The Effects Of Fire Fighting And On-Scene Rehabilitation .

2y ago
17 Views
2 Downloads
1.40 MB
33 Pages
Last View : 21d ago
Last Download : 2m ago
Upload by : Evelyn Loftin
Transcription

The Effects of Fire Fighting andOn-Scene Rehabilitation on HemostasisGavin P. Horn, Steven J. Petruzzello,George C. Fahey, Bo Fernhall,Jeffrey Woods, Denise L. SmithUniversity of Illinois Fire Service Institute11 Gerty Drive, Champaign, IL, 61820November 2010i

The Effects of Fire Fighting and On-Scene Rehabilitation on HemostasisThis study was supported by the National Institute for Occupational Safety and Health(NIOSH) through an R03 Grant (1R03 OH009111-01) awarded to the University of Illinois.ii

AcknowledgementsPrimary AuthorsGavin P. Horn, Ph.D., Director of Research, Illinois Fire Service Institute; Senior Research Scientist,Department of Mechanical Science & EngineeringSteven J. Petruzzello, Ph.D., Associate Professor, Director of Exercise Psychophysiology Laboratory,Department of Kinesiology & Community Health, University of Illinois at Urbana-ChampaignGeorge C. Fahey, Jr., Ph.D., Kraft Foods Human Nutrition Endowed Professor, Professor of Animal andNutritional Sciences, University of Illinois at Urbana-ChampaignBo Fernhall, Ph.D., Professor, Department of Kinesiology & Community Health, University of Illinois atUrbana-ChampaignJeffrey Woods, Ph.D., Professor, Director of Exercise Immunology Laboratory, Department of Kinesiology & Community Health, University of Illinois at Urbana-ChampaignDenise L. Smith, Ph.D., Professor of Exercise Science, Skidmore College; Research Scientist, Illinois FireService Institute, University of Illinois at Urbana-ChampaignWe wish to express our appreciation to the following Fire Departments from acrossIllinois who participated in the study:Johnston City Fire DepartmentOttawa Fire DepartmentQuincy Fire DepartmentSavoy Fire DepartmentStreator Fire DepartmentTri-Township Fire Protection DistrictUrbana Fire Rescue ServicesBloomington Fire DepartmentCalumet City Fire DepartmentChampaign Fire DepartmentCoal Valley Fire Protection DistrictCornbelt Fire Protection DistrictCrystal Lake Fire Rescue DepartmentEast Moline Fire DepartmentEdge-Scott Fire Protection Districtiii

Effects of Firefighting and On-Scene Rehabilitation on HemostasisWe gratefully acknowledge the substantial support we received from staff membersin the following University of Illinois departments and units:Illinois Fire Service InstituteAdministration and administrative staff, in particular, Sue BlevinsInstructional staffStokersInformation Technology staffLibraryDepartment of Kinesiology and Community HealthExercise and Cardiovascular Research Laboratory (Graduate Student: Chris Fahs)Exercise Immunology Research Laboratory (Graduate Student: Cesar Vasquez)Exercise Psychophysiology Laboratoryiv

Table of ContentsList of terms and abbreviations - 2 Abstract - 3 Background - 5 Motivation - 6 Literature review – Cardiovascular strain and hemostasis - 6 Specific Aims - 7 Procedures - 8 Study design - 8 Fire fighting drills - 9 Methodology -11 Descriptive variables - 11 Body temperature - 11 Hemostasis and cardiovascular alterations - 11 Plasma cortisol and catecholamines - 11 Arterial pulse waves/blood pressure - 11 Psychological/perceptual and cognitive function factors - 11 Data analysis - 12 Results and Discussion - 13 Descriptive measures - 13 Heart rate and core temperature - 13 Blood pressure - 15 Hemostatic variables - 17 Plasma volume - 17 Platelet number and function - 18 Coagulation and fibrinolysis - 19 Catecholamine response - 19 Arterial Function - 20 Myocardial oxygen supply and demand - 21 Psychological & cognitive responses - 23 Analysis of aerobic power - 24 Conclusions - 25 Summary of effects of fire fighting recovery - 25 Summary of effect of rehab condition - 26 Literature Cited - 27 -1

The Effects of Firefighting and On-Scene Rehabilitation on HemostasisList of terms and abbreviationsaDBP – aortic diastolic blood pressure (via arterial tonography)aMP – aortic mean pressure (via arterial tonography)aPP – aortic pulse pressure (via arterial tonography)aSBP – aortic systolic blood pressure (via arterial tonography)ACS – Acute coronary syndromesADP – adenosine 5’-diphosphateBMI – Body mass indexCBC – Complete blood cell countCPT - Continuous Performance TestDBP – diastolic blood pressure (via auscultation)EPI – EpinephrineFVIII – Factor VIIIGI – GastrointestinalHb – hemoglobinHct - hematocritHDL – High-density lipoproteinHR – Heart rateLDL – Low-density lipoproteinMANOVA - multivariate analysis of varianceNFPA – National Fire Protection AssociationOSR – On-scene rehabilitationpDBP – peripheral diastolic blood pressure (via arterial tonography)pMP – peripheral mean pressure (via arterial tonography)pPP – peripheral pulse pressure (via arterial tonography)pSBP – peripheral systolic blood pressure (via arterial tonography)Pai-1 act - Plasminogen activator inhibitor activityPai-1 agn - Plasminogen activator inhibitor antigenPF1.2 – Prothrombin fragmentPFA – Platelet function analyzerPPE – Personal Protective EquipmentRPE – Ratings of perceived exertionRPP – Rate Pressure ProductRT – Reaction timeSBP – Systolic blood pressure (via auscultation)SEVR – Subendocardial Viability RatioTco – Core temperatureTF – Tissue FactortPa act – Tissue plasminogen activator activitytPa agn - Tissue plasminogen activator antigenWAT – Wingate Anaerobic Test2

Abstractlar strain. Immediately post-fire fighting, coretemperature, heart rate, blood pressure and bloodcatecholamine levels were significantly elevatedfrom baseline conditions. Platelet function andnumber, along with coagulatory and fibrinolytic variables, showed significant increases frombaseline, suggesting that the hemostatic equilibrium was disrupted. Vascular function was significantly affected, as evidenced by a reductionin the ability to perfuse myocardial tissue (measured through the Subendocardial Viability Ratio – SEVR). Finally, firefighters’ psychologicalstate became significantly more dysphoric postfire fighting.Importantly, the time rate of recovery frommany of these effects appeared to be closer toseveral hours instead of minutes (as is often assumed). Heart rate and core temperature did notreturn to baseline levels for up to 60 minutes intothe recovery. Blood pressure was found to dropvery rapidly in many individuals during rehab,suggesting that we must be aware of the risk ofsyncope during rehab procedures. Vascular recovery data also showed that SEVR did not return tobaseline for up to 60-90 minutes into recovery.After 120 minutes of recovery, it was found thatfibrinolytic markers returned to baseline levels,but coagulation (specifically Factor VIII andplatelet function) remained significantly elevated. As many heart attacks on the fireground occurfollowing fire suppression, these results suggested a possible mechanism for the increased risk.At the 120 minute recovery period, firefighters’psychological state appeared to have returned tobaseline conditions.OSR had no effect on core temperature, suggesting that the active cooling process was nomore effective than passive cooling in cool environmental conditions in which rehab was conducted in a cool room. There was also no significant effect on blood pressure, coagulation orFire fighting is a dangerous occupation - inpart because firefighters are called upon to perform strenuous physical activity in hot, hostileenvironments. Each year, approximately 100firefighters lose their lives in the line of duty andtens of thousands are injured. Over the past 15years, approximately 45% of line of duty deathshave been attributed to heart attacks and another650-1,000 firefighters suffer non-fatal heart attacks in the line of duty each year. From 1990to 2004, the total number of fireground injurieshas declined, yet during this same period, thenumber of cases related to the leading cause ofinjury - overexertion/strain – remained relativelyconstant.It is well recognized that fire fighting leadsto increased cardiovascular and thermal strain.However, the time course of recovery from firefighting is not well documented, despite the factthat a large percentage of fire fighting fatalitiesoccur after fire fighting activity. Furthermore,on scene rehabilitation (OSR) has been broadlyrecommended to mitigate the cardiovascular andthermal strain associated with performing strenuous fire fighting activity, yet the efficacy of different rehabilitation interventions has not beendocumented.Twenty-five firefighters were recruited to participate in a “within-subjects, repeated measures”study designed to describe the acute effects offire fighting on a broad array of physiologicaland psychological measures and several key cardiovascular variables. This study provided thefirst detailed documentation of the time courseof recovery during 2½ hours post-fire fighting.Additionally, we compared two OSR strategies(standard and enhanced) to determine their effectiveness.As expected, a short term bout (18 minutes)of fire fighting activity resulted in significantphysiological, psychological, and cardiovascu3

The Effects of Firefighting and On-Scene Rehabilitation on Hemostasisto baseline after 120 minutes of recovery). Eachgroup was equally hydrated from baseline levels (based on changes in plasma volume), so thiseffect is not due to hemoconcentration. Finally,epinephrine levels remained elevated after 120minutes of recovery in the standard condition,but returned to baseline in the enhanced condition, potentially due to the additional ingestion ofcarbohydrates in the recovery drink.fibrinolytic variables or psychological measuresas a result of the enhanced rehab protocol. Theenhanced rehab protocol resulted in significantlyelevated heart rate throughout recovery and a statistically significant delayed return to baseline forboth heart rate and SEVR. However, the practical/clinical significance of these small differencesin heart rate are unclear. Platelet number was alsosignificantly elevated in the enhanced conditioncompared to the standard (which had returned4

BackgroundMotivationFirefighters encounter unique occupationalrisks. Hostile and dangerous conditions at thescene of a structural fire can include fire, heat,smoke, decreased visibility, high noise levels,chaos, and a constantly changing environment.Fire fighting is a dangerous occupation, inpart because firefighters are called upon to perform strenuous physical activity in hot, hostileenvironments. However, little is known aboutthe most effective methods to cool, rehydrate andreverse imbalances caused by working in suchstressful environments. Each year, approximately 100 firefighters lose their lives in the line ofduty and tens of thousands are injured. Over thepast 10 years, approximately 40-50% of line ofduty deaths have been attributed to heart attacksas shown in Figure 1 [1-16]. Another 650-1,000firefighters suffer non-fatal heart attacks in theline of duty each year [17-31]. In addition to therisk of a myocardial infarction, firefighter injuries continue to plague the fire service. In 2004,nearly 76,000 firefighters were injured, with 48%occurring on the fireground [17]. An analysisfrom 1990 to 2004 reveals that the total numberof fireground injuries has declined from 57,100to 36,880, yet during this same period the number of cases related to the leading cause of injury– overexertion/strain – remained relatively constant [17-31].It is well recognized that fire fighting leadsto increased cardiovascular and thermal strain[32,33]. However the time course of recoveryfrom fire fighting is not well documented despitethe fact that a large percentage of fire fighting fatalities occur after fire fighting activity [34]. Furthermore, on scene rehabilitation (OSR) has beenbroadly recommended to mitigate the cardiovascular and thermal strain associated with performing strenuous fire fighting activity, yet the effectiveness of different rehabilitation interventionshas not been documented.The purpose of this study was to describe theacute effects of fire fighting on a broad array ofcardiovascular variables, hemostatic variables,vascular function, psychological/perceptual variables, cognitive function, and to document thetime course of recovery of each. Additionally, wecompared two OSR strategies (standard and enhanced) to determine their effectiveness.The Effects of Fire Fighting and On-Scene Rehabilitation on Hemostasis5

On-Duty Firefighter Deaths - Cardiac vs Others(Source: NFPA Journal, 1991-2009)140Other fatalitiesSudden cardiac deathNumber of 00420062008Age GroupFigure 1. Firefighter fireground fatality trends from 1990-2009 [1-16].Literature review – Cardiovascular strainand hemostasisAcute coronary syndromes (ACS) are lifethreatening conditions that range from unstablepatterns of angina to acute myocardial infarctions. The majority of heart attacks result fromthe disruption of atherosclerotic plaque followedby platelet aggregation and the formation of anintracoronary thrombus [35]. The developmentof an acute coronary event involves the transition from chronic atherosclerosis (plaque buildup) to acute clot formation [36]. Fire fightingactivities involve strenuous muscular work in ahostile environment and leads to activation of thesympathetic nervous system (adrenaline surge).The increase in sympathetic nervous systemactivity can result in increases in heart rate andblood pressure that may cause a plaque to rupture. Thus, fire fighting is likely to dramaticallyalter the the blood vessel wall, platelets, and thethe blood clotting system (hemostatic system).Platelet activation and aggregation are thefirst step in blood clot formation. Abnormal plate6let function also plays a pivotal role in unstableangina, acute myocardial infarction, and suddencardiac death [37,38]. Aerobic exercise causesan increase in platelet number [39] and thereis strong evidence that intense exercise leadsto increased platelet aggregation and function[37,38]. Our recent work has demonstrated thateven short bouts of firefighting increases plateletnumber and activity. [40]Hemostatic balance refers to the balance between blood clot formation (coagulation) andblood clot breakdown (fibrinolysis). Hemostasisis carefully regulated to keep blood fluid undernormal circumstances and to promote the rapidformation of a blood clot when necessary. Therapid formation of a blood clot in response toinjury is essential to the preservation of life anddepends on the coordinated activity of platelets,the blood vessel wall, and plasma proteins (coagulatory and fibrinolytic factors). On the otherhand, excessive clot formation or the inability todissolve a clot once a wound is repaired can alsopresent life-threatening challenges. A blood clotBackground

that forms in the cardiovascular system is calleda thrombus, and it is the primary cause of a heartattack.Maintaining hemostatic balance is necessaryin order to prevent dangerous thrombus formation and is determined by complex interactionsbetween circulating proteins (coagulatory andanticoagulatory factors), platelets and the cellslining blood vessels. Research indicates that exercise leads to enhanced coagulatory potential (e.g.increased factor VIII activity) that is dependentupon intensity and duration of activity [41,42].Fibrinolytic activity is also enhanced followingexercise [41]. Importantly, however, researchsuggests that these coagulatory and fibrinolyticactivities do not recover at the same rate following aerobic exercise [41,42]. Hedge et al. havereported that both coagulatory and fibrinolyticactivity are enhanced following strenuous exercise, but coagulatory potential remains elevatedone hour post-activity whereas fibrinolytic activity returns to baseline during the same period[43]. Lin et al. have reported that elevated coagulatory potential (increased Factor VIII) persistedat 2 and 6 hours of recovery whereas fibrinolyticactivity fell sharply [41]. The discrepancy in co-agulatory and fibrinolytic potential during recovery from strenuous activity may account for anincreased vulnerability to myocardial infarctionin the hour following strenuous activity [41,44].There is a lack of research investigating theeffects of fire fighting on the hemostatic systemdespite the critical importance of the hemostaticsystem in acute coronary syndromes, the knowledge that myocardial infarctions are the leadingcause of line of duty deaths among firefighters,and research evidence of hemostatic disruptionfollowing strenuous physical activity. Thereforethe purpose of this study was to examine the effects of strenuous fire fighting activities andrecovery from fire fighting on key hemostaticvariables. A second aim of this study was to investigate the effectiveness of different on-scenerehabilitation interventions following structuralfire fighting tasks. This study provides importantscientific information regarding the effect of firefighting on the hemostatic system and practicalinformation for determining effective rehabilitation strategies for firefighters in an attempt tolessen the impact of dangerous heat stress conditions, mitigate cardiovascular strain, and improvefirefighter performance.Specific AimsThe purpose of this study was to describe theacute effects of fire fighting on a broad array ofcardiovascular variables - namely, hemostaticvariables and vascular function - and to document the time course of recovery. Additionally,we compared two on-scene rehabilitation (OSR)strategies (standard and enhanced) to determinetheir effectiveness.Specifically, we measured changes in hemostatic variables following strenuous fire fighting activity and documented the extent to whichthese variables return to baseline following 120minutes of recovery. In the same study, we investigated changes over 120 minutes of recovery to acontrol OSR intervention (hydration only – typical fire service practice) and an enhanced OSRintervention (aggressive rehydration, electrolytereplacement, and cooling).Firefighters performed strenuous live-firedrills in a training structure and received onscene rehabilitation prior to performing a test ofanaerobic power in order to allow us to addressthe following specific aims of the proposed research: Investigate the effects of strenuous firefighting and 120 minutes of recovery from firefighting on hemostasis (platelet function, coagulatory and fibrinolytic potential).The Effects of Firefighting and On-Scene Rehabilitation on Hemostasis7

Investigate the effects of different OSR protocols on subsequent anaerobic performanceand hemostatic variables following 120 minutes of recovery. Investigate the effects of OSR on vascularfunction. Bring research to practice by distributing theresults of this research to the Fire Service sothat occupation-specific scientific data can beused to inform the development of firefighterOSR protocols.ProceduresStudy DesignTwenty-five firefighters were recruited toparticipate in a study designed to investigate theeffects of strenuous fire fighting activity on hemostasis and the effectiveness of on-scene rehabilitation interventions on subsequent physicalperformance and physiological recovery. Eachsubject performed the same set of fire fightingdrills on 2 separate days and participated in eachOSR protocol. The two trials were separated by aminimum of 48 hours and administered in a counterbalanced fashion to ensure half of the participants received the control condition first and halfthe participants received the enhanced conditionfirst. Of the 25 recruited subjects, 21 completedboth trials of the study. A schematic descriptionof the timeline for each trial is shown in Figure2. Each of the measures outlined in Section Dwere obtained at baseline prior to engaging infire fighting drills. The subject then performedthe prescribed fire fighting drills in full personalprotective equipment (PPE). Immediately uponcompletion of the fire fighting evolution, a second blood sample was obtained. Participants thenrehabilitated for 15 minutes (control or enhancedcondition) followed by a second data collectionperiod for perceptual and cognitive function measures. Firefighters performed a dummy drag protocol as a measure of maximal anaerobic power.Following rehabilitation, participants changedinto dry clothes and walked to an adjacent building (fire station) where they would remain duringthe recovery period.8Participants then recovered for 120 minutesin their station uniform. During recovery, firefighters were in the seated position and engagedin classroom activities or reading to mimic whatmay occur at a fire station following a fire call(assuming the suppression crew was relieved ofoverhaul and clean-up duties). At the end of the120 minute recovery period a third blood samplewas obtained and a third set of perceptual datacollected. Throughout the scenario, core temperature and heart rate were continuously monitored.Blood pressure was assessed via auscultation immediately post-fire fighting, every five minutesduring rehab, and every 15-30 minutes duringrecovery. Rate Pressure Product (RPP) was calculated as the product of systolic blood pressureand heart rate divided by 100. RPP provides anestimate of myocardial oxygen consumption.Additionally, vascular function was assessed viaperipheral and aortic blood pressures and Subendocardial Viability Ration (SEVR) with an AtcorSphygmocor system pre- and post-fire fightingas well as post-rehab and throughout recovery.All blood samples were subsequently analyzedfor key hemostatic variables including: plateletnumber and function, coagulatory, anticoagulatory, profibrinolytic, and antifibrinoltyic variables, and for blood catecholamine (epinephrine,norepinephrine) and cortisol levels.Only the OSR protocol differed between thetwo trials. During the “control” trial, participantsremoved their helmet, hood, gloves, and bunkercoat. Participants were provided with only waterProcedures

ControlRehabFirefighting r*HR/Tco*BP*Perceptual*CognitiveFigure 2. Schematic of study design and timeline. Note that time is not drawn to scale.and the amount of water ingested was recorded.The control condition was meant to reflect whatis typically done at a fire scene - although werecognize there is great variability in how rehab is conducted. During the “enhanced” trialparticipants were required to remove all of theirturn-out gear (including bunker coat and pants),consume up to 500 ml of water and at least 355ml of a commercially available sport drink, andwere aggressively cooled using cold towels asis recommended by leading authorities on OSR[45-47]. In addition, during recovery, firefightersparticipating in the “enhanced” trial were provided with 355 ml of a commercially availablerecovery drink. Assessing maximal anaerobicpower via a dummy drag protocol provided estimates of the ability of a firefighter to performmaximal physical work following OSR. In fact,one of the goals of OSR is to ensure that firefighters have recovered physiologically so that theycan perform maximally if called upon to do so.Fire fighting drillsThe fire fighting drills were completed in 18minutes (requiring approximately 1 bottle of airfor most subjects) and consisted of nine 2-minuteperiods of alternating work and rest. The workcycles included stair climbing, simulated forcibleentry, a simulated search, and simulated hose ad-vance. These drills have been employed in previous studies and have been published in peerreviewed articles [e.g. 32,33] and Fire Servicejournals [e.g. 48-43].Each participant was paired up with a memberof the research staff, trained in fire fighting, andwearing full PPE to safely escort them throughout the protocol. Initially, the participant climbeda single flight of stairs to the second floor of thetower, walked to a corner of the room and kneltdown for a 2-minute acclimatization period. After acclimatization, the participant proceeded towalk up and down three stairs for 2 minutes. TheThe Effects of Fire Fighting and On-Scene Rehabilitation on Hemostasis9

lower three stairs were used to maintain a consistent thermal loading on the firefighter. Thesestairs were 7.5 inches high, 11 inches deep, and30 inches wide. During each test, the escort monitored the participant’s heart rate and work completed in each cycle and radioed this informationfor each station to the investigator downstairs. Atthe conclusion of each station, the participant rested for 2 minutes as the safety escort demonstrated the next task. Next, the participant straddled aforce machine (Keiser Force Machine), and useda 9-pound sledgehammer to drive a sled 5 feetdown and back on a metal track for 2 minutes.After another 2-minute rest period, the participant performed a secondary (slow and thorough)search from side to side along the back 14.5-footwall for 2 minutes. This was again followed bya 2-minute rest period. In the final 2-minute station, the participant repetitively completed a motion similar to advancing a charged hoseline ona 3.8-foot hose segment (1.5 inch diameter) attached to a cable that ran over a pulley and wassuspended vertically outside the building with a10-pound weight on the end. Upon completionof the final test, participants kneeled quietly for 2minutes and then proceeded downstairs.10In order to maintain room temperatures, threethermocouples were installed in the buildingnear the search station: located 6 inches abovethe floor, 4 feet above the floor and 8 feet abovethe floor ( 1 foot below the ceiling). Type K(chromel-alumel) thermocouples with factorywelded beads were utilized in conjunction witha digital data acquisition system (Omega Engineering, OM-DAQPRO-4300). Data were sampled from each thermocouple every 10 secondsand were continuously monitored.Firesets were lit anywhere from 30 minutesto one hour prior to subjects beginning their livefire testing. By preheating the building, relatively stable conditions could be maintained during testing. Throughout the burn, trained stokerscontrolled the temperature monitored by the thermocouples by adding small fuel packages to thefiresets sequentially and controlling the ventilation conditions in the room. The temperatures atthe mid-level point were maintained at roughly160-180ºF and the floor temperatures were maintained at 95-105oF. The prescribed fire fightingactivities required subjects to work almost exclusively in the vertical location between the middleand floor thermocouple.Procedures

MethodologyDescriptive variablesDescriptive variables were assessed priorto participation in the fire fighting drills. Afterparticipants read and signed an informed consent document, they were asked to complete 1)a background questionnaire, 2) a cardiovascularhealth inventory, and 3) a profile of several individual difference measures (e.g. trait anxiety (apprehension), neuroticism (extraversion, conscientiousness)). The following physiological variables were measured and/or determined: height,weight, body mass index (BMI), body composition/percent body fat (via skinfolds), and fasting glucose and cholesterol (from a finger sticksample via a Cholestek analyzer).Body temperatureBody temperature was continuously measured throughout both protocols using a Minimitter VitalSense monitor and a silicone-coatedgastrointestinal (GI) core temperature capsule.Relatively little research has measured core bodytemperature of firefighters using GI capsules,which is the best technology for non-laboratorysettings. Participants swallowed a small disposable core temperature sensor capsule (the sizeof a multivitamin), which passes through thebody and is eliminated in feces within 24 hours.While the sensor was in the GI tract, it transmittedtemperature information to the remote recordingdevice.Hemostasis and cardiovascular alterationsHeart rate was continuously measuredthroughout activities using Polar Heart RateWatches. Blood samples were drawn from theantecubital vein via venipuncture by a trainedphlebotomist. Blood samples were used to assesshemostasis by measuring: 1) platelet number andfunction, 2) coagulatory potential, and 3) fibrinolytic potential (tPA and PAI-1).Plasma cortisol and catecholaminesPlasma epi

of fire fighting activity resulted in significant physiological, psychological, and cardiovascu-Abstract lar strain. Immediately post-fire fighting, core temperature, heart rate, blood pressure and blood catecholamine levels were significantly elevated from baseline conditions. Platelet fu

Related Documents:

May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)

Silat is a combative art of self-defense and survival rooted from Matay archipelago. It was traced at thé early of Langkasuka Kingdom (2nd century CE) till thé reign of Melaka (Malaysia) Sultanate era (13th century). Silat has now evolved to become part of social culture and tradition with thé appearance of a fine physical and spiritual .

On an exceptional basis, Member States may request UNESCO to provide thé candidates with access to thé platform so they can complète thé form by themselves. Thèse requests must be addressed to esd rize unesco. or by 15 A ril 2021 UNESCO will provide thé nomineewith accessto thé platform via their émail address.

̶The leading indicator of employee engagement is based on the quality of the relationship between employee and supervisor Empower your managers! ̶Help them understand the impact on the organization ̶Share important changes, plan options, tasks, and deadlines ̶Provide key messages and talking points ̶Prepare them to answer employee questions

Dr. Sunita Bharatwal** Dr. Pawan Garga*** Abstract Customer satisfaction is derived from thè functionalities and values, a product or Service can provide. The current study aims to segregate thè dimensions of ordine Service quality and gather insights on its impact on web shopping. The trends of purchases have

And fire fighting training using Simulators, and live fire fighting on real fire by portable fire extinguishers and the use of fire suppressing equipments Duration Five days, from 9.00 am to 2.00 pm 3 days Theoretical Study 2 days Practical Training Trainees Fire fighting & emergency preparedness leading personnel in industrial organizations

Chính Văn.- Còn đức Thế tôn thì tuệ giác cực kỳ trong sạch 8: hiện hành bất nhị 9, đạt đến vô tướng 10, đứng vào chỗ đứng của các đức Thế tôn 11, thể hiện tính bình đẳng của các Ngài, đến chỗ không còn chướng ngại 12, giáo pháp không thể khuynh đảo, tâm thức không bị cản trở, cái được

Producer of Fire Fighting & Safety Equipments Introduction: lmen Tiar Engineering Company was established in 1999 and today is as a main manufacturer and supplier of fire fighting equipment. The main activities of this company are: 1) Produce the safety and fire fighting equipments. 2) Design and install the fire fighting systems.