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Byford Print Business Card Bottle Openers
Byford Print's Credit Card Bottle Openers are made from 1.2mm powder coated steel and printed in full colour and highly durable. These can be printed to both sides and are great promotional items to keep your brand front of mind. They can be individually numbered for Membership cards.
Byford Print, Byford, WA, 6122.
Email: firstname.lastname@example.com
Mobile: 0425 155 514
Byford Print offers a full range of services in the following suburbs: Printing Armadale, Printing Bedfordale, Printing Bibra Lake, Printing Brookdale, Printing Cockburn, Printing Forrestdale, Printing Gosnells, Printing Harrisdale, Printing Haynes, Printing Hilbert, Printing Mount Nasura, Printing Mount Richon, Printing Piara Waters, Printing Seville Grove, Printing Wungong, Printing Byford, Printing Cardup, Printing Darling Downs, Printing Karrakup, Printing Kelmscott, Printing Mundijong, Printing Whitby, Printing Jarrahdale, Printing Albany, Printing Denmark, Printing Esperance, Printing Pemberton, Printing Manjimup, Printing Dwellingup, Printing Margaret River.

subset: commoncrawl


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Login/Create Account
Check Out the new Remax App
Ask About This Home
Walk in to your dream home. All you have to do is move in as this studio is breath taking with every inch remodeled and professionally decorated. Big Walk in Closet and additional closets for storage. Includes high-end stainless steel appliances, sparkling granite countertops and granite floor tile, newly renovated bathroom and more. You have to see it to believe it! Elevator building and association fees include your heat, water & garbage removal. Club House and pool included for fun summer nights.
*This option is for a conforming mortgage. For amounts exceeding $484,350, you may need a jumbo mortgage.


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Property Management Website: Example 1
Construct an eye-catching, dynamic Property Management website using this website template. Make an impact by using GoCentral's features:
- Vibrant, unique images from our enormous Getty library (or upload your own!)
- Streamlined editing that lets you change content anytime, anywhere from any device
- SEO expertise to optimize your site for high Google® rankings
- A mobile site that's easy to navigate on all devices
- Custom domain recommendations
- GoDaddy's award-winning, 24/7 customer support


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Saints Peter and John Church, Auburn; The Rev. Kathlyn Schofield, Rector
St. Paul's Church, Aurora; The Rev. Bryan Bedell, Parish Priest
In our Diocese:
Pray for the youth and leaders at New Beginnings this week
In our Companion Diocese:
(we pray weekly for a parish, their village, department (state), and their priest)
Pray for San Jose, El Congo, The Rev. German Lopez
In The Episcopal Church:
Pray for the Rt. Rev. J. Scott Barker, Bishop of the Diocese of Nebraska
In the Anglican Communion:
Pray for the Episcopal Church in the Philippines


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Suicide warning signs
Suicide warning signs to observe with closed ones
Here are a few other warning signs of suicide:
- Aggressive behavior, changed behavior
- Total withdrawal from family, friends and community
- Too much mood swings
- Reckless and impulsive behavior
- Increased use of drug or alcohol or both
Suicidal behaviors are related to mind and it is a psychiatric emergency. If you observe your loved ones acting differently or behaving strangely then seek help. A person who is thinking about committing suicide can be:
- Giving away all his/her belongings
- Buying weapon, saving pills, too much on drugs and alcohol
- Trying to pay off all debts
- Organizing personal papers, suddenly writing will
- Withdrawal from everyone or visiting every person who he feels close
Author: Sumana Rao | Posted on: October 13, 2019


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- Storage provisioning complexities
- Legacy storage & fixed hardware model
- Difficult data management
- StoneFly Storage Virtualization Software – Storage Concentrator Virtual Machine (SCVM™)
- Quicker & simpler storage provisioning
- Simplified Data Management
- Seamless storage & performance expansion for provisioned storage repositories
- Reduced cost – Better TCOs and ROIs
A hosting company, based in New Jersey, with service offerings such as web hosting, virtual desktops, dedicated remote Windows and Linux servers, and cloud-based data storage to customers worldwide.
Hosting Service Industry | Infrastructure as a Service (IaaS)
The hosting company dealt with a wide range of use-cases for their customers. In order to facilitate different customers, they had to provision different types of storage and compute servers. With legacy infrastructure, this was usually done by setting up dedicated servers or desktops. This process was time consuming, usually very expensive, and it created storage silos that were huge in volume and complex to manage.
Legacy infrastructure made their job and business difficult. If they needed to provision new file storage and sharing server for a new user, they had to setup a dedicated or shared server. Once provisioned, they were unable to use the unused storage space in the server.
If another customer reached out to them to setup a VDI (Virtual Desktop Infrastructure), they had to setup another desktop or a Hyperconverged Infrastructure (HCI) for it.
In other words, they were not fully in control of their storage infrastructure and were struggling with the "fixed hardware model".
"We were managing different servers for different types of customer needs. Even if we had unused space in a server, once it was provisioned we needed a different one for a different type of application. You can imagine this created an expensive and rather large data center; not to mention the data management challenges" – noted Deborah, the data center administrator of the hosting company.
StoneFly SCVM – software-defined, hardware agnostic storage virtualization software. The SCVM simplifies data management for data center owners by facilitating virtual storage provisioning on integrated servers.
With the SCVM virtual storage appliance, users can provision virtual NAS, virtual SAN, and unified virtual NAS, SAN and object storage on on-premises hyperconverged infrastructure, offsite servers, or in the cloud.
Learn more about StoneFly SCVM
Our solutions transformed everyday business for the hosting company. They were able to fully utilize their data center infrastructure and repurpose unused space to provision storage resources for new clients.
"StoneFly really put us back in control of our infrastructure. We were able to provision available storage space the way we needed it and that changed our entire experience and the way we did things" said Deborah.
Unified NAS, SAN & Object Storage in a Server
Instead of setting up dedicated servers for different types of storage, the hosting company was able to provision virtual unified NAS and SAN storage on a single server. This enabled them to fully utilize available storage resources before getting new ones. Therefore the data center footprint was effectively reduced and consequently they experienced better Total Cost of Ownership (TCO) and Return on Investments (ROIs).
Easily Scalable Provisioned Virtual Storage Appliances
Unlike traditional storage infrastructure, the provisioned virtual storage appliances made scalability look easy.
"When we used to get requests for more storage, it was a long process that needed network switches, more hardware and storage drives. Now, we simply expand with a few clicks using the storage capacity we already have. It's simple, it's easy, and it's quick too. Our customers love the experience" said John, the Chief Technology Officer for the hosting company.
Simplified Data Management
Instead of using multiple tools to manage different NAS, SAN and Hyperconverged servers, SCVM enables the hosting company to manage all of their storage resources using a single centralized management interface.


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Trees are critical components of the ecosystem. They make your home landscape great and cool. They offer shade and refresh the air. Trees have a destiny when they mature. They are cut and used for various purposes such as firewood, timber, and posts. If you have mature trees and you need any of these, you can harvest one or few trees. The trees may need to be removed in case they are risky. A risky tree is one that is overhanging other structures.
A tree that is too tall can be considered risky as well. You may also want to remove a tree that is bending. Removal of trees may have to authorize by the local government if it is big. If a tree is small, you may remove it on your own since it does not have risks. However, removal of large trees can pose various risks the tree can fall on other structures and public utilities such as power grid. This makes it necessary to have permitted remove the tree. You will also have to show who will remove the tree. Commercial tree removers are licensed in the state they do this services at this website.
They have the best equipment to remove the tree safely. Some large trees require the use of machinery to remove them. These trees are also hazards and need to be controlled. The expert has ways of controlled the duration to which the tree will fall. This helps to ensure that the tree does not fall on the risky side or at least causes minimal damage if any.
They can help you cut the tree down to small, sizes that are desirable for next tasks. For instance, they can cut it to timber logs in preparation for sawing. In case you wish, they will saw it to the timber sizes and amount that you want. They will cut the branches to timber since the branches can be used for other purposes. If the whole tree is to be made to firewood, they will do exactly that. This can be very handy especially in preparation for the winter. They will help you cut chop the tree to manageable sizes. Know more claims about tree services at http://www.huffingtonpost.com/faisal-hoque/letting-go_b_3267140.html.
After cutting down the tree, the stump also needs to be removed. This matters a lot when the land occupied by the tree stump is to be used for more purposes. They will remove the stump and make the place usable for other purposes.


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Digital TV News: thePlatform
Wicket Labs unveils audience insights platform
Oct 10, 2017 – Wicket Labs has introduced Wicket Scorecard to enable media and entertainment companies to automatically see, measure and predict video customer usage and growth for their direct-to-consumer subscription businesses.
News categories: Wicket Labs, Madrona Venture Group, Marty Roberts, Ian Blaine, Big Data, Digital TV, OTT, USA, Worldwide
Comcast creates Technology Solutions division
Oct 19, 2016 – Comcast Technology Solutions has been unveiled. The division unites three of Comcast's media and technology businesses to marry the quality of broadcast delivery with the flexibility of digital distribution on every screen.
News categories: Comcast Technology Solutions, Time Inc, Matt McConnell, Brandon Fong, Content Distribution, Digital TV, Mobile, USA
thePlatform selected for Australia's 'Stan' SVOD
Mar 31, 2015 – thePlatform has announced that it has been selected by Stan, the joint venture between Nine Entertainment and Fairfax Media, to provide back-end video services for the Australian subscription video-on-demand (SVOD) service.
News categories: thePlatform, Stan, Marty Roberts, Mike Sneesby, Australia, Content Distribution, Digital TV, Mobile, OTT
thePlatform launches Cloud-based Virtual TV Framework for service providers
Sep 26, 2013 – thePlatform has introduced a new Virtual TV Framework to enable cable, satellite and IPTV service providers to replicate their 24 hour, live, linear programming and video on demand (VOD) television services via the cloud.
News categories: thePlatform, Ian Blaine, Cable TV, Content Distribution, Digital TV, IPTV, Satellite, TV Everywhere
Classic Video on Demand vendors risk losing half VOD market by 2018
Jun 4, 2013 – The shift of video consumption to tablets and smartphones is causing operator requirements for video on demand (VOD) systems to change as vendors struggle to keep up with current generation needs, according to ABI Research.
News categories: ABI Research, Content Distribution, Market Research
thePlatform selected by BT as Central Video Logistics System for TV
Mar 14, 2013 – thePlatform has disclosed that its cloud-based video publishing system, mpx, is serving as the central logistics system for BT's newest IP-based TV services in the UK, including BT Vision and YouView from BT.
News categories: thePlatform, BT plc, Content Distribution, IPTV, OTT, UK
Liberty Global Launches Horizon TV
Sep 7, 2012 – Liberty Global (NASDAQ: LBTYA, LBTYB and LBTYK) has announced the launch of Horizon TV, a new family of media products that allow customers to view and share all of their favorite content across the TV, computer, tablet and smartphone.
News categories: Liberty Global, Cable TV, Digital TV, Germany, Ireland, Middleware, Netherlands, OTT, Set Top Box, Smart Home, Smartphone, Switzerland, Tablet, TV Everywhere
Cisco-NDS and Google-Motorola Acquisitions Upend TV Middleware Market
Jul 10, 2012 – The TV middleware market, long led by Nagra and NDS worldwide and Motorola and Cisco in North America, is in a state of upheaval as Cisco's bid for NDS waits to close while Google has yet to give a clear direction for its Motorola business unit.
News categories: ABI Research, Digital TV, Market Research, Middleware, Set Top Box
Hybrid Web-to-TV Set Top Boxes Enable Operators and Broadcasters for Internet Video Battleground
Sep 29, 2010 – With an Internet Protocol (IP) link coming in to nearly every possible consumer electronics device with a screen, hybrid Web-to-TV set top boxes (STB) will be vital tools that enable broadcasters and operators to compete, says In-Stat.
News categories: In-Stat, Cable TV, Digital TV, IPTV, Market Research, OTT, Satellite, Set Top Box, Terrestrial
Latest News
- Tulix creates streaming platform for launch of Vidgo content
- 605 earns SOC 3 security certification
- Ampersand launches platform for audience-based TV advertising
- Comcast cable video subscribers down 149,000 in 4Q 2019
- 'Swisscom TV X' combines Netflix and TV content
- Netflix releases fourth-quarter 2019 results
- U.S. weekly time watching Netflix and Hulu up 20 minutes in 2019
- Allegro DVT unveils VVC compliance test bitstreams
- Synamedia partners with USSI Global for the U.S. market
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- Syncbak to debut simplified OTT syndication and monetization tools at NATPE 2020
- No growth expected for MENA pay TV revenues
- Indian communication satellite GSAT-30 launched successfully
- NBCUniversal unveils Peacock freemium streaming service


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- $89,900 price
- s1234779 mls id
Former legal office with a 2-bedroom apartment on second floor currently rented out to professional. Property being sold "AS IS". Law Office entrance (with lockbox) is on the E Albany St. side. Apartment entrance is on E 10th St. side. Tenant requires 24 hr notice for showings pf the apartment.
- Site Link
- Style Other Style
Related Listings
17 Pictures
Nice Ranch home on quiet street. WALK TO LAKE ONTARIO. CLOSE TO SHOPPING & SCHOOL & PARK. 3 Bedroom with 1 full bath modern Kitchen and dining area. Full basement great potential for family room. Huge yard to enjoy for all your fun times
MLS ID s1141150
3 beds, 1 baths, $82,900
25 Pictures
Welcoming front porch and entrance into this one floor living charmer!! Every bit of the cozy atmosphere has been tastefully remodeled so that the new owner can come in relax and enjoy!! Spacious open floor living from living room through kitchen. The master is big enough to accommodate all your...
MLS ID s1234965
2 beds, 1 baths, $84,900
3 Pictures
Great location for this 2 family Ranch style home. Perfect property for living in one apt. and renting out other to help pay your expenses. Perfect for investment property also. Long term tenant in back apt. Front apt. tenant going on 2 yrs. Both 2 Bedroom 1 Bath apt. in good condition.
MLS ID s1232530
4 beds, $85,000
31 Pictures
This two-story home has such curb appeal. It has a rocking chair front porch and large fenced in yard that offers relaxation on the patio for the adults and room to roam for the kids and pets. Double lot offered here, (66 x 100) with a detached 1-car garage. The owners have made the yard area extra...
MLS ID s1214661
4 beds, 1 baths, $87,000
7 Pictures
Large 5 bedroom home, currently rented until January 2020. Nice convenient location to downtown and SUNY Oswego. There is a shared driveway with a large parking area in back of the home. The home has 2 bedrooms and full bath on the first level and 3 bedroom and full bath on second. Two living room...
MLS ID s1217619
144 W Bridge Street Oswego, NY
5 beds, 2 baths, $89,900
2 Pictures
Large 4 bed, 1 bath city home on 44x100 lot with off street parking. House features original hard wood floors, living room, family room, den, huge eat in kitchen/dining room with 1st floor laundry. Two (front & back)staircases take you upstairs to the four large bedrooms and full bath. Lots of...
4 beds, 1 baths, 2,255 sqft, $89,900
Courtesy of: CENTURY 21 Galloway Realty
Office Phone: +13153422111
Listing Agent: Ed Fayette
Updated: 18th January, 2020 2:43 AM.
269-271 E 10th Street Oswego, NY


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It is more fun to find leisure in serving while using your time to rest away from the hustle and bustle of life. choosing what's wise to do with your leisure time can be a tedious exercise and at times you want something captivating that will harness your energy to productive resting that will be both beneficial to you and to someone else that can be reached by your little acts of kindness.
At Elohim tours, we have understood touring for years and its with this kind of a perception that we have come up with a tailor made venture where we can offer you a luxury of touring and a platform for giving back purposefully.
we do believe that in everyone's heart is the element of humanity where everyone gets to a place of giving a helping hand and the need to bridge the gap of imbalance.
We have a programme that we believe will cater for your leisure and heart of hearts. in this programme, we intend to show you all what there is in bird watching, wildlife watching, mountain climbing and aquatic /marine leisure and still keep an eye of the hearts or hearts.
In the heart of hearts segment, we intend to show you the different cultural diversities that Kenya has and how well the rich African culture is extended, and from which, the core of heart of hearts is derived. depending on your need to reach a heart, we would like to present to you the different areas where the heart of hearts would like to reach. and that's the element of reaching the less fortunate in our midst.
we intend to reach the children who are the future of our motherland, reaching out and investing in children can be a very rewarding venture for the heart of hearts segment. we believe that it's a collective responsibility to bring up a whole child who can be productive in his adulthood to bridge the gaps that are present. and so we intend to reach the homeless and the orphans, the hungry and the sick and all that may need their hearts to be reached.
Evaluation results
Kenya has very many children homes that reach different needs to the under privileged children in the society, however, its paramount to note that there are so many gaps that are left behind due to the imbalance of resources and the work force involved in the course of brightening the children's life, and this leaves some specific group of children unattended. this has been attributed to insufficient funds to bring on board the facilities and the equipments that can support the different disabilities with our children and the community at large.
its also important to note that main reason for this particular venture would be to bridge the gaps that are present with the availability of resources available to us in any given period of cooperate responsibility to the society. however we would like to also address the matter extensively by reason of partnership from willing donors and friends of Elohim tours.
having noted with a deep interest the kind of management that is employed to run this children homes, we have realized that due to the unskilled labour that is brought on board, abuse of funds and or misappropriation of funds have been one of the main reasons why the children homes in our community are not effectively served.
with the reflection above, Elohim tours through the technical team have embarked on evaluation of the projects at hand with a possible view of other projects that may be addressed to effectively reach the community at whichever the capacity. here are some of the strategies that we feel can be able to work out bridging of the gaps effectively:
- visiting the individual homes and physically going through their list of urgent needs to see the possibility of attending to the needs without giving financial support.
- create a module by which we can enhance the capacity of the homes by taking their staff through a training that will help them actualize management of the available resources.
- come up with set points where we could help them cut on the cost of spending by helping the homes have small gardens from where they could grow vegetables like onions, coriander, kales and cabbages, tomatoes of some fruits that don't require to much attention to grow like paw paws, avocadoes or tress fruits to enable them cut the cost of expenditure.
- have our own children home from where every available resource can be utilized to reach to the wider community through which we intend to reach the unreached in this segment of heart of hearts.
Touring strategy
At Elohim tours,we are known for exceptional touring to our clients, we intend to have a system by which a tourist can enjoy the nature and finally at our own cost take them around the community from where they can see what their participation with Elohim tours means. through the heart of hearts segments, our tourists will not just tour, but they will tour with a purpose that will leave a mark in the scent of time.


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|Han, Z; Sani, B; Mrozik, W; Obst, M; Beckingham, B; Karapanagioti, HK; Werner, D: Magnetite impregnation effects on the sorbent properties of activated carbons and biochars, Water Research, 70, 394-403 (2015), online: 17.12.2014, doi:10.1016/j.watres.2014.12.016 [Link]
This paper discusses the sorbent properties of magnetic activated carbons and biochars produced by wet impregnation with iron oxides. The sorbents had magnetic susceptibil- ities consistent with theoretical predictions for carbon-magnetite composites. The high BET surface areas of the activated carbons were preserved in the synthesis, and enhanced for one low surface area biochar by dissolving carbonates. Magnetization decreased the point of zero charge. Organic compound sorption correlated strongly with BET surface areas for the pristine and magnetized materials, while metal cation sorption did not show such a correlation. Strong sorption of the hydrophobic organic contaminant phenanthrene to the activated carbon or biochar surfaces was maintained following magnetite impreg- nation, while phenol sorption was diminished, probably due to enhanced carbon oxidation. Copper, zinc and lead sorption to the activated carbons and biochars was unchanged or slightly enhanced by the magnetization, and iron oxides also contributed to the composite metal sorption capacity. While a magnetic biochar with 219 ± 3.7 m2/g surface area nearly reached the very strong organic pollutant binding capacity of the two magnetic activated carbons, a magnetic biochar with 68 ± 2.8 m2/g surface area was the best metal sorbent. Magnetic biochars thus hold promise as more sustainable alternatives to coal-derived magnetic activated carbons.
|Do. 30.01.2020
BayCEER Mitgliederversammlung
|Geographisches Kolloquium:
|Di. 28.01.2020
Adivasis in the Anthropocene - What an Environmental History of Eastern India can tell us about the global agricultural and food crisis
|Naturwissenschaftliche Gesellschaft Bayreuth:
|Mo. 27.01.2020
Das Insekten- und Vogelsterben vor dem Hintergrund der Natur- und Kulturlandschaftsgeschichte – und wie wir es überwinden können
|Ökologisch-Botanischer Garten:
|So. 02.02.2020
Mehr als Sonne und Strand: Pflanzen der Karibik
|SFB Mikroplastik:
|Mo. 27.01.2020
Wissenschaftskommunikation: Nachhaltigkeit und Mikroplastik
Why Science Communication?
Stoichiometric controls of C and N cycling
Flying halfway across the globe to dig in the dirt – a research stay in Bloomington, USA
EGU – interesting research and free coffee


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From Med's biggest nesting ground, turtles swim to uncertain future
- 3 months ago
- 436
- Science
Each parent knows the dissatisfaction of reacting to an infant's cries, thinking about whether it is ravenous, wet, tired, needing an embrace,
Why Online Therapy Has Been Making Waves
Online therapy has changed the game, and there are a few reasons for this. Here,
The account of how present day people came to be is as yet muddled and cloudy, however one thing's turned out to be clear in the course of the
On the off chance that you need to structure something right, seek nature for motivation – that is the message from researchers who have
Rubbish removal might seem like a relatively simple task. You just bung everything into a black bin bag with general waste, and then wait for your
Medical science has improved astronomically in recent years. Ailments and injuries which would have deemed incurable in the not too distant past
Environment has always been an important topic for every scientist. Humans can't escape the environment and therefore, for centuries in human
Can you learn while you sleep? The answer is yes, apparently. In a research study published recently, French researchers report that the sleeping
There are many prosperous chemical companies in Canada that offer high-end chemical solutions to their clients over the generations. Starting from


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We were Lucky
When I met Lucky, I waved a broom at him to scare him off. When he dropped by again the next day for a snack (kittens need a lot of snacks) from my other cat's dish I sprayed him with water from my hose. I didn't want another cat, even one with such huge fireman's boots paws.
He was undeterred by my efforts to keep him out of our yard, and came right up to my lap one day on the front porch rocker. Yep, we've got another cat, now. No, I don't know what we're going to do with four. Yep, I've gone 'round the bend. I'm officially dotty, I told Susie when she drove up on the new Madonna and child on the front porch.
He knew his place among the existing cats. He knew to stay clear of Sam, the outdoor-only short haired gray. We had in-and-outdoor cats, Cheech and Chong, the Burmese brothers. Lucky also stepped lightly around the old bachelors who were set in their ways. They looked down their noses at him at first, but only hissed a few warnings at him. They knew the Two Legged that lived with them already had another cat, a parrot and a dog. What harm could a kitten do?
I named him Lucky, because I'd heard of a man where I worked with that name and liked it. What would your life be like if your name were Lucky? I gave it a try on the big-pawed kitten. Besides, he was lucky to live with us. We had a great life to offer a cat, lots of food and water, trees, grass, tons of pillows and sunny windows to nap beside. Hugs and love. The necessary trip to the vet to get neutered and all his shots. Well, no one could be all luck. But, overall, Lucky adapted well to the new home he had selected.
Lucky wasn't a fighter like our gray cat, Sam, who was rescued from a traffic island, howling in pitiful protest. He was in an awful mood after that, understandably. Except for sleeping and eating (barely) he spent most of his life sulking and ready to fight with the world. Lucky for us, the new cat was more like Cheech and Chong, who were also rescues. They came from a vet's office, and their lives as kittens were much safer, apparently, as their names suggest, very mellow and happy.
His breed was Maine Coon, and his personality was true to his kind of cat: gentle, loving and easy-going. He was still a kitten, though, and Cheech accommodated him with practice wrestling matches that sometimes resulted in fur flying. Lucky didn't keep grudges over being whipped by Cheech, who had tons more years of practice wrestling with his brother Chong, not to mention sheer bulk.
Here was a true people cat. Lucky always stayed close to home. When we were there, he sat or slept right beside where ever we were. I could see he had been careful in who he chose to live with. I suspected he had been born nearby at a family's two doors behind us whose children had helped raise him to be fond of Two Legged folks like us.
When a woman doesn't have children of her own, she has the extra time and money to spend, some of it at the veterinarian's office, or the grocery store for pet food. Even so, her hugs, however romantically fulfilled by adults, still require a wee thing to squeeze and connect with. Lucky was a handful and grew to 14 pounds, but was always glad to have a hug and never minded being treated like a baby doll, learning to make the sign of the cross or being hung upside down by his big paws to show off the curly blond fur on his formidable belly.
Lucky lived indoors, and slept under the bed for many years, and later in a basket in the pantry. In the summers he slept in the screen porch. A true Maine Coon, he sat in the middle of any group of family, friends or artists working at the house. When the house was full of people, and doors were likely to be left ajar, Lucky would slip outside, preferring a wander to visiting, but he would be back in an hour or so, leading me to his food dish, which he knew I would magically fill for him.
A very large short-hair yellow tom stray lived in the neighborhood, sleeping close to the houses, but generally living wild in the hills. He caught Lucky and showed him who was bigger, but there were no injuries requiring doctor visits, and I'm not sure Lucky even minded his encounters with the yellow tom. There's something a bit wild about all cats, if you are honest about it, even with a gentle old bachelor like Lucky had become after thirteen years with our family.
Lucky watched television with us, never begged at us for food (he had his own place to eat, thank you) and was always at the door to say hello, follow me I have this empty dish to show you.
He was a load to pick up and hug every day, but a mom has to do her duty, doesn't she?
Lucky forgave us for leaving him accidentally locked in a bedroom without food or water for five days while we attended a niece's wedding in California, for over-zealously thinning out his tail fur, again by accident, and in his elder years, when we should have been more respectful, for making him perform his 'dog trick' in front of visitors: "Come, Lucky" the Two Legged stands holding cat treat. Lucky glances up from grooming to see the green teeth-cleaning treat the Two Legged pays five dollars for at the pet store. Lucky trots over to hear her hiss out "sssit!" "sssit, Lucky!" while raising the pet treat across his nose and up to his ears. What the...OK, I'll follow the treat with my eyes, therefore down goes my rump. Why do you insist on hissing "sssit?" Lucky wonders as he takes the treat delicately between his two incisors and crunches down.
The weather looked to be good that night after an unending winter, so after a night of watching TV with us, we put his basket in the screened in porch for the night. The wind picked up in the middle of the night and was so strong it turned over a cot. In the morning I went to check in on him, but he had escaped through an opening in the screening the wind had blown open.
It's been several days of looking for him, waiting for him and feeling someone missing from my heart. A neighbor says her four cats, and the yellow tom are now all missing. We think the coyotes, who have come up from the valley looking for food with the drought this year must have found them.
Human beings are great, but they're not the heavy bundle of paws, fur and whiskers curled up on your lap that was Lucky.


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January 23, Cynthia Hartung's recently published article recommends more consistently and systematically considering sex and gender in all aspects of psychopathology research. Hartung, an associate professor and director of the Psychology Clinic in the University of Wyoming's Department of Psychology, co-wrote the article with Elizabeth Lefler, an associate professor of psychology at the University of Northern Iowa. The article was released recently in Psychological Bulletin.
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Here's how to inoculate ourselves against negative ones. Verified by Psychology Today. The How and Why of Sex Differences. Listen to this post, or right-click to download mp3. Is it a sex difference or a gender difference? According to the Publication Manual of the American Psychological Association, " Gender is cultural and is the term to use when referring to women and men as social groups. Sex is biological; use it when the biological distinction is predominant.
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The Giants loss to Dallas has dropped then to only a 1% chance of winning the division according to playoffstatus.com. Their chance of making a wildcard remained unchanged at virtually nil. The Giants played a tough game and hung in there against a good team. Like the Patriot game the final score is not indicative of how close the game was. Daniel Jones again shows his toughness and competitive nature. His fumble on the scamper was due to him knowing where the first down marker was and doing all he could to make it. I like Will Hernandez sticking up for his quarterback. The one handed catch by Golden Tate by the goal line was up there with the Beckham catch. Barkley flashed his talent on that 65 yard run on a screen pass. Unfortunately his three game career streak of 100+ yards from scrimmage versus the Cowboys came to a end. Barkley had only 95 yards from scrimmage on Monday night.
What a beautiful sight 😍#GiantsPride | #DALvsNYG pic.twitter.com/ZH9vJVYmds
— New York Giants (@Giants) November 5, 2019
The Giants are now 2-7 and fans are clamoring for the coach's head. Shurmur can turn this around and salvage the season. If the Giants get to 6-10 they would match the season record for the last two coaches that started a first round quarterback. Both Tom Coughlin starting Eli Manning and Ray Perkins starting Phil Simms went 6-10 those years. Both kept their jobs for the next season. Coughlin went on to help lead two Giant teams to Super Bowl victories.
Looking at the schedule there are three games the Giants should win and an additional one that could also provide a win.
The Giants have yet to play Jets, Bears, Packers, Eagles (twice), Dolphins, and Redskins. The four best chances of a win based on team records would be Jets, Bears, Dolphins and Redskins. Here is a look at some various statistics that put those four teams with their league rank. The Giants come in at a better rank than all four of those teams for these statistics.
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Yards Per Offensive Play
Third down conversion Percentage
Passing Yards Margin
The Giants have to cut down the turnovers and shore up the defense. Defensively the Giants come in poorly on the statistic lists.
Opponent Touchdowns
Opponent Passer Rating
Opponent Passing Yards
Opponent 3rd Down Conversion
Turnover Margin
There is still a lot of football left to play. It is too soon to be calling for the coach's job. If the Giants can find four more wins and get to 6-10 that would be an improvement from last season and with a rookie quarterback. Daniel Jones appears to be playing well with some rookie growing pains. I believe a lot of his turnover problems are due to his competitive spirit and trying to make a play when there may be none to be had. The solution is to find a fine balance and not to clamp down on that aggressive play style. Shurmur has a history with helping develop quarterbacks. If he can get the Giants to 6-10 they should keep him for the continuity and guidance he can provide to Daniel Jones.
Bring On Gang Green in a must-win game for both teams. The game is more than just Metropolitan Bragging Rights. The Giants and Jets are now tied together as the Giants passed on Sam Darnold in the draft to take Daniel Jones the following year. The development of these quarterbacks will be followed closely by Jets and Giant fans. This is one of the few remaining games in which the Giants will be favored. It is a do-able win to get to a a 6-10 record and justification of Pat Shurmur remaining for another season.


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Long Pages in this Wiki
Long pages are pages with a high amount of content. This listing is sorted by longest page. Some long pages may need to be broken into multiple smaller pages, though not all.
Enemies (~9,436 characters) C-5 Piece at Last (~9,174 characters) D-2 Hit Rock Bottom (~8,604 characters) B-4 Pool Party (~8,532 characters) D-1 Cold Case (~8,026 characters) E-2 Double Trouble (~7,960 characters) E-3 A Train to Catch (~7,904 characters) B-3 Graveyard Shift (~7,888 characters) E-1 Front-Door Key (~7,694 characters) B-2 The Pinwheel Gate (~7,687 characters) C-Boss Showtime (~7,566 characters) A-2 Gear Up (~7,455 characters) C-3 Roundhouse Brawl (~7,285 characters) C-2 Underground Expedition (~7,130 characters) Treacherous Mansion Gems (~6,574 characters) B-1 A Job for a Plumber (~6,510 characters) A-1 Poltergust 5000 (~6,407 characters) Concept Art (~6,357 characters) D-3 Across the Chasm (~6,282 characters) C-1 A Timely Entrance (~6,172 characters) A-3 Quiet Please (~6,023 characters) A-4 Visual Tricks (~5,827 characters) A-5 Sticky Situation (~5,633 characters) A-Boss Confront the Source (~5,467 characters) Haunted Towers Gems (~5,406 characters) Secret Mine Gems (~5,324 characters) C-4 Play Catch (~4,925 characters) B-Boss Tree Topping (~4,855 characters) Gloomy Manor Gems (~4,625 characters) Old Clockworks Gems (~4,411 characters) E-5 Paranormal Chaos (~4,322 characters) Final Boss - A Nightmare to Remember (~3,865 characters) B-5 Doggone Key (~3,855 characters) E-4 Ambush Maneuver (~3,467 characters) D-Boss Chilly Ride (~3,380 characters) E-Boss Stop the Knightmare (~3,132 characters) Allies (~3,084 characters) Walkthrough (~2,532 characters) Secret Doors (~2,462 characters) King Boo's Illusion (~2,351 characters) A-Bonus Gradual Infiltration (~2,330 characters) B-Bonus Hostile Intrusion (~2,173 characters) C-Bonus Outlandish Interruption (~2,149 characters) 3DS Cheats (~2,136 characters) Main Page (~2,052 characters) E-Bonus Terrifying Invasion (~1,942 characters) Old Clockworks Boos (~1,891 characters) Gloomy Manor Boos (~1,762 characters) Treacherous Mansion Boos (~1,706 characters) Haunted Towers Boos (~1,697 characters)
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Concerns over crime and public safety were a common theme at Let's Talk Red Deer, says Mayor Tara Veer.
Red Deerians shared their concerns, ideas and more with city council and staff during the annual event at Parkland Mall Saturday.
"I think there is a growing recognition of the drug trade and trafficking problem that Red Deer and region are faced with and how that's fuelling property and persons crime in Red Deer," said Veer.
Veer said there is concern over the social challenges the community is facing, including addiction and the need for more shelter space for the homeless.
But "a lot of citizens are … saying when they call 911 that they are getting responsiveness, so I think that's a step in the right direction," she said, adding there was a positive reception to the RCMP's downtown patrol officers.
Other discussions with residents at Let's Talk focused on snow and ice control, taxation, the economy and the implementation of a cart system in the city.
Veer said Red Deer will need to move forward on its strategic direction, which includes creating a safe community, with a revitalized tourism industry and strong local economy.
"The past year a lot of the issues we dealt were issues that came our way from the provincial and federal governments and it's been challenging for us … to move forward on city council's strategy direction.
"The key strategic areas of transformation for our community that this council has identified, we need to move very quickly on implementing them. Those are the areas that are responding to what we're hearing from citizens. I think our citizens on the whole feel heard and what they need to see is action on some of those key areas," she said.
The Let's Talk event gives residents a chance to identify services in need of improvement, said Veer.
"City council and administration have committed to having open, transparent government. For us to do that we have to be in contact, regular contact and informal contact with the citizens we serve," said Veer.
It's important to continue having conversations with residents throughout the year and not just during the Let's Talk event, she added.
"There are a lot of ways citizens can share their concerns with us," said Veer. "We hear feedback from … formal forums like Let's Talk, we receive emails, we receive letters, we receive engagement on social media, we have anecdotal conversations at the grocery store and community events."
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Haiti Update
Thank you all for your thoughts, prayers and concerns for our work and for the country of Haiti. Things have been tense over the past several weeks with violence and protests aimed at overthrowing a corrupt government. Police are in a particularly precarious situation as many of them are in agreement with the aims of the protesters yet are being asked to maintain law and order. The upheaval has disrupted life at every level. People have not been able to move freely about the city, markets, banks and petrol stations were closed for over a week and since have only been open intermittently. People are unable to access basic necessities. Fear and lawlessness is becoming the norm. This has had a negative impact on hospital census and income.
In this gutsy 6 minute episode of Vice https://www.youtube.com/watch?v=3eNzEGEsxr0 one can get a quick overview of the situation which exposes a lot of unanswered questions. The unfinished bridge scene at 2 minutes is 1/2km from Hôpital Adventiste and marks the home stretch of my morning running route.
Additional fury was created when some heavily armed US mercenaries were caught red handed by the Haitian police in an unmarked vehicle that belonged to top Haitian government officials. These ex-navy seal snipers who specialize in top level security jobs had barely made it out of the airport on their ill-fated mission when they were apprehended by the Haitian traffic police and then thrown into the local slammer. Some unknown negotiations between the US embassy and the Haitian government allowed them to return to PAP airport in shackles. American Airlines required them to be unshackled prior to boarding and then they were set free when they arrived at MIA. News of the botched operation has gone viral and basically ruined any future clandestine security opportunities for these questionable characters. In the meantime the president denies having anything to do with them.
Dr. Alexis was unable to come to the hospital for over a week due to all the roadblocks and manifestations. Most of the employees live in the local neighborhood and were able to make it to work, although for several days we did not even have a single patient make it to clinic or surgery. I held down the ortho service during this time – which was not difficult. We took advantage of the situation by doing a lot of spring cleaning and organization of materials in the OR. Food and fuel stocks ran low, but thankfully never completely ran dry.
As for danger – there have not been any direct attacks aimed at us or unnerving events at our hospital or the immediately adjacent area. We do often hear gunfire and yelling down the street and off in the distance. There is no question about the dangers and dramatic affects this situation has had on everyone. Thankfully the loss of life has been rather limited. Nonetheless, with level 4 alerts from the state department, missionaries are being evacuated and all non-essential embassy employees are being sent home. I am not sure I understand the logic of all that, as missionaries are needed more than ever, and it may not be that much more dangerous than the all the of the subtle influences of the United States.
On one particular day we had to take to the airport in the heat of the riots. This occurred the morning after an apathetic speech from the president who will not step down. One of our patients asked if there was any way we could take him to Delmas in the ambulance and since Jere was going to the airport that day I arranged for the patient to go along. Patrick and Michel wanted me to come and bring an oxygen bottle and box of medical supplies so we looked official. Without that I don't think we would have made it. We almost took our patient back to the hospital just so we could make it back ourselves. We had to navigate multiple road blocks and at one point this guy in a red shirt whose smile was almost as big as his muscles started running 50 feet in front of us clearing the way and negotiating passage with the barricade ring leaders. Some were quite stern and were armed. They looked inside the ambulance very carefully to make sure it was really functioning as an ambulance. Fortunately it was… We had to navigate a lot of smoke and fire leaving a burned rubber smell on our clothes. Once the road cleared a bit the guy in the red shirt and his buddy held on to the outside of the vehicle until they were chastised by some police officers. We had to let them go, but then after we let Jere off at the airport we went back and found the them and proceeded to Delmas to drop off the patient. Then Patrick had another prayer which the escorts appreciated. We gave each of them 500 gourdes ($7) and took down their phone number for future reference.
In any case maybe not more dangerous than navigating your way by all the shopping malls and fast food joints on a trip from Loma Linda to LAX!
The past several days I have been in the US on a previously planned trip. Dr. Alexis has been able to make it to work on most days and has taken care of several gunshot wounds. He said one of the days demonstrators were pouring oil all over the streets as he drove to the hospital from his home near Petionville. In Martisant (corridor between hospital and center of town) there were two citizens killed in one day and on another day a police officer was shot and killed by the bad guys.
For those of you planning trips… predicting the situation is equally as difficult as predicting tropical storms. Forceful storms come and go rapidly as burning tires in the streets. I do imagine that until a major change in political power occurs that the situation will remain quite volatile.
Scott Nelson, MD
February 7, 1986 was the day that dictator "baby doc" Duvalier was overthrown in Haiti. To mark this occasion 33 years later and call for the resignation of Haiti's current president the Haitian people have come out in force. Inflation continues to rise out of control (the gourde is now 82 up from 65 this time last year) and corruption plagues the government who has not been able to satisfactorily account for US$3 billion in the Petrocaribe deal. A call to action was made last Thursday where thousands of people protested on the streets of Port au Prince.
This paralyzed all transportation and most businesses. Our patient census is very low and patients are not showing up to clinic as there is no public transportation and it is impossible to safely travel even relatively short distances. On Friday there was a reticent return to normalcy. And Saturday, things seemed to start out relatively normal and then at midday, chaos erupted on the streets of Carrefour with fiery roadblocks and a large mob of angry citizens making their way towards central Port au Prince. Our hospital is located near the main road connecting the entire southern part of Haiti with Port au Prince. This thoroughfare is a favored area for disrupting commerce by creating roadblocks. Tension continues to mount. In spite of all the disruption PAP airport has remained open. This morning we had to make a trip to the airport. We went in the ambulance and I wore hospital scrubs and my badge. Most of the demonstrators kindly let us through, but on the way home at 7 am many more roadblocks had been created. These are made from any combination of rocks, tires, branches, furniture, trash, overturned cars and fire.
In spite of burning tires and the sound of gunshots in the distance no one should worry much about our personal safety or discomfort. Many people cannot get food and fuel because of the disruption. Delimart has been closed and barred up most of the time since Thursday with the Haitian militia protecting it. For those of you not familiar, Delimart is our local food source outside of the fresh food we buy from street vendors. The owner of the Delimart chain is thought to be a supporter of the president and thus it is particularly prone to looting and mass destruction unless proper measures are taken. If the market does not open up again soon I might be eating canned garbanzo beans for breakfast! But I doubt I will suffer any serious hunger. All petrol stations are still closed and motorcyclists are being stopped by gangsters to make mandatory donations of gasoline to fuel their fires. Our diesel reserves for running the hospital generator are down to the last day. (city power only arrives at night for a few hours) The maintenance crew was able to rally up a 55 gallon drum of diesel yesterday to keep things going at least until now. We have powered down air conditioners and are only running essential systems.
In spite of turmoil great things are also happening. Rozanie is a 57 year old lady who had a tumor removed from her right knee in 2011 at one of the best hospitals in Port au Prince. This was a giant cell tumor, this is benign but is known for its tendency to recurr. When she presented to me several weeks ago the tumor had recurred and totally destroyed her knee creating a large visible mass. I texted my friend Lee Zuckerman who is an ortho tumor specialist at LLU to ask if he thought amputation or fusion would be the best option. Of course he recommended a $25,000 total knee mega prosthesis! But unlike other first world advice that I sometimes get, he said he would get Onkos Surgical to donate the prosthesis and come down to do the case. That same day a couple hours later I met Wilthur a 2 year old who had a tumor (lipofibromatosis) removed from his forearm and it was now bigger than ever. I sent a photo to Dr. Z and we scheduled both cases for February 6. He flew in from Los Angeles the day before and left the day after. Both cases came quite close to cancelling after he arrived… which would have been tragic. Rozanie was anemic. We had ordered blood for her, but the situation with blood here is a long and complicated story. Her blood type is O Neg which is present in only 7% of the population. In spite of trying to get blood during the 2 weeks prior, the Red Cross was unable to accommodate. We did the calculations and promised ourselves not lose one drop over 600cc of blood, which gave us a small margin for safety. The case went perfect and she ended up only losing 300cc.
Dr. Zuckerman and Charlie the Onkos rep were able to catch the first flight out Thursday morning before the "manifestations" went into full effect. Subsequently Rozanie has recovered beautifully and is getting some extra rehab while waiting for the street scene to calm down.
Scott Nelson, MD
City of Sun
Just 2 months ago Marni and I arrived in Port au Prince. This time it was with one way tickets. This is both literal and figurative. It is not that we won't be going back to the United States, in fact some voyages are already planned, but we now live in Haiti. We don't have a home in California – it is rented out. Trips will now originate from PAP not LAX.
Living in Haiti is different than visiting. We won't be going "home" in a week or two. The differences of another culture have to be accepted and embraced. Two more languages have to be learned. And administrative issues at the hospital cannot be ignored. I keep reminding myself that there are benefits of doing hard stuff. This is hard stuff. But even though it is hard, I still have it better than most people living in this city. To some it may seem a life of hardship and sacrifice but it really is not. Don't feel sorry for us. Although the challenges are overwhelming, each one of these challenges presents an opportunity. A lot more on that in upcoming posts… But I can summarize by saying I am happy to be here, working with wonderful people, attempting to make a difference for our patients, our hospital and the country of Haiti??.
Marni and I have now settled in to our 300 square foot cottage. That did not really take long. Basically it consisted of unpacking a couple of suitcases and putting sheets on the bed. Our place is about 100 feet from the door of the emergency room. Living so close has its pluses and minuses but for now they are mostly pluses. Commuting time is minimal, we have 24 hour water and electricity, there is security and we have a relatively large garden area around our house. There are several people that are living in small buildings within the same area.
Amongst other cases this week we took care of Michelot an 8 year old boy from Cite de Soleil (city of sun) one of the most impoverished slums in the western hemisphere. Appropriately named for the tropical sun that beats down on those toiling in the streets where all vegetation and signs of nature have been completely eradicated. Life is not easy especially when injuries or illness occur. Michelot developed a fever with pain and swelling in his right thigh earlier this year. He was seen at a local hospital where a very small incision was made to drain some pus from the thigh. The infection was seeded in his femur and progressed to the point where the bone integrity was compromised and fractured. He was placed in a cast which ended at the site of the fracture only making the situation worse. When it did not heal he was told he would probably need the cast for a couple more years. That was when someone found him and brought him to Hôpital Adventiste.
Osteomyelitis or bone infection is an amazing process when nature is allowed to run its course. This is a process rarely witnessed in developed countries where the first signs of infection are aggressively treated in order to avoid further destruction. In Michelot's case the shaft was devascularized by the infection and walled off (sequestrum) and then new bone started growing around it (involucrum). The involucrum was not yet fully mature and a fracture had occurred preventing him from being able to walk. We were able to remove the sequestrum and stabilize the bone. At this point nature can resume its course and hopefully the newly growing bone will consolidate and become strong.
Early light is just starting to welcome in another day as I sit in the peace of the morning under the mango tree in front of our place. A few chickens and their babies are cackling as they are out here scouring the ground for insects. Yesterday Marni asked Jacques, the gardener to capture the rooster that roosted in the tree above our place and started cock-a-doodle-dooing at 4am every day, so the morning is a bit more peaceful than usual.
Scott Nelson, MD
12 Janvier
This is one of those dates that reminds me of where I was at 4:53pm on this same afternoon in 2010. People in America and around the world remember with clarity where we were on the morning of 9-11-2001 when 2996 people lost their lives. Today the Haitians remember every terrifying detail of this same afternoon 9 years ago when more than 200,000 people lost their lives. Special mention was made at our church service today in Carrefour about this event. Praise was given to God for bringing the people through this event and blessing them over the past 9 years, knowing that He has special plans for each and every one of us. I was not here, but I did experience the earthquake on my way home from work that day in Santo Domingo. Every detail of the next 72 hours is well engraved in my mind as this was a significant change in direction for me. I had been here to Hôpital Adventiste d'Haiti several times before. At the time these experiences were less than inspirational and the hospital had largely lost the luster of its early years. It was operating on a shoestring budget and striving to cater only to those who had significant resources.
Before I arrived here in Port au Prince 48 hours after the earthquake I realized that in spite of the tragedy this may become an opportunity to recreate a mission hospital. The story is one that many of you have been part of. The deterioration of the hospital that had occurred in the years preceding the earthquake superseded any damages brought to the building which was the closest major hospital to the epicenter. With great gusto and lots of external support an orthopedic program was launched. I spent 6 months working here full time and then Terry Dietrich came with his wife for another whole year and was joined by Dr. Francel Alexis who has been the mainstay of our program here over the last 8+ years. We have had many victories and frustrations, but when looking back there have been many more victories than defeats.
This week we made a significant leap towards realizing our mission of providing hope and healing to people of all economic classes. We now have a designated office for financial counseling and social support that will help facilitate communication and financial support for patients without sufficient resources. Developing prices for surgeries is always tricky in mission hospitals. If we make it cheap enough that everyone can afford it, then balancing our budget and paying our employees is difficult or impossible. In addition other health care institutions would resent us for undermining them. If prices are too high then poor people get turned away. If they are in the middle then some of both problems will happen. This mandates some flexibility with pricing especially in situations regarding medical emergencies. Hopefully our new financial counseling office will help us to treat all of our patients with the highest level of dignity and respect.
Scott Nelson, MD
Bon Bagay at HAH
Bon Bagay means "Good Stuff" in Kreyol. If you say it a few times it becomes addicting. It is a fitting title for this week's events. Team Sinai returned for their 7th trip to Hôpital Adventiste d'Haiti. This is a group led by John Herzenberg MD one of the most respected limb deformity surgeons in the world. His wife Merrill is the organizer of these trips which include a comprehensive team of people from 6 different countries many of whom speak French and Kreyol.
I first met Dr. Herzenberg in 2004 when I went to the Baltimore Limb Deformity Course as a young surgeon. He is the course chairman. This course really opened my eyes to a new world of surgical possibilities and taught me many surgical concepts I had never before known. I learned about limb alignment, bone lengthening and gradual correction of severe deformities. There is so much to learn that I decided to repeat the course two years later and at that time I asked if I could come and spend a summer in Baltimore at the International Center for Limb Lengthening. This was an amazing experience both for mentorship and learning. I never dreamed that these surgeons would all come down multiple times to work with me in Haiti and the Dominican Republic. Mothers in Europe, the Middle East, and Asia are Google searching for well-known clubfoot and limb deformity surgeons and find John Herzenberg, meanwhile, moms come across Port au Prince from some of the worst slums in the western hemisphere to Hôpital Adventiste to find the same guy. Bon Bagay!
We had a great week with the team which included a lot of operations as well as a Taylor Spatial Frame workshop. This consisted of 4 hours of lectures for local surgeons and residents and then another 4-hour laboratory session to teach hands-on application of the TSF (graduates pictured in banner image).
For those of you who are not familiar, TSF is a type of external fixator used for limb lengthening as well as gradual correction of various deformities. It is based on a mathematical theorem that allows you to correct all kinds of exotic deformities but requires some computer programming in order to do so.
Meanwhile, a lot of other Bon Bagay is occurring at the hospital. Last week a CT scanner arrived from Florida Hospital (see banner image). There are only 2 others to my knowledge in the country and one of them is usually broken down.
The installation for this is quite complex as it needs a 480V line, so if you have cancer please don't stand by until we get this thing up and going, it could be a little while yet. Thankfully we have an electrical master, JT Haas on site who is getting the job done. Previously he was in charge of power distribution for the central coast for Pacific Gas and Electric. He recently retired and is giving his time and expertise to help us solve some major issues.
We were told these issues would cost about two or three hundred thousand dollars to fix, but by redistributing some of our power and working out some practical solutions JT is going to have the job done for less than $30,000. Bon Bagay!
Scott Nelson, MD
HAH Enters the Digital Age!
As I deplaned at MIA this morning, we were immediately directed towards an escalator leading to the Skytrain. I stepped on to the elevator and the young man about 25 years old right in front of me fell down and dogpiled with the man next to him on top of my bag as I tried to pad his fall. At that point, his feet were up and his head down as I struggled to lift him up. He looked like a young healthy man and did not seem to be drunk after this short morning flight. As I helped him up his friend explained to me that it was his "first time". I said "welcome to the United States of America!". I only know of one escalator in Haiti – it is in the arrivals hall at PAP. Out of the many times I have arrived there it has only been working once.
This experience gave perspective to some of the things we have been trying to accomplish at Hôpital Adventiste – commonplace endeavors to take us up to the next level sometimes end up in a dogpile at the bottom of the escalator as we tumble over each other trying to communicate, understand and stand up again.
One such endeavor is our new PACS system. Some of you may not know what that is, and the rest of us who do, still might not know what those letters stand for…Picture Archiving and Communication System. Virtually all hospitals in the United States now have such systems which electronically store radiographic images. This technology is to the traditional x-ray what digital cameras are to film cameras. The way it works is by the use of a 14×17" digital detector which is the size of a standard x-ray cassette. X-rays out of any old, new, portable or stationary machine can be beamed through the patient onto the DR detector and voila! The image shows up on an adjacent computer via Bluetooth. It is then labeled, edited as necessary, and archived onto our server using an Agfa PACS database program.
The benefits of a digital system especially at a mission hospital are many. Film x-rays often require about $20 US of film and chemical per study. Bypassing the need for film allows us to more easily afford x-rays for people who cannot pay and yields more profit for the folks that can. If a poorly performed x-ray is taken then it can either be edited for clarity or retaken without wasting materials.
Gone is the day that you could not get an x-ray because the patient could not afford it and you did not want to put your hospital further in the lurch! Now we are lowering our prices, creating more accessibility for the common man, woman and child with an even better quality of care than before.
The reality of this system occurred over a cup of coffee early one morning on my way to work at LLUMC last November. I met with a friend who told me to let him know if I needed some financial support for a project in Haiti. I presented him this idea thinking that he may be able to provide a small jumpstart for this $95,000 project. Halfway through our cappuccinos he had heard enough of my enthusiasm to reach his hand across the table and shake on a promise to fund the whole project! Mike Haman director of our PACS at LLUMC used his VIP status with Agfa Healthcare to strike a 70% discount on the software and then put the whole system together, travel to Port au Prince and spend a week for installation and training.
Entering good data with consistent attention to spelling and details is where we began to stumble at the bottom of the escalator. We soon discovered that there were at least 7 existing medical record numbering schemes, with many patients having duplicate numbers. Continuing with this database nightmare would create chaos and frustration when searching for patient images. Fortunately, Jere Chrispens, our CEO is a seasoned IT executive who was able to come to the rescue. An eighth medical record numbering system was created with a consistent 7 digits to supplant all previous systems. It seemed like a simple scheme but various complexities arose which created moments of frustration amidst the joys of our new system. This has now led us to create a demographic database in order to avoid duplicate record numbers, have the consistent spelling of names, and contact patients when needed. These concepts don't intrinsically exist in Haiti. But by padding the falls, communicating, and helping to lift each other up we are standing on the escalator and moving to the next level. Welcome to HAH!
Scott Nelson, MD
Total Joint Program Launched at HAH!
For me it was a historic day. Seeing people day after day here who are in pain, who have severe deformities, who are disabled, motivates me to work hard and continually try to improve. Malades (malade = patient in French) come to HAH with all types of orthopedic problems. Some of the most difficult to treat are hip problems. In 2010, it was 2 months after the earthquake that we received a beautiful C-arm, complements of our orthopedic colleagues back home. This enabled us to take care of many patients who had hip fractures that were nearly impossible to operate without x-ray guidance.
Soon after, we were able perform hemiarthroplasties (partial hip replacements usually used for femoral neck fractures in the elderly). But the option of doing total hip replacements had continued to be an elusive dream, until today. We had to renovate our operating room, we had to get air handlers and filtration system working properly, we had to find implants which tend to be way out of the budget for our patient population, and we had to find a committed surgeon. Starting a joint replacement program was one of my major goals during this 6-month period of time that Marni and I are living in Haiti. That finally materialized due to the generosity of Renovis (total hip implant company) and Dr. Mark Mildren.
Over the past few weeks we called some of the patients on our total hip waiting list that was started in 2011. The list is huge. There are people that are in their 30's and 40's some younger some older that have been suffering from hip problems for years. One patient had an acetabular fracture several days before the 2010 earthquake but was unable to get treatment because of the thousands of victims crowding the hospitals. Beyond that he did not even go to the hospital because he was afraid they would just amputate his leg. He has been walking with a crutch for more than 8 years. Finally, we can take care of him. Another man had a femoral neck fracture in the earthquake and told me about how he looked for treatment all over the city, but no one could take care of it. He got the idea to come to "Diquini" (address of our hospital) and we did a hemiarthroplasty. I looked at his record and amazingly my operative note was there. Several years later he started having pain and needs to have a conversion to a total hip arthroplasty as expected. Many of our patients with hip problems are quite young, mostly due to accidents causing femoral head or acetabular fractures. Some others have untreated childhood hip disorders or avascular necrosis.
Due to the young age of our patients it is particularly important to use the highest quality implants since a failed hip replacement down the road would be quite a disaster. We have spoken to several companies about donating implants but nothing worked out until recently when I spoke to Renovis a company based in Redlands. They have top quality implants and were willing to donate them for the cause. I would like to give a big shout out to this company not only because of their high-quality product, but for their can-do attitude, customer service, and the relative simplicity of the process for donating the implants.
Mark Mildren (seen in action in cover photo) is a total joint specialist from Eugene, Oregon. He finished his residency at Loma Linda University in 2016 and subsequently did a fellowship. He came to Haiti with me as a resident in 2015. Those years that many of us spent training Mark to become an orthopaedic surgeon are now paying off! It is exciting to see him supersede me, operate as an attending and take the lead on cases. It was important to find someone committed to more than just a one-time visit. Ideally, we would like to perform total joint replacement surgery here every 3 months and have a couple of surgeons that each come twice a year. Mark is building his practice, paying off loans, and has 3 kids and a wife. But since he still drives the beat-up Hyundai that was given to him by a fellow resident who was buying a new car, he has the freedom to do this sort of stuff. Even though he is an attending now, he had an overnight layover at LAX on his way down here and sat in the terminal all night to save money.
Special thanks to Dr Scott Epperly, orthopedic surgery resident from Loma Linda University and Dr Paul Kim, anesthesiologist from Redlands, CA for their assistance facilitating this program. Stay tuned for total knee replacement! Hopefully coming later this year…
Scott Nelson, MD
What's Happening at HAH?
I would like to give you a brief update on what is going on at Hôpital Adventiste d'Haiti (HAH). Because of your support and generosity, we are on schedule to accomplish unprecedented goals this year. There are dedicated people from Haiti and the United States working at HAH, creating an exciting synergy that is unique amongst healthcare institutions in the country.
The new outpatient clinic (pictured below), which is a $1.6 million USD project, is scheduled to start July 1, 2018. The existing dilapidated structure (pictured above) that houses the administration and central storage depot will be demolished. These services must be relocated inside the hospital. Renovations are currently underway to accommodate this, as well as to install a CT scanner and PACS (digital x-ray archival system). Repairs to the plumbing and electrical infrastructure are also in progress. We have a great team consisting of Dan Brown from Maine, who is our facilities manager, local workers, professional health care architects and a construction company.
Beginning last December, Marni and I are spending 6 months working full time in Haiti until June. The impetus for this was partially based on the need for surgical leadership. Alex Coutsoumpos MD (general surgery) has been at HAH full time for the last two years and has moved to Florida. In addition, I have risked my reputation to raise money from all of you and want to make sure every penny is aspirated out of your donor's dollar in regards to the upcoming building project.
With our decision to move to Haiti several serendipitous events occurred. Most notably, Jere Chrispens a seasoned CEO and IT expert from Loma Linda has decided to join us for this venture and will serve as interim CEO of HAH. His leadership will be key to helping create sustainability while maintaining our mission focus.
With pledges, cash on hand, and matching funds, we are in a strong financial position for the outpatient clinic building project. I would like to express a special gratitude to some donors who have already given their entire 5-year pledge. The option of paying these pledges ahead of schedule is helpful as it mobilizes matching funds, and gives an immediate tax deduction to the donor.
Once again, I thank all of you for your generosity and assure you that lives are being changed in amazing ways. This would not be possible without your help.
Scott Nelson, MD
Big Day In The OR/Day 6
The first case of the day was a left tibial plateau fracture sustained in a motorcycle accident a few days ago. After touring the orthopedic ward at the University Hospital downtown yesterday we are once again reminded that trauma, particularly the musculoskeletal variety, remains a neglected epidemic in developing countries like Haiti causing more than five million deaths each year, roughly equal to the number of deaths from HIV/AIDS, malaria and tuberculosis combined.
The surgery was long and complicated. First both femurs were osteotomized (broken), straightened then the rotation normalized. Both "broken" femurs had the correction stabilized with locked intramedullary nails.
The next and last case of the day was the older sister of the patient I just finished describing above who had similar, but not as severe, bowleg deformities secondary to rickets.
No femoral osteotomies were required in the older sister, but the Taylor Spatial Frame application on the tibias was very similar to the younger sister's surgery. It is estimated that the correction in both girls will take approximately 3 months before the hardware could be removed.
Day Of Rest/Day 5
Since Hopital Adventiste is a Seventh-day Adventist sponsored facility, no elective surgery is performed on the 7th day Sabbath. Obviously, this mandate is set aside when it comes to emergent cases that present to the trauma bay. Around midnight this morning we were awakened by the Chief of Surgery, Dr Alex Coutsoumpus, who informed us that there was a gentleman admitted to the hospital who presented with a severe crush injury to his left hand sustained while unloading grain from a ship.
We got back to bed around 2 am and slept well until rising to attend the Sabbath service down the road from the hospital. All of the service was conducted in French but we were inspired by the boisterous which was boisterous and heartfelt. When we first arrived the Sabbath School was in full swing and lesson study was a cacophony of loud and enthusiastic discussion (click on audio clip below) which apparently didn't seem to distract from the overall experience for most worshipers.
After dinner we wound our way back to the hospital through the streets of Port au Prince in a thunderstorm which clogged the roadways with debri rendering progress virtually impossible. Still 3 miles from HAH, we elected to abandon the vehicles and walk the remaining distance through the chaos on the streets finally getting to bed around 1 AM. Not much rest on "Rest Day."