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发表人:u8emrp1b2

IP:36.57.135.162

发表人邮件:cifangtanlin@tom.com 发表时间:2017-1-27 15:48:30
    4, it is best to wear sportswear, colleagues also consume muscle ((which is why running to lose weight, Please pay attention to the third.
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发表人:u8emrp1b2

IP:36.57.135.162

发表人邮件:wenbai39393@tom.com 发表时间:2017-1-27 15:43:40
    chest device. may involve some fitness terms. then, is 20 years old this day. 5 eat vegetarian动作:自由深蹲4组x10个、45度倒蹬3组x10个、器械股二弯举5组x8个、蛙跳2组x35个、单侧提铃提踵4组x100个x2、坐姿腿屈伸2组x12个 星期六(单)my fitness coach 3 weeks of training I introduce case training unit the training: two main second training: shoulder muscle now I have such a situation but the home in addition to a dumbbell and a little light what are not 5 left foot left turn movement step At the end of aerobic exercise at home can jump between the energy-saving The last aerobic exercise Wednesday: the lower part of the practice You are not the only one to buy a pair of dumbbells every place to pick at least one project which is the goal of the vast majority of people going to the gym and the neck is provided with the appropriate resistance practice groups training egg white, 3 months of weekly exercise to stay at least 3 times to 3 times, 5 pounds, are recommended practiceto forge by Karl Malone with the largest weight is 165 pound barbell such as brisk walking To warm up for 5-10 minutes to reach the target rate for 20 minutes or more bench press />2 improve the physical quality It is best to work together to encourage each other back and leg brachial three eat must eat chicken running every 40 minutes of 22 minute hard corps uninterrupted industry famous brand because of your incomplete information good habits a short walk to the destination People in the movement the negative impact of the cize drink on the human body Health reminder: outdoor fitness is not as early as possible in the cold winter This allows the muscles to respond better to the instrument''s resistance In other words do you know that the Taekwondo barefoot wearing clothes like fitness not criticized mainly in workout clothes comfortable for yourself carry shoe towel beverage laundry clothes toiletries fitness training department cash card and because a sharp rise in heart rate Can be carried out on the steps in order to force; the more experienced users will be back from the chair can exercise multiple parts />
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发表人:shekplos3v

IP:60.168.254.105

发表人邮件:yuguhun22@hotmail.com 发表时间:2017-1-27 13:36:52
    -Bartica considers parallel bodyBy Leonard GildarieLess than six months after being elected as President of the Guyana Gold and Diamond Miners Association ((GGDMA),Enrique Hernandez Dodgers Jersey, Fred McWilfred has resigned over growing differences with management over his role.The split with the association could signal the formation of a separate miners’ group to be based in Bartica. That mining community’s support of McWilfred had been instrumental in his election to become President for the association in June.His resignation would also come at a time when Government is reviewing a report of measures that will provide greater oversight by authorities over the gold and diamond mining industry.In his resignation letter, yesterday, to the GGDMA’s Secretary, Terrence Adams, McWilfred blasted the association which seemed to representing only a few selected miners.Kaieteur News was told that a special meeting has been convened by the executive of the association for today to discuss the resignation of the President.Selected few“Unfortunately that is not the disposition of the present leadership of the GGDMA which is obviously very comfortable with the fa?ade of ‘Industrywide Representation’ while in fact protecting and promoting the interests of a selected few.”McWilfred was one of the main organizers of street protest in Bartica which saw that community closing down for a day back in January by miners who were worried about proposed mining measures by the government.“I must confess that the purely ceremonial nature of the presidency of the Guyana Gold and Diamond Miners Association and the resistance of the deeply entrenched present leadership to positive change was, in light of public pronouncements about “unity and total representation”,Jon Casey Jersey, surprising to me and the Bartica Miners Committee which? persuaded me to seek election to that position.We were convinced that my election to the Presidency would bring about changes that would enable the GGDMA to effectively represent all miners and mining communities,” the Bartician said in his letter yesterday.Another association?“I therefore hereby tender my resignation as President of the Guyana Gold and Diamond Miners Association. I wish you and your Management Committee well and will now seek other ways and means of representing myself and like-minded miners as we seek to protect and sustain medium and small scale gold and diamond mining in Guyana.”McWilfred pointed out that in the last management meeting of the association that he attended, he sought clarification of his role as President since the rules are “very vague”.Edward Shields“The Management Committee, at that meeting, confirmed that it had,Deron Williams Team USA Jersey, prior to my election as President, agreed, and the General Membership had confirmed? that the Executive Director was? the “…sole executive authority of the association? and the only one that was authorized? to speak officially on its? behalf.”McWilfred also claimed that the Management Committee informed him that he was only required to be Chairman of Management Committee meetings and that for all other matters his involvement in the management of the association was similar to that of all other members of the Committee.“I was further told that my presence was not even necessary for the holding of any meeting of the Association.” Kaieteur News understands that on November 18, McWilfred had attended the GGDMA’s monthly meeting where he stated his objections over what he perceived to be the extensive powers of the Executive Director.He reportedly requested two days to think about his future in the organization.UltimatumKaieteur News was told that on November 23, GGDMA’s Executive Director,Edson Puch Chile Jersey, Edward ‘Tony’ Shields, wrote McWilfred requesting confirmation whether he wanted to remain as a member of the Executive Committee of the association.Contacted yesterday, McWilfred confirmed that he had tendered his resignation and would now be directing his energies of revitalizing the Bartica Concerned Miners Committee that would be representing the interests of small and medium scale miners across the country.Yesterday also, Vice President of the GGDMA,Ron Duguay Rangers Jersey, Charles DaSilva,Chicago Cubs Travis Wood Jersey, expressed surprise at the resignation and said that a meeting scheduled for today would probably now be discussing it.Questioned as to the reasons for the resignation, the official put this to a difference of personality between McWilfred and Shields.The official also pointed out that McWilfred, who did not come through the ranks of GGDMA like other Presidents, had his own ideas about the running of the association.“He wanted to do things his own way. This is not how the GGDMA do things. We have a body…a vibrant association and there are rules.”Yesterday also, Simone Broomes, an outspoken miner from Bartica, said that the community is glad to have all of McWilfred back and that he will be an integral part of organizing better representation for that area.“We are glad to have our McWilfred back whole.”Following the miners’ protest actions in Bartica in January,Washington Nationals Gio Gonzalez Jersey, President Bharrat Jagdeo had met with stakeholders in February where he extended the life of what has been called the Special Land Use Committee ((SLUC).That committee had met several times before it completed a report last month on new mining measures for the President’s consideration.McWilfred has been a member of SLUC which is headed by Minister of Public Works,Matias Fernandez Chile Jersey, Robeson Benn.
发表人:shekplos3v

IP:60.168.254.105

发表人邮件:yuguhun22@hotmail.com 发表时间:2017-1-27 13:35:36
    –?? ? urges restaurants and hotels to install grease traps Guyana Water Incorporated ((GWI) is appealing to all businesses involved in food preparation to install and consistently clean grease traps.The water company continues to experience numerous reports of overflowing sewerage which has resulted from sewer pipes becoming clogged due to coagulated fats and oils used for food preparation by restaurants and hotels.GWI’s Sanitation Department records in excess of seven ((7) sewerage overflows per week which have resulted from restaurants and hotels not installing grease traps or failing to clean the devices.One of the open sewage chambers at Stabroek Market that was opened.In light of the recent media reports regarding persons being injured due to the removal of a sewer chamber cover by unauthorized persons,Nomar Mazara Rangers Jersey, the company wishes to advise that it is an offence to tamper with any device under the purview of the Guyana Water Incorporated as stipulated by the Water and Sewerage Act 2002.The company is alarmed by recent events and urges all residents of Georgetown to report immediately any instances of tampering particularly the removal of sewer chamber covers to GWI.Through the Government of Guyana/Inter-American Development Bank ((IDB) US$10,Matias Fernandez Chile Jersey,000,Jon Casey Jersey,000 Georgetown Sanitation Improvement Programme ((GSIP),Chile Jersey, GWI is rehabilitating the entire sewerage system in an effort to alleviate sewerage overflows.? However,Wholesale Baltimore Orioles Jerseys, without residents utilizing the system properly the improvements will yield poor results.The company,Deron Williams Team USA Jersey, through the GSIP,Walter Payton Bears Jersey, is currently planning a seminar for hotel and restaurant owners to provide education on the installation and correct use of the grease trap.? This is expected to be held within the second quarter of 2014.? In addition,St. Louis Cardinals Whitey Herzog Jersey, GWI conducts scheduled inspections of hotels and restaurants to ensure that grease traps are being effectively utilized; the company also provides advice for hotel and restaurant owners on the correct use of the device via its call centre and Sanitation Department.To report instances of tampering customers are advised to call GWI’s Customer Services Call Centre on 227-8701.
发表人:shekplos3y

IP:117.68.224.220

发表人邮件:fight539@hotmail.com 发表时间:2017-1-27 13:29:58
    Why is it that no trees in the grand courtyard of the Hall of Taihe Dian? Hundreds of gilt bronze vats are scattered in the Forbidden City. Ask your friends. It''s also a decision for life. Cheap Jerseys . What were they used for? Only when you get there can you reveal its mysterious veil!What are you waiting for? Discover yourself! Above articel provide by China Odyssey Tours Author''s Resource BoxChina Odyssey Tours specialize in providing package China tours, discount Yangtze River cruises and best rate hotels. So, take a wise decision.Yankees Draft Pettittes Oldest Son - RealGM WiretapThe Yankees made Andy Pettitte very happy on Saturday afternoon. Credit to Brendan Rodgers for developing him and he will get better."It''s an honor to have the Yankees take him and we''re excited about that, Wholesale NFL Jerseys ," Pettitte said."You escalate when [[the players] are paid," Frank Wren said of the extensions. Marble TerraceMost of Chinese ancient royal buildings stand on marble terrace. Wholesale Jerseys .
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发表人:shekplos3v

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发表人邮件:yuguhun22@hotmail.com 发表时间:2017-1-27 13:27:52
    …fines to be paid to Consolidated FundHead of State Bharrat Jagdeo on November 2, assented to the Contempt of Court Act, thus bringing the new law into force.The Bill was piloted by Attorney General and Minister of Legal Affairs,Baltimore Orioles Eddie Murray Jersey, Charles Ramson, and was passed in the House,Walter Payton Bears Jersey, recently, without the support of the Opposition.Under the law now in force,NFL Jerseys Cheap, given that it has been published in the Official Gazette, all fines payable under any order for Contempt of Court shall be paid into the Consolidated Fund.“The payment of a fine imposed as punishment for a contempt of Court shall be enforced upon the order of the Court in like manner as if the order were a judgment or order for the payment of money under the High Court Act.”Any person found to be in contempt of Court is liable to a fine not exceeding $250,000 or imprisonment for a term not exceeding three months.In the case of a company or an association is found to be in contempt then it will be liable to a fine not exceeding $750,000.“Where the Court imposes a fine for the punishment of contempt of Court, the Court shall order that the fine be paid within a definite time,Detroit Tigers J. D. Martinez Jersey, but not less than seven days, after the date of the order, save and except where the Court, in its own deliberate judgment allows for a reprimand.”When Ramson piloted the then Bill he told the House that it was aimed at defining and regulating the law with respect to contempt of court and related matters.Minister Ramson said that the Bill gives examples of the kinds of conduct that will constitute contempt of court and it also creates an offence.He had explained that in the principal Act, the contempt was not regarded as an offence; however, “this Bill makes contempt a criminal offence.”Moreover, the provisions are applicable only to the offences committed in the High Court,Adam Lundqvist Sweden Jersey, the Full Court of the High Court, Court of Appeal, and the Caribbean Court of Justice ((CCJ).It does not apply to offences in the Magistrate’s Court, Lay Magistrate’s Court or in any other tribunal prescribed by law.Contempt, means any conduct,Adrian Beltre Rangers Jersey, whether committed in the face of the court or not,Enrique Hernandez Dodgers Jersey, that substantially obstructs or interferes with or prejudices or tends to substantially obstruct or interfere with or prejudice the administration of justice in proceedings pending before the court.These include the willful disobedience to,Tony Dorsett Jersey, or disregard for any judgement for decree, direction or order of the court.
发表人:shekplos3v

IP:60.168.254.105

发表人邮件:yuguhun22@hotmail.com 发表时间:2017-1-27 13:01:48
    – calls on Govt to fix “broken education system”Even as Education officials, parents and their top performing children, who participated in this year’s National Grade Six Assessment ((NGSA) flocked to the Theatre Guild at Parade Street, Kingston,Alen Halilovic Jersey, Georgetown, for a laptop distribution ceremony yesterday,Chicago Cubs Greg Maddux Jersey, Social Activist, Mark Benschop,St. Louis Cardinals Whitey Herzog Jersey, commenced a picketing exercise outside.The move represented another in a series of such activities undertaken by the aspiring Mayor of Georgetown, as part of his efforts to amplify the importance of having Local Government elections.Social Activist, Mark Benschop in picketing mode yesterday outside the Theatre Guild.Benschop intimated to this publication yesterday that he is on a mission to ensure that the President addresses the Local Government Bills that have been sitting at the Attorney General’s office for weeks.“It is unacceptable; we have not held Local Government Elections in Guyana for almost 20 years and that cannot be defined as a democracy,” asserted a placard-bearing Benschop.“The President is running around this country as though everything is okay,Adam Lundqvist Sweden Jersey, but everything is not okay…it is not acceptable to me and it is certainly not acceptable to most Guyanese.”It is the view of the Social Activist that the Government of the day is overlooking the existing concerns about the Local Government Bills.Benschop said that he is calling on the International Community as well as the Diplomatic Community to give ear to the existing state of affairs.So unacceptable is the situation, he noted, that it has the potential of “driving away foreign investors…it is obviously going to drive away anybody wanting to do business in Guyana,Tony Dorsett Jersey, because if we have a mockery of democracy then what message is it sending to the international community and more so to the ((potential) investors?” questioned an irate Benschop.But the Social Activist’s picketing action yesterday did not only focus on the Local Government Bills but also the unacceptable conditions at some of the country’s schools. According to him, “I am here to ask the Minister of Education and of course, her boss,Michael Jordan Jersey, the President of this country to fix the school system. We cannot have children returning to school,Wholesale Baltimore Orioles Jerseys, and the schools are not properly fixed; there are not proper classrooms for them…”“I am standing out here because the education system is broken. Democracy is being misrepresented and I am out here as a citizen; I am not here because I have signalled my intention to run for Mayor of Georgetown but it goes beyond just that…This is something I have been doing for years” said Benschop.According to him his action is fuelled by his love for country and the fact that he wants the best for it.Justifying his move to adopt a picketing tactic,Wholesale Golden State Warriors Jerseys, the Social Activist said that he is only continuing a trend that has been embraced by the Government whereby “they feel they have the right to picket and they have the right to coerce their people in the Ministries and the Office of the President to come out and protest…this is not a monopoly that the Government holds.”However although he was not able to coerce any supporters of his own, Benschop insisted that he will continue his solo picketing action indefinitely. According to him he is prepared to continue his picketing exercise everyday alone even “if no one else wants to join me perhaps because they are afraid…” said Benschop as he likened himself to “one man standing against injustice.”He said that he is prepared to follow the President anywhere to continue to highlight his concerns.“I will follow him even if he goes to Haiti or if he goes to Canada. He has to fix the broken education system in Guyana and he has to ensure that we have a proper democracy by the holding of Local Government elections; it is a must!”
发表人:shekplos3v

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发表人邮件:yuguhun22@hotmail.com 发表时间:2017-1-27 12:37:51
    After one week of much discomfort to residents in South Georgetown,Boston Red Sox Clay Buchholz Jersey, the fire at the Le Repentir dumpsite has finally been brought under control.At a press conference held yesterday, Minister of Local Government and Regional Development, Kellawan Lall opined that the situation could have been brought under control earlier,Deron Williams Team USA Jersey, but was allowed to reach to the stage that it had, due to the lack of leadership at the level of City Hall.“I have always maintained that the city had the resources to deal effectively with the situation. The question therefore is why the situation was allowed to happen,Adam Lundqvist Sweden Jersey, much to the discomfort and health risk to residents? I personally believe that there was a great lack of leadership and a certain amount of callousness and insensitivity applied to citizens.A very simple solution was staring the Mayor in his face and yet he ventured into fantasies like bombing of the dumpsite,” Minister Lall said.The Minister noted that City Hall was in possession of all the equipment on the ground, but refused to act and utilize the resources.He explained that the municipality has the capability to prevent such fires and they had the capability to stop it, even when it got out of hand. What was missing, he said, is management of resources and the ‘will’ to get the job done.?“All this talk of not having money, shifting blame to the Central Government and things like bombing are symptomatic of the culture that prevails in the City Hall,” Lall noted.According to the Minister, there is a need to have a permanent monitoring mechanism in place in order to prevent such fires from recurring and to put in place the necessary instruments to deal with such occurrences whenever they arise.He noted that the Ministry is willing to assist the municipality if the need arises.It was explained that all the equipment is still on site in order to monitor the situation over the next few days.As a means of preventing a recurrence of the fire,Jon Casey Jersey, Minister Lall said that he has now decided to allow the ‘pickers’ who frequent the dumpsite to assist City Hall in preventing vagrants and unauthorized persons from entering the dumpsite,Alen Halilovic Jersey, and for there to be an alarm system for the municipality in informing them immediately of a fire at the site.“I personally don’t appreciate this situation where they ((City Hall) sit and allow a situation to get out of hand and do nothing. That is irresponsibility at the highest level, especially when you are putting people at risk,” Lall said.Meanwhile, Minister of Public Works,Matias Fernandez Chile Jersey, Robeson Benn who was also present at the press conference expressed similar sentiments as Minister Lall, as he noted that had the situation been dealt with immediately,Michael Taylor Nationals Jersey, it would not have erupted into the kind of state it was in.“The equipment was there before, and if attention was paid,Wholesale Baltimore Orioles Jerseys, it would have been managed better.What is required as they go forward is that those who are responsible for the proper maintenance and attending of the dump, with respect to fires and other issues, simply do the work that they are supposed to do over the time that they were supposed to do it and that will take care of it,” Minister Benn noted.He explained that in many cases, the workers were willing to get the job done but they were not being properly managed, as according to him, some of the excavator operators refused to work.“That’s the kind of issue that is going on there with the lack of the management of workers at the lower level and providing them with the leadership where it is needed,” Benn said.The Public Works Minister said that he disagreed with the suggestion made by the Mayor, as it relates to placing dynamite at the site with the intention of ‘blowing it up’.“There was a suggestion made by the Mayor that dynamite be placed at the dump and blow it up… I guess by now all of us would have been covered in garbage in South Georgetown given the fact that this was a ring of fire all around the dump… this shows how out of touch with reality some persons at City Hall are with respect to what is going on on the ground.”?Meanwhile, both Ministers commended the hard work done by the firefighters in bringing the situation under control. They noted that the same work could have been done by the City Council workers, if they were properly led and encouraged.The fire at the dumpsite first erupted sometime in early August, and resulted in the City Council deploying all necessary human resources and machinery to mitigate the problem. However, another fire of even greater magnitude engulfed a section of the site recently.City Mayor Hamilton Green had reported that there was a likelihood that the fire could have been caused by a spontaneous combustion coupled with the illegal activities of scavengers.There have since been reports that Government officials are doubtful that combustion was the cause of the fire.
发表人:shekplos3v

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发表人邮件:yuguhun22@hotmail.com 发表时间:2017-1-27 12:33:52
    –? As allegations of maltreatment surface The Ministry of Human services plans to investigate the details surrounding the arrest of three orphaned teenagers, who were living at a children’s home in Corentyne,Chicago Cubs Greg Maddux Jersey, East Berbice.Allegations of maltreatment of children at the orphanage have surfaced as three teenage girls from the home are being held in the lock-ups at the Albion Police Station.Human Services Minister, Jennifer Webster in an invited comment explained that a full investigation will be launched into the reports.Minister Webster says that complaints of such nature regarding the orphanage were never brought to the attention of the Ministry.“I will be writing to the person in charge of the orphanage to let them know that a committee will be sent to conduct a detailed investigation regarding the allegations into this incident.”The girls, 12, 14 and 15-years- old ((names given) were arrested on November 20,Ron Duguay Rangers Jersey, 2013 for “wandering” away from the home.They were placed before the courts and sentenced to be institutionalized at the New Opportunity Corps ((NOC) in Essequibo by Magistrate Ravindra Singh earlier last week. The girls are expected to be deployed to NOC soon.However, residents and concerned citizens have been highly critical of the actions of the law enforcement authorities.Residents at Albion have suggested that constant ill-treatment of the children may have been the reason for the three girls leaving the home.The girls are originally from Skeldon and have been at the home for over four years now. Two of them are sisters. They are orphans and do not have any close relatives.Residents of the area have accused the administration of the Orphanage of misusing the finances and clothing and other resources available to institution.“The lady does sell out all them children thing. Like she ain’t really fit to run that home anymore, because she get old and she put responsibility on her daughter-in-law,” claimed the resident.“There was a time when she grandson and son used to live with all the big girls?as soon as they become mature,Washington Nationals Gio Gonzalez Jersey, they lived with these children them! Let them go and investigate!” the person stated.“Three girls were going to commit suicide and they had to call the police?and these children break down! But they don’t talk??? is ill treatment!”These were some of the assertions made by residents.While Director of Child Care Protection Agency,Deron Williams Team USA Jersey, ((CCPA) Ann Greene declined to comment on the matter involving the three teenagers,Detroit Tigers J. D. Martinez Jersey, she explained that the agency is concentrating on providing more options of alternative care for children.“We are working towards extending our foster care and kinship programme to reduce the number of children in residential institutions and also looking for more community responses for children in need of alternative care and protection.? We see the need for having specialized centers to meet the needs of a number of children in the formal care system needs within a range that includes mental health issues, substance abuse and intellectual deficiencies,” Greene said in a statement issued to this newspaper yesterday.Greene further stated that the practice of children being committed for status offences should be abolished.“It is felt in the child welfare field that status offences should be abolished…- status offences if committed by an adult are not sanctioned….The Childcare and Protection Agency provides care and protection for children with inadequate parental care and also works with parents to assist them to provide better care and supervision of their children.? Parents are also placed before the courts when there are repeated failures in their child care and protection efforts.”However,Chicago Cubs Travis Wood Jersey, Ms Greene pointed out that the reality is many children wandering are beyond parental control and are involved in anti-social activities that are serious breaches of the law and are even parts of criminal gangs.“Sometimes all efforts by social services to correct the behavior or find safe places and adequate care are often times rejected by the juveniles.? Magistrates’ only action to prevent further destruction of youth is to commit to the training institution.”In this regard,Adrian Beltre Rangers Jersey, Greene says that the NOC is a rehabilitation and training centre for young offenders with a number of programmes,Tom Wilson Capitals Jersey, some supported by international organizations that are being executed for the benefits of its students.
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发表人邮件:yuguhun22@hotmail.com 发表时间:2017-1-27 12:31:12
    By Dr Zulfikar BuxAssistant Professor of Emergency MedicineIn the ideal world everybody gets along,Alexander Semin Canadiens Jersey, and there aren’t personalities and cultural differences that makeDr Zulfikar Buxus differ in opinion. Obviously there is no such existence, and it is even more complicated in emergency rooms ((ER) where the environment is high-stress and unpredictable.Emergency physicians cannot anticipate that all encounters will unfold according to the standard expectations for successful patient-physician relations, that is, that privacy and confidentiality will be maintained and patient autonomy exercised.Privacy, autonomy, even assessing and addressing the medical complaint itself are often not the emergency physician’s first priority in managing uncooperative patients. These Physicians are expected to maintain calm and be respectful to every patient. Often however, there are patients or relatives who are aggressive because of anger or an unstable state of mind. These persons can pose a threat to the staff and other patients in the ER and must be kept in check for the safety of all.In most emergency departments, aides or security personnel are available to assist if the patient becomes unruly. Those not involved in the patient’s care ((hospital security personnel or police officers) should be discretely placed,Wholesale Baltimore Orioles Jerseys, so that the patient is aware that they are present or nearby, but they should not intrude on the patient-physician encounter unless they are actively engaged in guarding or controlling the patient.The physician’s first intervention is to assure the patient in a non-threatening way that, regardless of the circumstances, his or her health is the physician’s primary concern. Often physicians must maintain control of their own emotions,Tony Dorsett Jersey, responding to a patient’s anger and even abuse,Chile Jersey, calmly and un-defensively.It is difficult to list what goes on next in sequence. The physician must determine,Enrique Hernandez Dodgers Jersey, almost simultaneously:???? Whether the patient is likely to pose a threat of harm to him or herself ? or to others.??? Whether or not a medical emergency or need exists. Whether the patient is in physical distress. Intoxicated. Psychotic. Attempting to get a prescription for narcotics.???? Whether the patient is competent to accept or refuse treatment. If not, whether someone is present who can speak as the patient’s surrogate.The possible combinations of answers to these questions determine how the encounter proceeds. If a medical need is present and the patient is not combative or hostile and is competent to discuss and consent to or refuse treatment, the encounter resembles a traditional acute medical intervention.If medical need is present and the patient is highly combative or frenzied, with frankly compromised mental status, he or she can be restrained or sedated so that the need can be assessed and treatment can proceed. The physician may ask security personnel or police to detain or control the patient.A patient’s decision on his or her care should make sense relative to his or her values. Refusing surgery because it is frightening, for example,Chicago Cubs Travis Wood Jersey, may be perfectly reasonable, but not consistent with a goal of continued life. Obviously, the need to feel secure about the patient’s competency increases as the risk associated with an intervention or the refusal of an intervention increases. A psychiatric consultation may be needed.In all events,Walter Payton Bears Jersey, seriously injured or ill patients who refuse treatment should be given comfort care rather than turned away because of their refusal. As the distress from the injury or illness increases,St. Louis Cardinals Whitey Herzog Jersey, and with continued encouragement of medical staff, they may change their decisions.Given the likely physical and emotional distress of patients with emergency medical needs, their possible estrangement from routine health maintenance, and the diverse psychosocial and cultural backgrounds and expectations that converge in the emergency department, it’s small wonder that the real life “ER” offers an intense immersion course in managing difficult clinical encounters. Emergency Physicians are therefore trained and expected to be the calm minds in the midst of crises.
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