by. Egypt may be an emerging-market darling, but the macroeconomic picture does not align with people's experiences. Austerity measures imposed under an IMF loan program have been punishing. Real incomes have fallen and the poverty rate has risen again, to just under a third of the population. While the regime has persuaded a sizable chunk of the public that it is a bulwark against further turmoil as well as political Islam, others have had enough.
At the UN general assembly in New York, Donald Trump lauded Mr. Sisi as "a great leader" when asked about the protests; not a great surprise since he had previously reportedly hailed him as "my favorite dictator". European leaders have been more tasteful in their remarks on the Egyptian leader, but they too have made their peace with him, seeing him as essential to limiting migration and as a bulwark against terrorism, and – in France's case – an enthusiastic purchaser of arms and security equipment. There is no sign that the British prime minister, Boris Johnson, even mentioned the demonstrations when they met.
They should pay more heed. It is still unclear why the protest sites had not been put under tight security last Friday, as they had been after previous calls for protests, and why it was a little while before authorities cracked down. Some wonder if parts of the system are unhappy and wanted to send a message to their boss. (If so, his trip to the US suggests it went unheard.) Another explanation, perhaps more plausible, is that they were taken by surprise: when repression is harsh and wholesale, who expects people to object?
Most of those detained appear to be young; too young, in most cases, to have been involved in the 2011 revolution. That is a reminder that an increasingly youthful population sees little hope of any improvement in its circumstances. Mr. Sisi's many friends overseas have made a bad call. They should make it clear to him that a bloody crackdown will not be tolerated. They should do so to protect the basic rights of Egypt's people. Closing the safety valve only means the pressure builds.
Statement by the U.S. Working Group on Egypt
The Working Group on Egypt (a US bipartisan group of foreign affairs experts formed in 2010), on September 25, 2019, issued a statement calling on the U.S. government officials to restate clearly the United States' support for peaceful protests in Egypt.
The statement, signed by Robert Kagan (co-chair), Michele Dunne (co-chair), Reuel Gerecht, Amy Hawthorne, Neil Hicks, Thomas Hill, Sarah Margon, Stephen McInerney, Andrew Miller, Tamara Wittes, Ken Wollack, reads as follows:
[As members of the Working Group on Egypt, we call on U.S. government officials to restate clearly the United States' support for peaceful protests in Egypt. Authorities there have arrested more than 1,400 people after peaceful anti-corruption protests broke out in 14 Egyptian provinces on September 20 and 21.
More protests are possible in the coming days and weeks. In Egypt, President Trump's statements after meeting with President Abdel Fattah al-Sisi on September 23 are being interpreted as giving Sisi a green light to use force against demonstrators and to engage in a broader crackdown.
We ask U.S. officials in the executive and legislative branches to make clear that the United States continues to stand for the following principles regarding demonstrations in Egypt, just as it has done recently regarding protests in Russia, Hong Kong, Iran, and Sudan:
Egyptians have the right to protest peacefully, and to exercise that right without fear of state violence or other retribution.
The military and police should show restraint, avoid conflict, and remain committed to the protection of the people.
All detained peaceful protesters, journalists, lawyers, and human rights defenders should be released immediately and any charges against them dropped.
Robert Kagan (co-chair)
Michele Dunne (co-chair)
Reuel Gerecht
Amy Hawthorne
Neil Hicks
Sarah Margon
Stephen McInerney
Tamara Wittes
Ken Wollack]
2 million children in war-torn Yemen risk exploitation
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Egypt: Unjustly jailed couple "Aisha El-Shater and M. Abo-Horeira" tried by Emergency Court
June 19, 2022 MEO Staff Egypt Latest News
Aisha El-Shater, 41, daughter of Muslim Brotherhood senior leader Khairat El-Shater, and her husband lawyer Mohamed Abo Horeira are on trial by the Emergency State Security Court on bogus charges These bogus and trumped up [ More … ]
Sisi to prosecute 54 million people for boycotting mock elections
Egypt's National Elections Authority said boycotting the Senate vote should result in prosecution Egypt's election commission on Wednesday announced it would refer around 45 million citizens who did not vote in this month's Senate elections to [ More … ]
Egypt's Sisi vows to raise price of subsidized bread
August 3, 2021 MEO Staff Egypt Latest News
Egypt's Abdel Fattah al-Sisi said Tuesday his administration is preparing for raising the price of subsidized bread as part of its continued austerity measures which have badly affected Egyptians, especially the poor. "The time has [ More … ]


I met Kate Young in the most on brand place imaginable - in the basement kitchen of Tottenham Court Road Waterstones. The Australian food writer and chef is equally obsessed with books as she is with food and her long-awaited book combining the two, The Little Library Cookbook, was published by Head of Zeus in September. While she prepared the food for a three course Virginia Woolf-themed supper club, we spoke about why food matters in fiction, how food makes up your sense of self and told me something about Enid Blyton that BLEW MY MIND.


text:
Dr. Lena Crouso named new vice president
By Jim Smith April 4, 2018
(Photo obtained from globalpartnersonline.org)
The following information was obtained from a press release published by Southern Nazarene University.
Today, President Newman announced that, with the approval of the Executive Committee of the SNU Board of Trustees, Dr. Lena Crouso is joining the Senior Leadership Team here at SNU as the inaugural Vice President for Intercultural Learning and Engagement. Dr. Crouso will officially begin her duties on July 1, 2018.
Dr. Newman commented, "The addition of Dr. Crouso represents a strategic commitment to our present and future. The depth and breadth of her education and experience will impact our institution immediately and I know her influence will create a powerful ripple effect. I look forward to learning from her, serving with her, and watching what God will do through her ministry in our community and across the Region."
Dr. Crouso comes to us from Indiana Wesleyan University where she served as the Dean of the Office for Intercultural Learning and Engagement for the Residential Campus. She is a sought-after presenter, consultant and advocate on issues of race, diversity, equity and justice. At SNU, she will provide leadership for the design and implementation of institution-wide efforts to ensure diversity, inclusion, equity, respect, and the promotion of reconciliation in the SNU community.
Provost, Dr. Melany Kyzer, said, "I am excited about Dr. Crouso joining our team – she will be a great asset to us as we continue to learn how to best serve our diverse student population." Dr. Kyzer continued, "She is a leader of compassion, integrity, warmth and generosity, as well as an educator committed to academic excellence."
The daughter of Indian Immigrants, Dr. Crouso spent her formative years growing up in India, and states that her journey from Hinduism to Christ, and her diverse life path, have given her a heart and mind for the empowerment of all people through intercultural understanding and a desire to lead people in spiritual, emotional and social transformation and freedom.
"I am thrilled that Dr. Crouso will be joining us at SNU," said Misty Jaggers, Associate Dean for Student Success. "With each conversation we've had, I've become more and more convinced that she is the person, ordained by God, to lead our campus in our endeavors to be a diverse and inclusive community," said Jaggers.
Rev. Dr. Crouso is an ordained Elder in the Church of the Nazarene. She holds a doctorate in Multicultural Christian Counseling from Andersonville Theological Seminary and an Education Specialist Degree in Leadership from Stetson University, as well as an Educational Counseling Degree from the University of Central Florida. Currently, she will complete a second doctorate this spring in Transformational Leadership and Culture from the Bakke Graduate University. She and her husband, Kendall, are the parents of three grown daughters, Kayla (married to Alan), Chloe, and Addie, who share a love for Christian service here and in India.
By Jim Smith
Prof. Jim Smith, Echo Faculty Advisor Prof. Smith is a professor of Mass Communication at SNU where he has been on the faculty for 25 years. His greatest passion is seeing students develop and grow passions of their own.
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I woke up early in the morning hearing birds chirping on my windowpane. Two birds came to fight on my window. I could not find any difference in their fighting style and my kids. They both were making more noise than action. I went to see the beauty of the morning standing on the window and I saw one peacock dancing in the rain, with its luscious tail spread out behind it. I was amazed to view this spectacular show. But in few seconds he went to a place where it was no longer visible due to the wall. I shouted at the wall, "Why do you always stop the magnificent views? Can't you become transparent when I want you to be?". "Look at yourself first before shouting at me", the wall shouted.
It continued, "You can't see through the walls that you create in your mind and you are blaming me. How many times you misunderstand your loved ones by their exterior looks or actions.". I did not expect the wall to talk to me in such a rude manner early in the morning. Anyway, responding to every blame made on me is my inherent quality.
At the age of remote control, I just wanted things to happen by pressing some buttons and somehow it has affected the way relationships are maintained. I want to see and understand others by putting very little effort. But thankfully something's I life are still not so easy to achieve.
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