text:
Tuesday, April 01, 2008
It's Emergency April Fool's Day
In the spirit of April Fool's Day we are, just for today, going to do the following in our ER...
1. We will see all comers regardless of their ability to pay, and regardless of whether they are drunk, high, lying, in the country illegally, have just murdered someone, or are coughing up blood after having smoked four packs a day for 50 years and have never seen a doctor before.
2. We will pull out all stops for all patients and do the absolute best medicine anywhere in the world for all patients mentioned in #1 and collect what we can from people with nothing to do with any of the patients in #1.
3. We will smile and respond 'yes ma'am' and 'yes sir' to patients and their families when they call us "asshole" or similar epithets and hit us, spit on us, and threaten our lives.
4. We will comply with all regulations and laws promulgated by the federal government to do all of the above without any funding to back up said rules, and with full exposure to liability for medical negligence for any of the patients mentioned in #1.
5. We will strive to comply with all JCHAO regulations, my favorite of which forbids us to eat at our work space (ostensibly to protect the health of the patient), but allows patients to eat in their rooms in the ER and upstairs.
6. We will surrender our power, gained by detailed expert knowledge and training, to people with clipboards who work 9 to 5 and haven't seen a patient in their lives, or, if they have, are no longer involved in patient care.
7. We will approach the art of medicine by applying a strict business model, striving for customer satisfaction with our patients, and look quizzically at each other since we have no idea how much particular tests or procedures cost, and have no expectation of being paid by any particular patient.
8. We will 'go paperless' and put dotting the "i"s and crossing the "t"s on the computer ahead of getting stuff done in a timely fashion for our patients.
9. We will dump more and more work on fewer and fewer providers (nurses, doctors, techs, and paramedics), and buff out that bottom line for our masters with clipboards and 9 to 5 jobs and zero clinical experience etc...
10. We will look the other way as our EMS system is abused by people calling 911 who "can't get a ride" to the ER or have that pesky 4am insomnia which is very uncomfortable for them.
11. We will happily put our helicopter crews at risk by flying at night and around dangerous obstructions to rescue the folks who plow their cars, drunk, into other cars, into crowds of people, or into bridge abutments, and cry a little each time a crew is lost.
12. We will see the same patient for the same complaint for the thirtieth time this year and spend thousands of dollars of other people's money looking for an imaginary diagnosis because the patient simply wants narcotics.
13. We will groan as clipboard people create new forms to supplement old forms and new requirements to supplement old requirements.
14. We will meekly comply as clipboard people and entitled patients demand quicker throughput in the ER while doing all of the above.
15. We will listen sympathetically to patients who are doctor shopping and tell us, "no one has ever done anything for me" while trying to make sense of their 500 page charts.
16. We will attend required meetings at 7am after working all night where freshly showered and manicured clipboard people in suits tell us that we need to work harder, faster, and better for less money.
17. We will look at the salaries of hospital administrators, often equal to or greater than ours, and put a grim smile on our faces while swallowing very hard.
18. We will wonder how an undergraduate degree cum laude from a top university, a doctor of medicine degree from a top-ten medical school, and a top-ten residency in our specialty of choice is worth less than an undergraduate degree in business from the State College of Northern Bumfoodle (with distinction).
19. We will attempt to resuscitate 96 year-old, severely demented nursing home patients because their family, not having seen them in 8 years, rushed to the hospital when they heard that 'dad was sick', and are demanding that we do 'everything'. We will crack the old man's ribs doing CPR, and wince with every 'snap', suck vomitus out of his oropharynx while we intubate him under chemical paralysis, and push tons of drugs into his veins in hopes that we get him back to his normal state of nothingness (with the family staring daggers at us).
20. We will walk into patient's rooms and smile at them while we wait for them to finish their cell phone conversation and order their super-expensive pregnancy test (that costs $5 at the drug store). We will then send their bill to the taxpayer.
21. We will break the spirit of brilliant and motivated medical students and residents as they shoulder the burden of 100 hour work weeks, an almost universal sense of patient entitlement, and we will pay the residents less than minimum wage.
22. We will give depositions to attorney's representing patients whom we may have harmed in some way and fret about our licenses and family and sleep and whether we really hurt or killed someone.
23. We will work shifting schedules that are akin to flying to Europe to work a few days and flying back here to work for a few days. Then we will take a few days "off", then repeat.
24. We will wonder why we chose to do this.
25. We will tell our kids not to go into medicine.
26. We will search for an exit and despair at our silver-plated handcuffs.
27. We will pay down our medical school debt way into our forties and then think about getting a nice house or car.
28. We will watch "House, MD" and laugh hysterically at that farce while knowing that people think that's what we do.
29. We will work a ten hour shift and realize, right at the end, that we are really hungry and need to pee really badly.
30. We will smile and feel good when that one patient in ten, thanks us for helping them.
31. We will consider going back to school to get a more valuable but much easier "advanced degree" so that we can get out of medicine and maybe retire at sixty.
32. We will pronounce a baby dead after trying everything we know and cry with the parents and cry later too. Sometimes the parents will be drunk..
33. Come to think of it, we'll just do this every day... I was mistaken, it's Groundhog Day.
54 comments:
- Anonymous1:00 AM, April 01, 2008
We will be more than happy to thoroughly examine all five of your children for their "sniffles" just because you came in for a chronic toothache and were unable to have someone watch them. We cheerfully applaud you discipling them by allowing them to be running around the department and be loaded with Cheetos and Pepsi.
Immediately linked.ReplyDelete
Vast respect. *bow*
Just wanted to say thanks for doing what you do.ReplyDelete
And this is why you fly straight to the top on the hotness scale even though I have never even seen you. People who do what you do are amazing people. Thank you very much for doing what you do.ReplyDelete
- Anonymous8:16 AM, April 01, 2008
Ha Ha, we used to do Aprils Fools preops for the real asshololic residents. "Non english speaking 102yo morbidly obese quadrupple amputee, bad airway, MRSA, h/o malignant hyperthermia, sickle cell, HIV positive, for laser guided drainage of pilonidal cyst, allergic to narcotics and sedatives, and please use paper tape" To top it off we'd add a joke name like Seymour Hymen, and a room that didn't exist. Fun Times.ReplyDelete
the 20's are my favorites. btw is #26 a reference to SAW by any chance?ReplyDelete
- Anonymous9:03 AM, April 01, 2008
Do you like it, or do you think it's hokey if a patient sends you a thank you note for helping them in the ER?ReplyDelete
thanks, MDOD. You've made my day!ReplyDelete
- Anonymous9:56 AM, April 01, 2008
thanks for cheering me up. now i'm going to go kill myself.ReplyDelete
"Will" you slow down you are not doing your health any good.ReplyDelete
I can envision future generations taking a long, hard look at our society and shake their heads while muttering, "No wonder they went the way of the Romans. They had idiots running the place and failed to listen to those who produced."ReplyDelete
Geez, how black is my mood??
questions so far...ReplyDelete
no intentional referfence to SAW
i love thank you notes sent to the ER!
Ugh. Now I'm depressed. How do you guys do it? So many people have no clue what doctors do.ReplyDelete
Dont you just wonder how long it's going to go on before things just snap? It's like the system's been rigged and held together with duct tape for too long. Eventually it's going to full on break down.
- boredmedstudent12:14 PM, April 01, 2008
Love #21. One time I had to explain to a cop (got pulled over, oops) that med students actually pay a lot of money to go to school and are not paid in any form for what we do. Took a minute for him to understand that I'm broke and very far in debt. Can't wait for my $2/hr residency!! (Ironically, waiters/waitresses in Texas make $2.15 an hour, not counting cash tips)ReplyDelete
Wow 911, hand that revolutionary list of grievances to George III (or the Rominovs, depending on your leanings) and sign my name at the bottom. Every freaking day is April fools. You are the poet laureate of med blogs, my friend.ReplyDelete
Come on over to the MonkeyHouse, my friend. We'll drink a lot of alcohol and watch UNC roll as we celebrate our burned-out-ed-ness.ReplyDelete
Excellent post. Almost makes me wish I was working tonight.
Monkey Girl,ReplyDelete
You have more faith in UNC than I do at this point. It will be a true champion that wins this year. Anyone could win it. I wish Davidson had managed to pull it out agains KU. How's my pinky?
- Anonymous7:37 PM, April 01, 2008
Okay, fair enough. I have a counterpoint. I have been in the ER for the following:ReplyDelete
1) bilateral kidney stones that needed to be removed by lithotripsy
2) very, very, very diseased gallbladder
3) miscarriage
I was rear-ended in an automobile collision and declined to be transported. Saw my primary care physician and requested a referral to a physical therapist. Was told that that was the "easy way out" and he prescribed Flexeril, some sort of codeine derivative, and massive doses of Tylenol. Eventually a month later he grudgingly wrote the referral for the physical therapy.
Oh, and also, I have taken my children to the ER because they have been in excruciating pain from
1) urinary tract infection
I took my child to the pediatrician, who promptly had my toddler admitted for three days for
1) rotavirus
So. Let me tell you what happens when you are a legitimate patient who walks into the Emergency Room, who would rather stick pins in her eyes than take narcotics.
Narcotics make my eyeballs itch. I can't sleep on narcotics. I get ferociously constipated and then I get depressed because I can't sleep. I fail to see the appeal. I don't want narcotics.
If I am in your ER it is because I am in excruciating pain, and I want you to make it stop. My doctor's office is closed. The pain woke me out of a sound sleep. If I go to my primary care physician with this kind of pain, there is absolutely nothing he will be able to do for me.
But what I find, is because I am a woman of childbearing age -- even though I have an advanced degree and bathe regularly -- while the folks up front do a "wallet biopsy" you guys biopsy me -- to see if I am really human.
You will do a pregnancy test even if I tell you that I am currently menstruating, then you will treat me like dirt until the pregnancy test comes back negative, because I am married.
If I am in pain, you will presume that it is PID, even if I tell you I am sexually inactive. Then you will treat me like dirt until the ultrasound reveals a kidney stone the size of a one-carat diamond.
If I am in pain, because I am a woman of childbearing age, you will presume that I have VD, or that I am pregnant, or have PID, or that I am in some other way some kind of dirt ball, even though I have come to your department sober, requesting Toradol and not Dilaudid.
I was not seeking drugs, my gallbladder needed to come out.
Oh, and, note to recovery room nurse: Right after you have your gallbladder out, just as you're coming out of anesthesia, you really do need additional painkiller. So telling me to "SHUT THE HELL UP!" really isn't useful. I'm crying because it really hurts. In fact, I have to crouch over and put my hands on my knees in order to breathe. Since I always come to the same ED, you can look in my chart and see that when I came here for the kidney stone I asked you for Toradol, so perhaps if I'm asking for something after you pulled my gallbladder out of my navel, you could get off your fat ass and get me something for the pain.
I realize that most of you folks hate your jobs, hate most of your patients, and don't want to talk to a member of the public unless they're spurting arterial blood or suffering from a full-blown heart attack.
But until you can tell those of us in serious pain from legitimately painful conditions that really require urgent medical treatment where we can go when it's Friday night and we have a kidney stone, we're going to come to your ER. Because kidney stone pain really, really, really, really hurts.
It would help those of us of childbearing age who bathe, are sober, and drug-free, and are asking for Toradol, if you would not automatically assume that we are pregnant by someone not our spouse, suffering from PID or VD, or seeking drugs, and talk to us like we are pieces of shit with legs, until at least the initial tests come back.
Signed, The Gallbladder Had to Come Out, and I Promise You I'd Rather Clean Up My Cat's Hairballs Than Come To Your ER, So Lose The Attitude
dear anonymous,ReplyDelete
i can tell from reading your post that you have indeed been to the ER many times. my eyeballs hurt from reading your post. best of luck and HTFU. thank you for proving my point.
and anonymous,ReplyDelete
sounds like you were properly diagnosed and treated so WTF are you angry about?
- Anonymous9:04 PM, April 01, 2008
too bad she never got TOBASH therapy.ReplyDelete
ok drackman, explain. you got me.ReplyDelete
- Anonymous9:11 PM, April 01, 2008
You asked me tonight "why not NP, or PA?"...and I think this sums it up. Every burned-out medic, doc, nurse, tech, hospitalist..we all should read this because this post is overwhelming, and it makes my throat hurt and my eyes burn, and my shoulders sag against the battles we are losing. And at the end of many shifts, I sit in the floor of my shower and I cry, both for the ones I lost and the ones I saved, both the nine week old baby and the ninety year old woman, neither of which we brought any justice to, one we should have saved, and one we should have let go...I don't want to further myself in this field, I spend too much time already crying in the shower while the scalding hot water washes the injustices and stupidity of the world away...I'm afraid if I stay much longer, the ignorance will seep into me and spread to my children.ReplyDelete
anonymous (last),ReplyDelete
took me a minute to figure out who you are and now i know. God Bless you, you make my job enjoyable in little bits. hopefully this all this counts for something somehwere better. if not we are truly fools.
- Anonymous9:54 PM, April 01, 2008
"TOBASH" southern Alabama slang term used primarily by resident physicians and nurses to indicate what they would like to do with a particularly unpleasant patient.ReplyDelete
S- HOOT in
example, "Dr. Drackman, theres a TOBASH in room 4"
- Anonymous9:59 PM, April 01, 2008
14, 16, 17 and 18 are the best! Those apply universally- it seems there is always someone who has never done your job telling you how to do your job!ReplyDelete
thanks for doing what you do! Many people couldn't take it!
911 Doc, you rule!ReplyDelete
- Anonymous10:20 PM, April 01, 2008
What I am angry about, asshole, is that before I got my gallbladder hauled out through my navel, I had to listen to a grossly-overweight, furious, pretentious, nasty, bitter, patronizing bitch of an ER nurse lecture me about how I can't possibly know whether I'm really pregnant and who sent the OB/GYN to make sure I really didn't have suppurating VD and in general acted like she hated life, and me, and herself, but not necessarily in that order.ReplyDelete
In other words, you people -- some of you -- have your own, shall we say, isshers, which you visit on members of the public who aren't spouting blood to the ceiling or are in total cardiac arrest.
The nurse could stop talking to me like I was a piece of shit on two legs...I wasn't the one who could stand to lose 50 pounds, and I wasn't there because I wanted to be there, and no, I wasn't pregnant, and no, there was no way in heaven's name that I had VD. No, there was no way that this nurse was pregnant or had VD either, because she was such a perpetually angry, resentful bitch that she actually demanded that the anesthesiologist walk me to the bathroom because she was too busy. I promise you she hasn't had a date recently, and perhaps that was her basic problem.
I was telling her where it hurt and what was wrong, and she couldn't hear me.
Same thing with the kidney stone situation. I was pissing red, folks...I was puking it hurt so much. But as much as you folks are just so awesomely brilliant that you not only know about medicine, but you know about everything else too, I really didn't want to be there. It's just that nothing else made me stop pissing opaque blood and puking from the pain.
But until I pissed into the cup, the nurses were calling the OB/GYN and demanding pregnancy tests.
Yes, I have heard about the 400-pound people that somehow make it into the third trimester without knowing they are pregnant.
I am a size 2. And I am pissing blood and puking. And I told you that both things were taking place. And yet the nursing staff couldnt' decide whether I was human or not until after the ultrasound. Then, I got to be treated like a human being.
Before that point, I was either presumptively an adulteress with PID or a drug-seeking malingerer.
Some of you folks just don't fucking listen. You've gotten it all figured out already.
You want to bitch about the asshole with the hangnail that calls the ambulance? Okay, tell the bitch in the recover room that after a cholecystectomy you're supposed to provide pain relief.
Never fear, I'm projected to still be paying my school debts when I'm 52.ReplyDelete
dear anonymous, again,ReplyDelete
i'm glad you are well. you seem like a nice person and really on the right track. best wishes to all your family and friends and please continue to visit and spread sunshine and happiness everywhere you go.
thanks dramamama.ReplyDelete
joeymom, never fear, the government is here and will fix it all. besides, there's lots of folks named anonymous out there who will make your job worthwhile and rewarding.
911 doc,ReplyDelete
You rock my world.
This comment has been removed by the author.ReplyDelete
Layin' into those business majors pretty hard there, nine one one. For April 1 in the lab today, somebody slipped high above the door an official Stockholmy looking announcement about the most recent Nobel Prize: "The Nobel Committee, after heated and thorough deliberation, has chosen to bestow upon Terry J. Peters, MBA, South Jersey College of 'Office Solutions,' the 2009 Nobel Prize in Physiology and Medicine for his timeless commitment and raptuous insight concerning the treatment of every disease known to mankind. From his middle management position at a mid sized regional hospital, and through the transcendent brilliance of his 6 year, "Let's Make the Voyage Together- A journey to the highest quality of care in every single aspect of health service across the entire continium of patient care while fostering a culture of Service Excellence!" philosophy, Mr. Peters has lifted the spirits of millions, setting free an overarching panacea to which we all owe our very health. Thank you, Terry."ReplyDelete
I think that in addition to holding an MBA, some of these hospital admins. should have to be poet laureates. It seems a natural prerequisite, as those people find the most creative ways of telling you to drop the soap, take it, and not to make a peep. Oh, and scrub the floor while you're at it.
That would've been a punctual way to end this post, but I almost forgot: Thank You Doctors, those that blog here, those that just stop by, and I guess thanks Pathologists too. I have an odd feeling that there is a large, largely silent majority that greatly appreciates (even if they don't fully comprehend) the sacrifices upon sacrifices that the profession demands. We pay our bills. Goodnight!
Sexually inactive?ReplyDelete
That's a shocker.
dear rubyridgway,ReplyDelete
at my place they aren't MBAs. i've got no beef with business folks, just with trying to fit a capitalist and profit based model onto a house of cards built on a ponzi scheme.
anonymous - You have heard about 400 pounders who come to term without realising they're pregnant? Good for you.ReplyDelete
Now do your homework on ectopic pregnancy.
Doctors and nurses go to school for a long time for a reason. There's a lot that can be wrong with a human being, apart from kidney stones.
- Anonymous8:02 AM, April 02, 2008
Gee Annonymous, I recommend you see a specialist, Dr. Zahari can see you at 4:30.ReplyDelete
- Anonymous8:09 AM, April 02, 2008
From Anonymous 3 (if I am counting correctly).ReplyDelete
What anonymous #1 doesn't realize is that the human race is prone to lying. Shocking, but true, and an ER doctor, who has no previous relationship with a patient, but does have a significant amount of liability for missing key diagnosis has to go through the regimen for ALL female patients of child bearing age. Even in my small town, where the ER doctors would know me personally (and I hope believe me), I would have no problem submitting a urine for a pregnancy test, despite knowing that I would not be pregnant. There is no litmus test for being truthful, and ER doctors have to deal with that.
Point 19. Well taken. I have heard that we do not have to deliver medically futile care, but given the liability no doctor will not go through the motions, even though it feels awful to beat on a body that is already nearly in the grave. When will our society come to terms with the fact the dying is a natural end to the living process? We can not cure everything.
In our system, there was a patient with end stage cancer with no other reasonable therapies available (had been to the big referral centers who concurred) who was hospitalized repeatedly with complications of said cancer. Despite extensive conversations with multiple physicians the patient and family demanded that everything be done. On the last hospitalization the patient was intubated. The patient became septic (likely from tumor eating through bowel), went into renal failure and required on going pressor support for days. When she coded, since death will happen eventually despite the wishes of the family, the ER physician responded (in our small hospital that is how it works). After appraisal of the situation, the ER physician spoke to the family about letting the patient go (assuming, I think, that the primary doctors hadn't already tried on a daily basis). He came back to run the code because "it's like they don't even seem to realize that the patient is sick."
That hospitalization ate up thousands and thousands of dollars of what everyone on the case felt was futile care; however, given the palpable anger of the family no one felt comfortable in denying care for fear of lawsuit.
Society needs to take a look at this. Physicians are not god, we can not predict when someone will live or die, but we have a pretty good idea in some situations. There is a point where care is futile.
On some other blog, I read about an ethics case regarding a family refusing to withdraw care on a basically brain dead patient because of "religious" beliefs. A patient with absolutely no chance of meaningful recovery, on a ventilator with a feeding tube. How about having the church pay the medical bill? Since when did it become a sin to die?
OK.....I seem to be on a soap box and I may be about to step on toes....but in a society that has a limited pot (in part because we like to spend so much on other activities) we need to look at "doing everything" all the time. I don't have a great answer, but I know the system is broken and there needs to be more talk about some of the tough decisions.
- Anonymous8:31 AM, April 02, 2008
I am not a physician myself, but to sympathize with you guys- it *has* to be irksome for someone to walk into your ER asking for a specific med, much less a narcotic. WTF? The doctor hasn't even had time to see you or make a diagnosis and you're already demanding drug A or drug B.... to the anonymous poster- yes I understand you had legitimate problems- but did you ever consider how you come off coming in and demanding meds?ReplyDelete
- Anonymous8:52 AM, April 02, 2008
anon #1:ReplyDelete
I completely agree with everything you say. Thank you for enlightening these heartless bastards. You are an inspiration to patients and women everywhere.
Oh, April Fools, BITCH! Eat a fucking cupcake and plump up that flat size 2 ass (the pissing blood thing turns me on, don't get me wrong.) You sound like a real charmer. I'm sooooo sorry that you a) went to the ER, b) were appropriately diagnosed and treated, and c) were temporarily annoyed by a mildly overweight nurse. Wow. Sounds like a HORRIBLE experience. You convinced me: doctors really are jerks.
Take your whiney, entitled, Karen Carpenter body and try to treat yourself next time you are "really" sick. (please refer to prior photo of Hillary Clinton and paste your photo over her face)
Happy April Fools!
Anonymous 3 who then became Anonymous 5:ReplyDelete
That's why you're my favorite. Cuz you're cute and smart, too.
You need a screen name. Your common sense is making the Anonymi look good. Don't give them any more power.
If you don't want a screen name, just begin each rant with, "I don't mean to be ugly, but..."
- Anonymous10:05 AM, April 02, 2008
Hey, I thought Karen Carpenter was hot.ReplyDelete
fascinating discussion - I think doctors overestimate the number of patients abusing narcotics, abusing the system, or abusing the right to be seen in an ED. Most patients aren't stupid, just have no where else to turn for immediate answer to their questions - somthing Americans value a lot and I think some do not feel responsible to pay for this service and/or terribly underestimate what it costs to provide that service. The abusive patients on drugs and alcohol ruin it for the patients who are not. The few actual devious drug seekers ruin it for those who have legitimate pain, with or without a findable cause. How to stay happy and cheerful in a place where you are expected to "take it" and dish out love at every corner while being the smartest person in the world and never missing a diagnosis is something I have not figured out. However, each individual patient should not suffer the woes of the world - SHED the burden of the day, the last patients problem, and societies downfall when you walk in the room with ONE patient adn JUST you and do what one human should do for another (keeping in mind that I don't mean you have spread flowers and love at every situation). The actions for that patient should be about that patient and not the rest of the issues that he/she has nothing to do with that day.... those are our, yours, mine, societies problems to fix. I suspect something will eventually fall apart and fix / destroy this issue all together... When there's no pie, no one gets a piece...ReplyDelete
So when do the skinny anonymous women start attacking etotheipi?ReplyDelete
I know this isn't the point of anonymous' rant up there, but what's the big deal about taking a pregnancy test? Right before my radiation I had to take one and I had just finished my period the day before AND also had my tubes tied. The radiation guy is a family friend of ours, and knew me well and still had to ask me to take one. How would a doctor you just met have any idea whether you were telling the truth or not?
- Anonymous2:36 PM, April 02, 2008
Back in the 80's before PFP occasionally doctors would take their own x-rays. I remember wheeling a patient into radiology and the surgery intern playing with the KeV knobs to document free air. The 11-7 x-ray tech was doing something else, and taking x-rays isn't exactly rocket science. A downside was the occasional KUB with a fetal skeleton right smack in the middle. It was usually left hanging for everyone to laugh at till the next idiot took one.ReplyDelete
Wow, skinny anonymous.. it looks like despite all that adequate treatment you received in the ED, they forgot to give you a happy pill.ReplyDelete
"I realize that most of you folks hate your jobs, hate most of your patients..." [gratuitous whining snipped for brevity's sake]ReplyDelete
No, Ma'am. We just hate you.
If you look up Etotheipi in the dictionary, you'll find a hunky dude spewing every cuss word known to Man. Cussing makes me hot all over...ReplyDelete
Wow, I always come to parties late. Maybe she would have preferred the gall bladder surgery where "they haul out" your gallbladder through a large incision instead of a little bitty incision that heals in about 10 days. I've never been more thankful for my doctors than after reading all her vitriol and ungratefulness.ReplyDelete
- michele6:58 PM, April 03, 2008
Anon - I do not believe you a nurse told you to "shut the hell up." I simply do not believe you. You are a nasty little foul-mouthed troll with nothing to add to this discussion except your own unpleasantness.ReplyDelete
Do you ever wonder why karma has thought to punish you with kidney stones and gallbladder pain? It's because you're a little twit.
Did anyone else notice that anon used a lot a big medical words for a layperson? Twit, are you munchausening yourself, and that's why you're so defensive and obnoxious?
I was thinking the same thing, Michele. I would love to meet Skinny-Ass Anonymous in a clinic. I would use so many big, long, medical terms her skinny head would be spinning. Put that biatch in her place! That would make my day. Skinny, move to Canada. Better hockey up there, too.ReplyDelete
Ah, I'm diggin' the movie reference.ReplyDelete
- Anonymous12:47 PM, April 17, 2008
I don't think the anonymous poster's issue was so much the fact that she was required to take a pregnancy test, but that it is so easy for nurses, PAs, and docs to talk down to patients. I've only needed to go to the ER once (broken wrist), but even in normal office appointments, it's not uncommon for medical personnel to be insultingly patronizing. I, too, went to school for a long time, endured a lot of poverty, and pay large student loan bills. I am paid far less as a college professor than most underpaid docs. I don't go into anyone's office demanding drugs, but I've certainly been talked to as if I were chronically dishonest or stupid.ReplyDelete


text:
|MLBPA Press Release
The Cool Kids Campaign is dedicated to improving the quality of life for pediatric oncology patients and their families as they go through the trauma of a cancer diagnosis and its treatments. Established in 2006, the Cool Kids Campaign distributes individualized care packages to children with cancer and publishes a quarterly Cool Kids Connection newsletter featuring educational and entertaining submissions from kids and their families. This fall, the campaign will launch its Cool Kids Learning Center designed to provide oncology patients with a normal childhood while addressing the academic, social and emotional issues that result from a cancer diagnosis. For more information about the Cool Kids Campaign, please visit http://coolkidscampaign.org/.
Courtesy of the Players Trust, the children will receive round-trip transportation to the game, meet the players and receive free tickets, food, beverages and souvenirs.
This season, Buses for Baseball will provide transportation and personal greetings for more than 750 underprivileged children attending Major League Baseball games as invited guests of their big league heroes. Buses for Baseball will provide many of the children with their first chance to attend a Major League Baseball game.
The Players Trust enjoys support from the Baltimore Orioles organization in providing this unique, up close and personal opportunity to share the thrill of Major League Baseball with those less fortunate.
To watch a brief video featuring the Buses for Baseball program, please visit the Players Trust Channel on YouTube at http://www.youtube.com/MLBPlayersTrust.

subset: commoncrawl


text:
Thalassemia is a blood disorder. It cuts down the amount of red blood cells and hemoglobin that the body can make. Red blood cells carry oxygen to all the organs in the body. Hemoglobin is a part of red blood cells that help grab oxygen at the lungs. Low levels of red blood cells and hemoglobin and abnormal hemoglobin can lead to anemia and difficulty carrying oxygen. Anemia interferes with normal bodily functions.
Thalassemias are split into 2 main categories. The categories are based on the part of hemoglobin that is affected:
- Alpha thalassemia—based on abnormality of the alpha part of hemoglobin
- Beta thalassemia—based on abnormality of the beta part of hemoglobin
Thalassemia is caused by faults in specific genes. It is an inherited disorder. This means the affected person received the faulty genes from the parents. The severity of the thalassemia will depend on the number of faulty genes that a child inherits. There are 4 genes needed for hemoglobin, 2 from each parent. The number of genes that are faulty will determine the severity and subtype of thalassemia:
alpha thalassemia:
- 1 abnormal gene—silent carrier, no signs of illness but can pass condition on to child
- 2 abnormal genes—thalassemia trait, may have mild anemia
- 3 abnormal genes—Hemoglobin H disease, moderate to severe anemia
- 4 abnormal genes—most severe form called Alpha hydrops fetalis, results in fetal or newborn death
In beta thalassemia:
- 1 abnormal gene—Thalassemia minor, carrier with mild anemia
- 2 abnormal genes—Thalassemia major known as Cooleys anemia, may have moderate to severe anemia
Risk Factors
Factors that increase your chance of thalassemia include:
Certain types of thalassemia may be associated with ancestors from certain parts of the world:
- Alpha thalassemias—Middle East, areas surrounding the Mediterranean Sea, Southeast Asia, Malaysia, and Southern China
- Alpha hydrops fetalis—Southeast Asian, Chinese, and Filipino ancestry
- Beta thalassemias—Africa, areas surrounding the Mediterranean Sea, and Southeast and Central Asia
- A family history of the disorder
Silent carriers will have no symptoms. For others, symptoms most often begin within 3-6 months of birth.
Symptoms of mild or moderate anemia may include:
- Feeling weak and tired
- Shortness of breath
- Lightheadedness or headaches
- Cold hands and feet
- Pale skin
Symptoms of severe anemia include:
- Lack of interest in activity
- Pale appearance
- Poor appetite/feeding
- Dark urine
- Jaundice
General findings of thalassemia may include:
- Slow growth and delayed puberty
Enlarged and fragile bones, including:
- Thickening and roughening of facial bones
- Bones that break easily
- Teeth that don't line up properly
Thalassemia can also lead to complications such as:
- Increased risk of developing infections
- Enlarged spleen
- Heart failure
- Liver problems
You will be asked about your symptoms and medical history. A physical exam will be done.
Blood tests will be done to analyze your hemoglobin and measure levels of:
- Hemoglobin
- Red blood cells
- Iron
Genetic testing may help make the diagnosis in some types of thalassemia
Treatment will be based on the type and severity of anemia. Mild forms may not need treatment. More severe forms may need:
Blood Transfusions
Blood transfusions will help provide healthy new red blood cells. The blood comes from a donor and is carefully screened before it is delivered in a transfusion.
Repeated blood transfusions can lead to high levels of iron in the blood. This can damage the heart, liver, and other vital organs. Certain medications can bind to the iron and carry it out of the body through urine.
Bone Marrow Transplant
Healthy stem cells from a donor's bone marrow are injected into a vein. The new cells travel through the blood into the bone cavities. There, they can produce new normal blood cells. This may be a cure in some. However, it can be hard to find a good match with a donor and there are many complications.
Thalassemia can cause the spleen to enlarge. An enlarged spleen can make anemia worse. A splenectomy is a surgery to remove the spleen. It may help reduce the number of blood transfusions that are needed.
General Health
Complications and impact on your daily activities may be reduced by following basic healthy lifestyle tips:
- Eat a well balanced diet. Your doctor may also recommend supplements like folic acid.
- Include regular physical activity.
- Take steps to prevent cold or flu. Wash your hand often. Avoid crowds in flu season. Get vaccinations as recommended.
- If you have thalassemia and you are pregnant, talk to you doctor about any special steps you need to take.
- Go to all medical appointments as recommended.
This disease is inherited. Blood tests and family genetic studies will show if you are a carrier. A genetic counselor can discuss the risks of passing on the disease.
Revision Information
- Reviewer: EBSCO Medical Review Board Michael Woods, MD, FAAP
- Review Date: 09/2018 -
- Update Date: 08/24/2017 -


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A burner is an injury to the bundle of nerves in your neck. These nerves run from the back of your neck into your arm. The nerves leave the spine and form a group called the brachial plexus. The plexus extends into the upper shoulder. From here, the nerves split into individual strings. The nerve strings go to all the arm muscles. A burner may also be called a stinger.
Brachial Plexus
Copyright © Nucleus Medical Media, Inc.
A burner may be caused by injury to the brachial plexus, such as:
- Overstretching—can be caused by your shoulder being pushed down while your head is forced to the other side
- Pinching— can happen if your head is moved quickly to one side
- Bruising—can happen when the area above your collarbone is hit directly or pressure on the top of your head compresses the brachial plexus nerves against bone
Risk Factors
Risk Factors
Factors that increase your risk for a burner include:
- Playing American football—increase chance of receiving direct blows to the head, neck, and shoulders
- Participating in contact sports
Symptoms may include:
- Numbness, tingling, or weakness in the shoulder or arm
- Burning or stinging feeling in one arm
- Burning or stinging feeling between your neck and shoulder
You will be asked about your symptoms and how the injury occurred. One of the most important questions is whether symptoms occur in one arm only or in both arms at the same time. Symptoms in more than one limb may be more serious. This may need more extensive evaluation.
The doctor will examine you for:
- Pain or tenderness
- Neck and arm range of motion
- Strength in the arm and hand
- Arm reflexes
- Sensation in the shoulder and hand
For serious burners, you may have an electromyogram (EMG). This is a test of the electrical activity of the muscle. It can help to determine the extent of the injury.
It is important to make sure symptoms are due to burners and not a more serious injury to the spinal cord. Early recognition of this condition can prevent reinjury and possible paralysis. Careful post-injury evaluation can help prevent permanent damage.
Some burners last only a few minutes. These will not need medical treatment.
Treatments options include:
Physical Therapy
If your burners last longer, it can cause muscle weakness. You may be referred to a physical therapist. The therapist will help you strengthen your muscles while the nerve heals.
The decision to return to a sport activity after a burner requires careful evaluation. It is important that the nerve has fully healed and there is a low chance of reinjury. AnMRI or EMG study may need to be done to confirm this. Multiple burner injuries in one season may be reason to restrict return to play. In this case, the player should consult an experienced sports medicine physician for evaluation.
Non-steroidal anti-inflammatory drugs, such as ibuprofen or naprosyn, may be used to reduce discomfort.
Icing the neck as needed may help to reduce discomfort.
To avoid burner, follow these guidelines:
- Keep the muscles around your neck and shoulders strong and flexible to help you withstand the stress of a direct blow.
- Learn safe sport techniques is essential.
- Avoid using your helmet as a contact point when tackling and blocking in football.
- Always make sure to wear the proper safety equipment for your sport.
- Pads and other modifications of athletic gear have been proposed in an effort to reduce the incidence of burners. These may be especially useful for players who have previously suffered injury.
American Orthopaedic Society for Sports Medicine http://www.sportsmed.org
Health Canada http://www.hc-sc.gc.ca
Accessed September 9, 2014.
Burners and stingers. American Academy of Orthopedic surgeons website. Available at:
Updated May 2010. Accessed September 9, 2014.
Dimberg EL, Ted M. Burns TM. Management of common neurologic conditions in sports. Clinics in Sports Medicine. 2005;24(3).
Kasow DB, Curl WW. "Stingers" in adolescent athletes. Instr Course Lect. 2006;55:711-716.
Weinberg J, Rokito S, et al. Etiology, treatment, and prevention of athletic "stingers". Clin Sports Med. 2003 Jul;22(3):493-500, viii.
Last Updated: 9/9/2014


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"No matter what we touch, an atom, or a cell, we cannot explain it without knowledge of the wide universe."
- Maria Montessori, 1948, To Educate the Human Potential
The Elementary students present their space projects in these photos from 2000 - 2001.
Stay warm out there and have a terrific Wednesday!
..and this was its steeple.
When we remodeled the former Calvary Baptist Church in 2000-2001 to become our Montessori school, we had to replace a few fixtures. The steeple was detached from the roof and lowered by crane to the parking lot below.
What do you do with a second-hand steeple? We gave it to a church down the road.
The demolition crew also removed the fiberglas baptistry by cutting it into pieces. All of the beautiful wood pews were sold. You can see one being used today in the school office. The colored windows were eventually replaced with clear glass.
This is what Building B looks like today.
Have a great Wednesday!
15 years ago the Lafayette Journal and Courier announced MSGL's plans to add an elementary program and move all of its programs to a new space.
The Morton Community Center on Chauncey Avenue had been MSGL's home since 1985.
As the article states, the new elementary program was originally going to be housed in a home on Rainbow Drive that had been donated by an MSGL family. A change of plans relocated that first class to some available classroom space inside the Temple Israel on Cumberland Avenue.
In February 2001, all of our programs, from the parent-infant class through elementary, moved into our permanent home in the former Calvary Baptist church on Soldiers Home Road.
In 2007, the elementary classes moved into the Montessori House, a remodeled home adjacent to the campus.
MSGL has plans to expand once again in the near future to add a second toddler classroom and a gym/gross motor space.
We're really reaching back here for Halloween gold - all the way back to 1989. Back in the day, the whole school had a costume parade in the Morton Center gymnasium. It was a big year for bunnies, clowns, and superheroes.
Winter is upon us and the staff of the Wayback Wednesday department is preparing to head south for the season. (The staff certainly wishes this was true.) Okay, we're not really going anywhere but we have discovered a treasure trove of awesome photos. We will be scanning them and organizing them over winter break. When everyone returns in January you can look forward to the beginning of "Building MSGL." It's the story of how our families built the MSGL campus that we know and love today.
To whet your appetites I am posting one photo from that winter of 2000. Look at this photo and see if you can figure out where in the school it is. The first commenter to get it correct wins a free Wayback Wednesday t-shirt. (The staff certainly wishes this was true.) Okay, no t-shirt but you can still be first. Have fun guessing!
Have a terrific Wednesday and an awesome winter break!
Today is school picture day!
When Harriet and "the ducky" show up to take our pictures, you can bet that the children are well-dressed, the snack is no-mess, and the staff is slightly stressed - for two whole days. Sometimes there are tears and pouty faces, but never in front of the children :)
These teachers from 2004 look pretty happy. Enjoy this week's Wayback Wednesday photos from 2004.
Smile, silly ducky! And have a terrific Wednesday.
This week we look back at some photos from 1998.
Anita McKinney, our first executive director, was leaving MSGL to live closer to her family in Florida. Her MSGL family held a farewell reception in her honor just before the winter break. These are photos of some of the children wishing her well.
Anita started working at MSGL in July, 1991 when the parent-owned school decided it needed a full-time. Up to then, the office staff coordinated with the Board of Directors. This next photo is actually from about 1996. It shows Anita with Beth Nichols, who was then the office manager, in the teeny, tiny office at Morton Center.
Beth is still with us and now works as our accountant. Anita has been working with Florida's Duval County Extension office since 1998. She is currently teaching personal financial management in Jacksonville. She is retiring in January and will start another "job" taking care of her twin grandchildren Dominic and Danica. She is excited about this new chapter in her life and told me, "They will be three by then , so I will start my own little Montessori home-school with them. I am looking forward to this next step!"
Best wishes, Anita! And happy Wednesday to you, faithful readers.


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My Day Snapshot
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Recent Activity
16 comments so far...
[email protected]yahoo.com
I read your profile today and it was so good to me.u know that i am interested to be a friend first.i also believe that coming to you will be a probability of meeting that very love that has been lacking in my entire life. please i will like you to contact me direct to my e-mail address, ([email protected]yahoo.com) i dont know the posebility of remaing in forum for long time,i will give you a full introduction of my self with my pictures ok. i will be waiting for your mail to my e-mail adsdress([email protected]yahoo.com) as you know
there is no age,race,colour n religion bar when it comes to true love,
cares Grace.
Flag as inappropriate Posted by on 7th November 2011
movie poster style birth announcements and invitation cards
www.myshowtimeposters.com or [email protected]myshowtimeposters.com
Flag as inappropriate Posted by on 1st October 2009
Did I tell you that "What the bleep do we know" is my favorite science movie?
Flag as inappropriate Posted by Lorena on 7th May 2008
Hey Kathy! Regarding Imbalance, I mostly feel out of balance at home.. I never have enough time to really do all that I need. Work I've got down to a science.
Flag as inappropriate Posted by The Tattooed Mommie on 21st March 2008
I took some time and read your blog, too funny, thanks for the laughs. Did you ever hire that beer b***h, cause I could use one !
Flag as inappropriate Posted by relaxnsmile on 16th March 2008
I was afaid to say I swear in front of my son that is definitly the run i dont follow!
Flag as inappropriate Posted by MommyDesignersDon'tCry on 5th March 2008
Kathy, I'll be thinking about you over my bottle of wine tomorrow night LOL
And is it bad that everytime I think of you I think of cervexia LOL
Flag as inappropriate Posted by The Tattooed Mommie on 29th November 2007
Hi Kathy-u guys had me giggling over ur comments on working out! If we all could be workout partners, I'm thinking there'd be beer bottles in the water holders and M&Ms coming out of our hydration packs.. and yes, i've fallen off a treadmill already a few times : )
Flag as inappropriate Posted by OliveMartini on 25th September 2007
Hi Kathy, I just read through a bit of both of your blogs and I really enjoyed them. I would love to add your links on to my blog.
Flag as inappropriate Posted by unkeptmomof3 on 21st September 2007
hi, i corrected the url. sorry. i checked out your blog. you are hilarious! glad to meet you.
Flag as inappropriate Posted by unkeptmomof3 on 20th September 2007
Thanks for the warm welcome, and you are right-it's so wonderful to meet someone in your neck of the woods. :)
Flag as inappropriate Posted by kellyandie on 19th September 2007
First, I have to congratulate you for being my first ever commenter on my blog! Ever. Yes, sad, I know.
And now I have to truly feel grateful that I'm not the only person on the planet that has a family member who hasn't been able to cut the umbilical cord, or in your case the, um, whatever it is that would be the male equivalent.
All I can say is, Thank God my mother hasn't learned how to text message, yet!!
Glad to meet you, I think we'll end up online BFF's because well, we both seem really awesome!
Flag as inappropriate Posted by The Tattooed Mommie on 19th September 2007


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Readings — From the November 2007 issue
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Readings — From the November 2007 issue
Readings — From the January 2002 issue
Article — From the October 1998 issue
When the Prague Spring came to a California high school
Article — From the March 1973 issue
Article — From the May 1950 issue
Article — From the April 1927 issue
A Timbuctoo portrait
Editor's drawer — From the July 1897 issue
Editor's drawer — From the September 1884 issue
Article — From the August 1884 issue
Fiction — From the June 1882 issue
Fiction — From the September 1881 issue
Poetry — From the September 1881 issue
Article — From the April 1881 issue
Editor's drawer — From the October 1880 issue
Fiction — From the January 1878 issue
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Article — From the October 1869 issue
Fiction — From the December 1861 issue
Editor's drawer — From the June 1857 issue
Thirty miles from the coast, on a desert plateau in the Judaean Mountains without natural resources or protection, Jerusalem is not a promising site for one of the world's great cities, which partly explains why it has been burned to the ground twice and besieged or attacked more than seventy times. Much of the Old City that draws millions of tourists and Holy Land pilgrims dates back two thousand years, but the area likely served as the seat of the Judaean monarchy a full millennium before that. According to the Bible, King David conquered the Canaanite city and established it as his capital, but over centuries of destruction and rebuilding all traces of that period were lost. In 1867, a British military officer named Charles Warren set out to find the remnants of David's kingdom. He expected to search below the famed Temple Mount, known to Muslims as the Haram al-Sharif, but the Ottoman authorities denied his request to excavate there. Warren decided to dig instead on a slope outside the Old City walls, observing that the Psalms describe Jerusalem as lying in a valley surrounded by hills, not on top of one.
On a Monday morning earlier this year, I walked from the Old City's Muslim Quarter to the archaeological site that Warren unearthed, the ancient core of Jerusalem now known as the City of David. In the alleys of the Old City, stone insulated the air and awnings blocked the sun, so the streets were cold and dark and the mood was somber. Only the pilgrims were up this early. American church groups filed along the Via Dolorosa, holding thin wooden crosses and singing a hymn based on a line from the Gospel of Luke: "Jesus, remember me when you come into your kingdom." Narrow shops sold gardenia, musk, and amber incense alongside sweatshirts promoting the Israel Defense Forces.
I passed through the Western Wall Plaza to the Dung Gate, popularly believed to mark the ancient route along which red heifers were led to the Temple for sacrifice. Outside the Old City walls, in the open air, I found light and heat and noise. Tour buses lined up like train cars along the ridge. Monday is the day when bar and bat mitzvahs are held in Israel, and drumbeats from distant celebrations mixed with the pounding of jackhammers from construction sites nearby. When I arrived at the City of David, workmen were refinishing the wooden deck at the site's entrance and laying down a marble mosaic by the ticket window.
A documentary about climate change, domain names, and capital
Eleven years ago, on a bitter January night, dozens of young men, dressed in a uniform of black berets, white T-shirts, and black pants, gathered on a hill overlooking the Nigerian city of Jos, shouting, dancing, and shooting guns into the black sky. A drummer pounded a rhythmic beat. Amid the roiling crowd, five men crawled toward a candlelit dais, where a white-robed priest stood holding an axe. Leading them was John, a sophomore at the local college, powerfully built and baby-faced. Over the past six hours, he had been beaten and burned, trampled and taunted. He was exhausted. John looked out at the landscape beyond the priest. It was the harmattan season, when Saharan sand blots out the sky, and the city lights in the distance blurred in John's eyes as if he were underwater.
John had been raised by a single mother in Kaduna, a hardscrabble city in Nigeria's arid north. She'd worked all hours as a construction supplier, but the family still struggled to get by. Her three boys were left alone for long stretches, and they killed time hunting at a nearby lake while listening to American rap. At seventeen, John had enrolled at the University of Jos to study business. Four hours southeast of his native Kaduna, Jos was another world, temperate and green. John's mother sent him an allowance, and he made cash on the side rearing guard dogs for sale in Port Harcourt, the perilous capital of Nigeria's oil industry. But it wasn't much. John's older brother, also studying in Jos, hung around with a group of Axemen—members of the Black Axe fraternity—who partied hard and bought drugs and cars. Local media reported a flood of crimes that Axemen had allegedly committed, but his brother's friends promised John that, were he to join the group, he wouldn't be forced into anything illegal. He could just come to the parties, help out at the odd charity drive, and enjoy himself. It was up to him.
John knew that the Black Axe was into some "risky" stuff. But he thought it was worth it. Axemen were treated with respect and had connections to important people. Without a network, John's chances of getting a good job post-degree were almost nil. In his second year, he decided to join, or "bam." On the day of the initiation, John was given a shopping list: candles, bug spray, a kola nut (a caffeinated nut native to West Africa), razor blades, and 10,000 Nigerian naira (around thirty dollars)—his bamming fee. He carried it all to the top of the hill. Once night fell, Axemen made John and the other four initiates lie on their stomachs in the dirt, pressed together shoulder to shoulder, and hurled insults at them. They reeked like goats, some Axemen screamed. Others lashed them with sticks. Each Axeman walked over their backs four times. Somebody lit the bug spray on fire, and ran the flames across them, "burning that goat stink from us," John recalled.
I couldn't leave. I couldn't get up—just couldn't get up, couldn't get up or leave. All day lying in that median, unable. Was this misery or joy?
It's happened to you, too, hasn't it? A habit or phase, a marriage, a disease, children or drugs, money or debt—something you believed inescapable, something that had been going on for so long that you'd forgotten any and every step taken to lead your life here. What did you do? How did this happen? When you try to solve the crossword, someone keeps adding clues.
It's happened to us all. The impossible knowledge is the one we all want—the big why, the big how. Who among us won't buy that lotto ticket? This is where stories come from and, believe me, there are only two kinds: one, naked lies, and two, pot holders, gas masks, condoms—something you must carefully place between yourself and a truth too dangerous to touch.
The Catholic School, by Edoardo Albinati. Farrar, Straus and Giroux. 1,280 pages. $40.
In a quiet northern suburb of Rome, a woman hears noises in the street and sends her son to investigate. Someone is locked in the trunk of a Fiat 127. The police arrive and find one girl seriously injured, together with the corpse of a second. Both have been raped, tortured, and left for dead. The survivor speaks of three young aggressors and a villa by the sea. Within hours two of the men have been arrested. The other will never be found.
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World Wildlife Fund (Washington)
A recent earthquake in Chile was found to have shifted the city of Concepción ten feet to the west, shortened Earth's days by 1.26 microseconds, and shifted the planet's axis by nearly three inches.
A federal judge in South Carolina ruled in favor of personal-injury lawyer George Sink Sr., who had sued his son, George Sink Jr., for using his own name at his competing law firm.
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"Nowadays, most states let just about anybody who wants a concealed-handgun permit have one; in seventeen states, you don't even have to be a resident. Nobody knows exactly how many Americans carry guns, because not all states release their numbers, and even if they did, not all permit holders carry all the time. But it's safe to assume that as many as 6 million Americans are walking around with firearms under their clothes."


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Pakistan Population: 201,995,540236 VISITORS FROM HERE!
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|The Indus Valley civilization, one of the oldest in the world and dating back at least 5,000 years, spread over much of what is presently Pakistan. During the second millennium B.C., remnants of this culture fused with the migrating Indo-Aryan peoples. The area underwent successive invasions in subsequent centuries from the Persians, Greeks, Scythians, Arabs (who brought Islam), Afghans, and Turks. The Mughal Empire flourished in the 16th and 17th centuries; the British came to dominate the region in the 18th century. The separation in 1947 of British India into the Muslim state of Pakistan (with West and East sections) and largely Hindu India was never satisfactorily resolved, and India and Pakistan fought two wars and a limited conflict - in 1947-48, 1965, and 1999 respectively - over the disputed Kashmir territory. A third war between these countries in 1971 - in which India capitalized on Islamabad's marginalization of Bengalis in Pakistani politics - resulted in East Pakistan becoming the separate nation of Bangladesh. In response to Indian nuclear weapons testing, Pakistan conducted its own tests in mid-1998. India-Pakistan relations improved in the mid-2000s but have been rocky since the November 2008 Mumbai attacks and have been further strained by attacks in India by militants suspected of being backed by Pakistan. Nawaz SHARIF took office as prime minister in 2013, marking the first time in Pakistani history that a democratically elected government completed a full term and transitioned to a successive democratically elected government. Following a series of bomb and suicide attacks by the Tehrik-e Pakistan Taliban (TTP) begun in 2007, the Pakistan Government and TTP representatives agreed to a cease-fire in early 2014. However, by mid-year 2014 the talks collapsed and the TTP resumed attack plotting against Pakistani targets.
Controls Khyber Pass and Bolan Pass, traditional invasion routes between Central Asia and the Indian Subcontinent
|Southern Asia, bordering the Arabian Sea, between India on the east and Iran and Afghanistan on the west and China in the north
|Geographic coordinates:
| total: 796,095 sq km
land: 770,875 sq km
water: 25,220 sq km
Size comparison: slightly more than five times the size of Georgia; slightly less than twice the size of California
|Land Boundaries:
|total: 7,257 km border countries (4): Afghanistan 2,670 km, China 438 km, India 3,190 km, Iran 959 km
|1,046 km
|Maritime claims:
| territorial sea: 12 nm
contiguous zone: 24 nm
exclusive economic zone: 200 nm
continental shelf: 200 nm or to the edge of the continental margin
|mostly hot, dry desert; temperate in northwest; arctic in north
|divided into three major geographic areas: the northern highlands, the Indus River plain in the center and east, and the Balochistan Plateau in the south and west
|Elevation extremes:
|Natural resources:
|arable land, extensive natural gas reserves, limited petroleum, poor quality coal, iron ore, copper, salt, limestone
|Land use:
| agricultural land: 35.2% arable land 27.6%; permanent crops 1.1%; permanent pasture 6.5% forest: 2.1%
other: 62.7% (2011 est.)
|Irrigated land:
|202,000 sq km (2012)
|Natural hazards:
|frequent earthquakes, occasionally severe especially in north and west; flooding along the Indus after heavy rains (July and August)
|Current Environment Issues:
|water pollution from raw sewage, industrial wastes, and agricultural runoff; limited natural freshwater resources; most of the population does not have access to potable water; deforestation; soil erosion; desertification
|International Environment Agreements:
| party to: Biodiversity, Climate Change, Climate Change-Kyoto Protocol, Desertification, Endangered Species, Environmental Modification, Hazardous Wastes, Law of the Sea, Marine Dumping, Ozone Layer Protection, Ship Pollution, Wetlands
signed, but not ratified: Marine Life Conservation
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| noun: Pakistani(s)
adjective: Pakistani
|Ethnic groups:
|Punjabi 44.68%, Pashtun (Pathan) 15.42%, Sindhi 14.1%, Sariaki 8.38%, Muhajirs 7.57%, Balochi 3.57%, other 6.28%
|Punjabi 48%, Sindhi 12%, Saraiki (a Punjabi variant) 10%, Pashto (alternate name, Pashtu) 8%, Urdu (official) 8%, Balochi 3%, Hindko 2%, Brahui 1%, English (official; lingua franca of Pakistani elite and most government ministries), Burushaski, and other 8%
|Muslim (official) 96.4% (Sunni 85-90%, Shia 10-15%), other (includes Christian and Hindu) 3.6% (2010 est.)
|201,995,540 (July 2016 est.)
|Age structure:
| 0-14 years: 31.99% (male 33,195,073/female 31,429,440)
15-24 years: 21.31% (male 22,194,064/female 20,845,816)
25-54 years: 36.87% (male 38,680,978/female 35,794,333)
55-64 years: 5.43% (male 5,498,126/female 5,463,453)
65 years and over: 4.4% (male 4,139,899/female 4,754,358) (2016 est.)
|Dependency ratios:
| total dependency ratio: 65.3%
youth dependency ratio: 57.9%
elderly dependency ratio: 7.4%
potential support ratio: 13.5% (2015 est.)
|Median age:
| total: 23.4 years
male: 23.3 years
female: 23.4 years (2016 est.)
|Population growth rate:
|1.45% (2016 est.)
|Birth rate:
|22.3 births/1,000 population (2016 est.)
|Death rate:
|6.4 deaths/1,000 population (2016 est.)
|Net migration rate:
|-1.4 migrant(s)/1,000 population (2016 est.)
| urban population: 38.8% of total population (2015)
rate of urbanization: 2.81% annual rate of change (2010-15 est.)
|Major urban areas - population:
|Karachi 16.618 million; Lahore 8.741 million; Faisalabad 3.567 million; Rawalpindi 2.506 million; Multan 1.921 million; ISLAMABAD (capital) 1.365 million (2015)
|Sex ratio:
| at birth: 1.05 male(s)/female
0-14 years: 1.06 male(s)/female
15-24 years: 1.06 male(s)/female
25-54 years: 1.08 male(s)/female
55-64 years: 1.01 male(s)/female
65 years and over: 0.88 male(s)/female
total population: 1.06 male(s)/female (2016 est.)
|Mother's mean age at first birth:
|23.4 note: median age at first birth among women 25-29 (2012/13 est.)
|Maternal mortality rate:
|178 deaths/100,000 live births (2015 est.)
|Infant mortality rate:
| total: 53.9 deaths/1,000 live births male: 57 deaths/1,000 live births
female: 50.6 deaths/1,000 live births (2016 est.)
|Life expectancy at birth:
| total population: 67.7 years male: 65.8 years
female: 69.8 years (2016 est.)
|Total fertility rate:
|2.68 children born/woman (2016 est.)
|Contraceptive prevalence rate:
|35.4% (2012/13)
|Health expenditures:
|2.6% of GDP (2014)
|Physicians density:
|0.83 physicians/1,000 population (2010)
|Hospital bed density:
|0.6 beds/1,000 population (2012)
|Drinking water source:
| improved:
urban: 93.9% of population
rural: 89.9% of population
total: 91.4% of population
urban: 6.1% of population
rural: 10.1% of population
total: 8.6% of population (2015 est.)
|Sanitation facility access:
| improved:
urban: 83.1% of population
rural: 51.1% of population
total: 63.5% of population
urban: 16.9% of population
rural: 48.9% of population
total: 36.5% of population (2015 est.)
|HIV/AIDS - adult prevalence rate:
|0.09% (2015 est.)
|HIV/AIDS - people living with HIV/AIDS:
|102,000 (2015 est.)
|HIV/AIDS - deaths:
|3,600 (2015 est.)
|Obesity - adult prevalence rate:
|4.8% (2014)
|Children under the age of 5 years underweight:
|31.6% (2013)
|Education expenditures:
|2.7% of GDP (2015)
| definition: age 15 and over can read and write
total population: 57.9%
male: 69.5%
female: 45.8% (2015 est.)
|School life expectancy (primary to tertiary education):
| total: 8 years male: 9 years
female: 7 years (2014)
|Unemployment, youth ages 15-24:
| total: 10.4% male: 9.4%
female: 12.9% (2014 est.)
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|Country name:
| conventional long form: Islamic Republic of Pakistan
conventional short form: Pakistan
local long form: Jamhuryat Islami Pakistan
local short form: Pakistan
former: West Pakistan
etymology: the word "pak" means "pure" in Persian or Pashto, while the Persian suffix "-stan" means "place of" or "country," so the word Pakistan literally means "Land of the pure"
|Government type:
|federal parliamentary republic
| name: Islamabad
geographic coordinates: 33 41 N, 73 03 E
time difference: UTC+5 (10 hours ahead of Washington, DC, during Standard Time)
|Administrative divisions:
| 4 provinces, 1 territory*, and 1 capital territory**; Balochistan, Federally Administered Tribal Areas*, Islamabad Capital Territory**, Khyber Pakhtunkhwa (formerly North-West Frontier Province), Punjab, Sindh
note: the Pakistani-administered portion of the disputed Jammu and Kashmir region consists of 2 administrative entities: Azad Kashmir and Gilgit-Baltistan
|14 August 1947 (from British India)
|National holiday:
|Pakistan Day (also referred to as Pakistan Resolution Day or Republic Day), 23 March (1940); note - commemorates both the adoption of the Lahore Resolution by the All-India Muslim League during its 22-24 March 1940 session, which called for the creation of independent Muslim states, and the adoption of the first constitution of Pakistan on 23 March 1956 during the transition to the Islamic Republic of Pakistan
|several previous; latest endorsed 12 April 1973, passed 19 April 1973, entered into force 14 August 1973 (suspended and restored several times); amended many times, last in 2015 (2016)
|Legal system:
|common law system with Islamic law influence
|18 years of age; universal; note - there are joint electorates and reserved parliamentary seats for women and non-Muslims
|Executive branch:
| chief of state: President Mamnoon HUSSAIN (since 9 September 2013)
head of government: Prime Minister Mohammad Nawaz SHARIF (since 5 June 2013)
cabinet: Cabinet appointed by the president upon the advice of the prime minister elections/appointments: president indirectly elected by the Electoral College consisting of members of the Senate, National Assembly, and provincial assemblies for a 5-year term (eligible for reelection); election last held on 9 September 2013 (next to be held in 2018); prime minister selected by the National Assembly
election results: Mamnoon HUSSAIN elected president; Mamnoon HUSSAIN (PML-N) 432 votes, Wajihuddin AHMED (PTI) 77 votes
|Legislative branch:
| description: bicameral Parliament or Majlis-e-Shoora consists of the Senate (104 seats; members indirectly elected by the 4 provincial assemblies and the territories' representatives by proportional representation vote; members serve 6-year terms with one-half of the membership renewed every 3 years) and the National Assembly (342 seats; 272 members directly elected in single-seat constituencies by simple majority vote and 70 members - 60 women and 10 non-Muslims - directly elected by proportional representation vote; all members serve 5-year terms)
elections: Senate - last held on 5 March 2015 (next to be held in March 2018); National Assembly - last held on 11 May 2013 (next to be held by 2018)
election results: Senate - percent of vote by party - NA; seats by party - PPPP 27, PML-N 26, MQM 8, ANP 6, PTI 7, JUI-F 5, PML-Q 4, BNP-A 2, NP 1, PML-F 1, other 7, independent 10; National Assembly - percent of votes by party - NA; seats by party - PML-N 126, PPPP 31, PTI 28, MQM 18, JUI-F 10, PML-F 5, other 22, independent 25, unfilled seats 7; 60 seats reserved for women, 10 seats reserved for non-Muslims; seats by party as of July 2016 (includes women and non-Muslim seats) - PML-N 188, PPPP 46, PTI 33, MQM 24, JUI-F 13, PML-F 5, other 21, independent 12
|Judicial branch:
| highest court(s): Supreme Court of Pakistan (consists of the chief justice and 16 judges) judge selection and term of office: justices nominated by an 8-member parliamentary committee upon the recommendation of the Judicial Commission (a 9-member body of judges and other judicial professionals), and appointed by the president of Pakistan; justices can serve until age 65
subordinate courts: High Courts; Federal Shariat Court; provincial and district civil and criminal courts; specialized courts for issues such as taxation, banking, customs, etc.
|Political parties and leaders:
|Awami National Party or ANP [Mian Iftikhar HUSSAIN] Balochistan National Party-Awami or BNP-A [Mir Israr Ullah ZEHRI] Balochistan National Party-Mengal or BNP-M [Sardar Akhtar Jan MENGAL] Jamaat-i Islami or JI [Sirajul HAQ] Jamiat-i Ulema-i Islam Fazl-ur Rehman or JUI-F [Fazlur REHMAN] Muttahida Qaumi Movement or MQM [Farooq SATTAR] Pakhtun khwa Milli Awami Party or PkMAP [Mahmood Khan ACHAKZAI] Pakistan Muslim League-Functional or PML-F [Pir PAGARO or Syed Shah Mardan SHAH-II] Pakistan Muslim League-Nawaz or PML-N [Nawaz SHARIF] Pakistan Peoples Party Parliamentarians or PPPP [Bilawal Bhutto ZARDARI and Asif Ali ZARDARI] Pakistan Tehrik-e Insaaf or PTI [Imran KHAN] Pak Sarzameen Party or PSP [Mustafa KAMAL] Quami Watan Party or QWP [Aftab Ahmed Khan SHERPAO] note: political alliances in Pakistan shift frequently
|Political pressure groups and leaders:
|other: military; ulema (clergy); landowners; industrialists; small merchants
|International organization participation:
|ADB, ARF, ASEAN (dialogue partner), C, CICA, CP, D-8, ECO, FAO, G-11, G-24, G-77, IAEA, IBRD, ICAO, ICC (national committees), ICRM, IDA, IDB, IFAD, IFC, IFRCS, IHO, ILO, IMF, IMO, IMSO, Interpol, IOC, IOM, IPU, ISO, ITSO, ITU, ITUC (NGOs), MIGA, MINURSO, MONUSCO, NAM, OAS (observer), OIC, OPCW, PCA, SAARC, SACEP, SCO (observer), UN, UNAMID, UNCTAD, UNESCO, UNHCR, UNIDO, UNMIL, UNOCI, UNWTO, UPU, WCO, WFTU (NGOs), WHO, WIPO, WMO, WTO
|National symbol(s):
|star and crescent, jasmine; national colors: green, white
|National anthem:
| name: "Qaumi Tarana" (National Anthem)
lyrics/music: Abu-Al-Asar Hafeez JULLANDHURI/Ahmed Ghulamali CHAGLA
note: adopted 1954; also known as "Pak sarzamin shad bad" (Blessed Be the Sacred Land)
|Diplomatic representation in the US:
| chief of mission: Ambassador Jalil Abbas JILANI (since 10 March 2014)
chancery: 3517 International Court NW, Washington, DC 20008
telephone: [1] (202) 243-6500
consulate(s) general: Chicago, Houston, Los Angeles, New York consulate(s): Louisville (KY), San Francisco
|Diplomatic representation from the US:
| chief of mission: Ambassador David M. HALE (since 3 December 2015)
embassy: Diplomatic Enclave, Ramna 5, Islamabad
mailing address: 8100 Islamabad Place, Washington, DC 20521-8100
telephone: [92] (51) 208-0000/[92] (51) 201-4000
consulate(s) general: Karachi consulate(s): Lahore, Peshawar
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Decades of internal political disputes and low levels of foreign investment have led to slow growth and underdevelopment in Pakistan. Pakistan has a large English-speaking population. Nevertheless, a challenging security environment, electricity shortages, and a burdensome investment climate have deterred investors. Agriculture accounts for more than one-fourth of output and two-fifths of employment. Textiles and apparel account for most of Pakistan's export earnings, and Pakistan's failure to diversify its exports has left the country vulnerable to shifts in world demand. Pakistan's GDP growth has gradually increased since 2012. Official unemployment was 6.5% in 2015, but this fails to capture the true picture, because much of the economy is informal and underemployment remains high. Human development continues to lag behind most of the region. In coordination with the International Monetary Fund (IMF), Pakistan embarked on an economic reform program in 2013. While the reform process has been mixed, and issues like privatization of state-owned enterprises remain unresolved, Pakistan has restored macroeconomic stability, improved its credit rating, and boosted growth. The Pakistani rupee, after heavy depreciation, remained relatively stable against the US dollar in 2014-15. Remittances from overseas workers, averaging more than $1.5 billion a month, are a key revenue source for Pakistan, partly compensating for a lack of foreign investment and a slowdown in portfolio investment. Falling global oil prices in 2015 contributed to a narrowing current account deficit and lower inflation, despite weak export performance. Pakistan's program with the IMF – a three-year, $6.7 billion Extended Fund Facility focusing on reducing energy shortages, stabilizing public finances, expanding revenue, and improving the external balance – is slated to conclude in September 2016. While passing most quantitative targets, Pakistan has missed targets on structural reforms and performance criteria throughout the program. Pakistan remains stuck in a low-income, low-growth trap, with growth averaging about 3.5% per year from 2008 to 2013. Pakistan must address long-standing issues related to government revenues, with the tax base being narrow at 11% of GDP. Given demographic challenges, Pakistan's leadership will be pressed to implement economic reforms, promote further development of the energy sector, and attract foreign investment to support sufficient economic growth necessary to employ its growing and rapidly urbanizing population, much of which is under the age of 25. Other long-term challenges include expanding investment in education and healthcare, adapting to the effects of climate change and natural disasters, improving the country's business climate, and reducing dependence on foreign donors. Pakistan and China are implementing the "China-Pakistan Economic Corridor", a $46 billion investment program targeted towards the energy sector and other infrastructure project that Islamabad and Beijing had agreed on in early 2014.
|GDP (purchasing power parity):
| GDP (purchasing power parity): $988.2 billion (2016 est.) $943.8 billion (2015 est.) $907.2 billion (2014 est.)
note: data are in 2016 dollars data are for fiscal years
|GDP (official exchange rate):
|GDP (official exchange rate): $271.1 billion (2015 est.)
|GDP - real growth rate:
|4.7% (2016 est.) 4% (2015 est.) 4.1% (2014 est.) note: data are for fiscal years
|GDP - per capita (PPP):
| GDP - per capita (PPP): $5,100 (2016 est.) $5,000 (2015 est.) $4,900 (2014 est.)
note: data are in 2016 dollars data are for fiscal years
|Gross national saving:
|14.3% of GDP (2016 est.) 14.5% of GDP (2015 est.) 13.4% of GDP (2014 est.) note: data are for fiscal years
|GDP - composition, by end use:
| household consumption: 80.1%
government consumption: 11.8%
investment in fixed capital: 13.6%
investment in inventories: 1.6%
exports of goods and services: 8.7%
imports of goods and services: -15.8% (2016 est.)
|GDP - composition, by sector of origin:
| household consumption: 80.1%
government consumption: 11.8%
investment in fixed capital: 13.6%
investment in inventories: 1.6%
exports of goods and services: 8.7%
imports of goods and services: -15.8% (2016 est.)
|Agriculture - products:
|cotton, wheat, rice, sugarcane, fruits, vegetables; milk, beef, mutton, eggs
|textiles and apparel, food processing, pharmaceuticals, construction materials, paper products, fertilizer, shrimp
|Industrial production growth rate:
|6.8% (2016 est.)
|Labor force:
|65.1 million note: extensive export of labor, mostly to the Middle East, and use of child labor (2016 est.)
|Labor force - by occupation:
| agriculture: 43.7%
industry: 22.4%
services: 33.9% (FY2013 est.)
|Unemployment rate:
|6.7% (2016 est.) 6.4% (2015 est.) note: substantial underemployment exists
|Population below poverty line:
|22.3% (FY2005 est.)
|Household income or consumption by percentage share:
| lowest 10%: 4.2%
highest 10%: 25.6% (FY2011)
|Distribution of family income - Gini index:
| revenues: $41.77 billion
expenditures: $54.63 billion note: data are for fiscal years (2016 est.)
|Taxes and other revenues:
|15.4% of GDP (2016 est.)
|Public debt:
|58.5% of GDP (2016 est.) 57.3% of GDP (2015 est.)
|Fiscal year:
|1 July - 30 June
|Inflation rate (consumer prices):
|Inflation rate (consumer prices): 3.7% (2016 est.) 2.5% (2015 est.)
|Current account balance:
|-$2.627 billion (2015 est.) -$2.627 billion (2015 est.)
|$20.96 billion (2016 est.) $22.73 billion (2015 est.)
|Exports - commodities:
|textiles (garments, bed linen, cotton cloth, yarn), rice, leather goods, sporting goods, chemicals, manufactures, carpets and rugs
|Exports - partners:
|US 13.1%, UAE 9.1%, Afghanistan 9.1%, China 8.8%, UK 5.4%, Germany 4.9% (2015)
|$38.25 billion (2016 est.) $39.29 billion (2015 est.)
|Imports - commodities:
|petroleum, petroleum products, machinery, plastics, transportation equipment, edible oils, paper and paperboard, iron and steel, tea
|Imports - partners:
|China 28.1%, Saudi Arabia 10.9%, UAE 10.8%, Kuwait 5.6% (2015)
|Reserves of foreign exchange and gold:
|$20.53 billion (31 December 2016 est.) $20.05 billion (31 December 2015 est.)
|Debt - external:
|$64.04 billion (31 December 2016 est.) $60.91 billion (31 December 2015 est.)
|Stock of direct foreign investment - at home:
|$33.82 billion (31 December 2016 est.) $31.82 billion (31 December 2015 est.)
|Stock of direct foreign investment - abroad:
|$2.059 billion (31 December 2016 est.) $2.009 billion (31 December 2015 est.)
|Market value of publicly traded shares:
|$43.68 billion (31 December 2012 est.) $32.76 billion (31 December 2011 est.) $38.17 billion (31 December 2010 est.)
|Exchange rates:
|Pakistani rupees (PKR) per US dollar - 105.1 (2016 est.) 102.769 (FY2015 est.) 102.769 (FY2014 est.) 101.1 (FY2013 est.) 93.4 (2012 est.)
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|Electricity - production:
|100 billion kWh (2014 est.)
|Electricity - consumption:
|82 billion kWh (2014 est.)
|Electricity - exports:
|0 kWh (2013 est.)
|Electricity - imports:
|400 million kWh (2014 est.)
|Electricity - installed generating capacity:
|24 million kW (2014 est.)
|Electricity - from fossil fuels:
|67.1% of total installed capacity (FY2014 est.)
|Electricity - from nuclear fuels:
|3.2% of total installed capacity (FY2014 est.)
|Electricity - from hydroelectric plants:
|29.2% of total installed capacity (FY2014 est.)
|Electricity - from other renewable sources:
|0.4% of total installed capacity (FY2014 est.)
|Crude oil - production:
|90,210 bbl/day (2015 est.)
|Crude oil - exports:
|0 bbl/day (2013 est.)
|Crude oil - imports:
|150,800 bbl/day (2013 est.)
|Crude oil - proved reserves:
|400 million bbl (1 January 2016 es)
|Refined petroleum products - production:
|235,300 bbl/day (2013 est.)
|Refined petroleum products - consumption:
|450,000 bbl/day (2014 est.)
|Refined petroleum products - exports:
|17,120 bbl/day (2013 est.)
|Refined petroleum products - imports:
|228,000 bbl/day (2013 est.)
|Natural gas - production:
|39.07 billion cu m (2014 est.)
|Natural gas - consumption:
|39.97 billion cu m (2013 est.)
|Natural gas - exports:
|0 cu m (2013 est.)
|Natural gas - imports:
|0 cu m (2013 est.)
|Natural gas - proved reserves:
|669.4 billion cu m (1 January 2016 es)
|Carbon dioxide emissions from consumption of energy:
|145 million Mt (2013 est.)
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|Cellular Phones in use:
|total: 125.9 million subscriptions per 100 inhabitants: 63 (July 2015 est.)
|Telephone system:
| general assessment: the telecommunications infrastructure is improving, with investments in mobile-cellular networks increasing, but fixed-line subscriptions declining; system consists of microwave radio relay, coaxial cable, fiber-optic cable, cellular, and satellite networ
domestic: mobile-cellular subscribership has skyrocketed; more than 90% of Pakistanis live within areas that have cell phone coverage; fiber-optic networks are being constructed throughout the country to increase broadband access, though broadband penetration in Pa
international: country code - 92; landing point for the SEA-ME-WE-3 and SEA-ME-WE-4 submarine cable systems that provide links to Asia, the Middle East, and Europe; satellite earth stations - 3 Intelsat (1 Atlantic Ocean and 2 Indian Ocean); 3 operational international (2015)
|Broadcast media:
|media is government regulated; 1 dominant state-owned TV broadcaster, Pakistan Television Corporation (PTV), operates a network consisting of 8 channels; private TV broadcasters are permitted; to date 69 foreign satellite channels are operational; the sta (2015)
|Internet country code:
|Internet users:
|total: 35.835 million percent of population: 18% (July 2015 est.)
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|151 (2013)
|Airports (paved runways):
| total 108
over 3,047 m: 15
2,438 to 3,047 m: 20
1,524 to 2,437 m: 43
914 to 1,523 m: 20
under 914 m: 10 (2013)
|Airports (unpaved runways):
| total 43
2,438 to 3,047 m: 1
1,524 to 2,437 m: 9
914 to 1,523 m: 9
under 914 m: 24 (2013)
|23 (2013)
|gas 12,646 km; oil 2,576 km; refined products 1,087 km (2013)
| total 11,881 km
broad gauge: 11,492 km 1.676-m gauge (293 km electrified)
narrow gauge: 389 km 1.000-m gauge (2015)
| total 263,942 km
paved: 185,063 km (includes 708 km of expressways)
unpaved: 78,879 km (2014)
|Merchant marine:
| total 11
by type: bulk carrier 5, cargo 3, petroleum tanker 3
registered in other countries: 11 (Comoros 5, Marshall Islands 1, Moldova 1, Panama 3, Saint Kitts and Nevis 1) (2010)
|Ports and terminals:
|major seaport(s): Karachi, Port Muhammad Bin Qasim container port(s) (TEUs): Karachi (1,545,434) LNG terminal(s) (import): Port Qasim
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|Military branches:
|Pakistan Army (includes National Guard), Pakistan Navy (includes Maritime Security Agency), Pakistan Air Force (Pakistan Fiza'ya) (2015)
|Military service age and obligation:
|16-23 years of age for voluntary military service; soldiers cannot be deployed for combat until age 18; the Pakistani Air Force and Pakistani Navy have inducted their first female pilots and sailors; the Pakistan Air Force recruits aviation technicians at age 15; service obligation (Navy) 10-18 years; retirement required after 18-30 years service or age 40-52 (2012)
|Military expenditures:
|3.5% of GDP (2013) 3.5% of GDP (2012) 3.2% of GDP (2011)
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|Transnational Issues
|Disputes - International:
|various talks and confidence-building measures cautiously have begun to defuse tensions over Kashmir, particularly since the October 2005 earthquake in the region; Kashmir nevertheless remains the site of the world's largest and most militarized territorial dispute with portions under the de facto administration of China (Aksai Chin), India (Jammu and Kashmir), and Pakistan (Azad Kashmir and Northern Areas); UN Military Observer Group in India and Pakistan has maintained a small group of peacekeepers since 1949; India does not recognize Pakistan's ceding historic Kashmir lands to China in 1964; India and Pakistan have maintained their 2004 cease-fire in Kashmir and initiated discussions on defusing the armed standoff in the Siachen glacier region; Pakistan protests India's fencing the highly militarized Line of Control and construction of the Baglihar Dam on the Chenab River in Jammu and Kashmir, which is part of the larger dispute on water sharing of the Indus River and its tributaries; to defuse tensions and prepare for discussions on a maritime boundary, India and Pakistan seek technical resolution of the disputed boundary in Sir Creek estuary at the mouth of the Rann of Kutch in the Arabian Sea; Pakistani maps continue to show the Junagadh claim in India's Gujarat State; since 2002, with UN assistance, Pakistan has repatriated 3.8 million Afghan refugees, leaving about 2.6 million; Pakistan has sent troops across and built fences along some remote tribal areas of its treaty-defined Durand Line border with Afghanistan, which serve as bases for foreign terrorists and other illegal activities; Afghan, Coalition, and Pakistan military meet periodically to clarify the alignment of the boundary on the ground and on maps
|Refugees and internally displaced persons:
|refugees (country of origin): 2.6 million (1.6 million registered, 1.0 million undocumented) (Afghanistan) (2015) IDPs: 1.459 million (primarily those who remain displaced by counter-terrorism and counter-insurgency operations and violent conflict between armed non-state groups in the Federally Administered Tribal Areas and Khyber-Paktunkwa Province; more than 1 million displaced in Northern Waziristan in 2014; individuals also have been displaced by repeated monsoon floods) (2015)
|Illicit drugs:
|significant transit area for Afghan drugs, including heroin, opium, morphine, and hashish, bound for Iran, Western markets, the Gulf States, Africa, and Asia; financial crimes related to drug trafficking, terrorism, corruption, and smuggling remain problems; opium poppy cultivation estimated to be 2,300 hectares in 2007 with 600 of those hectares eradicated; federal and provincial authorities continue to conduct anti-poppy campaigns that utilizes forced eradication, fines, and arrests
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Source: CIA - The World Factbook


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Free shipping on all orders within Europe* - See details
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text:
Hoke wrote:Which brilliant legislative and parental thinking led to the interesting situation where one county was at 19 years old, and the next county was at 18 years old, and (quite literally) hundreds of kids every night, with lots more on the weekends, driving up to the next county, getting bombed out of their minds, and then driving back home, with the usual litter of crashed vehicles and dead bodies scattered willy-nilly along the highways.
Just curious--in what state was this done on a county-by-county basis? I thought this was usually handled state-by-state. Still, the situation you describe did indeed occur at the Massachusetts/Connecticut border, when Massachusetts raised the drinking age from 18 to 19, but Connecticut still had it at 18.
Another question on this topic: what constitudes "abusive" and "pathological" drinking according to this report? I've seen some surveys and reports from neo-prohibitionist sources where if you had four beers at a weekend party, they'd class that as a "binge".
-Paul W.


text:
Second tug arrives to tow disabled cruise ship
UPDATE: The Coast Guard tells The Associated Press that a second tug boat has reached a disabled cruise ship in the Gulf of Mexico and is helping tow it to Mobile, Ala.
Coast Guard Petty Officer Richard Brahm in Houston says the ship was about 270 miles south of Mobile as of Tuesday morning. It is expected to arrive there Thursday, AP reports.
The second of two tugboats tasked with towing the disabled Carnival Triumph was scheduled to arrive at the cruise ship's site in the Gulf of Mexico on Tuesday and help direct it to an Alabama port, cruise officials said.
More Information
The 4,200 passengers and crew of the ship were initially set to arrive in Galveston Monday morning, but instead spent the last two days drifting aimlessly in the Gulf waiting for rescue after a fire erupted in an engine room Sunday morning. The fire knocked out the ship's propulsion system.
No injuries were reported.
The two tugboats, one from Mobile, Ala., and another from Mexico, were scheduled to began pulling the Triumph on Monday evening to Progreso, Mexico, the closest port.
But the ship had drifted about 90 miles north due to strong currents, cruise officials said Monday, That meant Mobile was just as close and with the current.
Mobile also provides simpler re-entry, officials said, noting that 900 passengers do not have passports.
The ship had been dead in the water at least 150 miles off the coast of the Yucatan Peninsula since the fire erupted. The ship's extinguishing systems stifled the fire.
The Triumph has been using its backup generator and passengers have had limited access to bathrooms, food and hot coffee since the engine failure.
Sunday afternoon, another cruise ship, the Carnival Elation, supplied dinners to the Triumph and Carnival Legend did the same on Monday. The U.S. Coast Guard Cutter Vigorous provided assistance early Monday morning.
The team on board has slowly been restoring auxiliary power to operate basic hotel functions. Public and cabin toilets are operational and some power has been restored to a few elevators and in a dining area.
Cruise officials said Carnival Triumph guests will receive a full refund of the cruise, along with transportation expenses. They will also receive a cruise credit equal to the amount paid for the current voyage, including reimbursement for most shipboard purchases during the voyage.
Triumph voyages scheduled for Feb. 11 and Saturday were canceled. Those guests will receive a full refund and a 25 percent discount on a future three to five-day cruise.
A similar situation occurred on a Carnival cruise ship in November 2010. That was also stranded for three days with 4,500 people aboard after a fire in the engine room. When the passengers disembarked in San Diego they described a nightmarish three days in the Pacific with limited food, power and bathroom access.
The Associated Press contributed to this report


text:
Warm Little Inflaton becomes Cold Dark Matter, João G. Rosa, Luís B. Ventura; Phys. Rev. Lett. 122, 161301 (2019), arXiv:1811.05493 [hep-ph].
Warm Little Inflaton becomes Cold Dark Matter
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