It is somewhat rare to find a tool that has multiple lifesaving uses in such a small package.  In this blog post, we will be discussing one of my very favorite and most used tools across the spectrum of emergency services, the Leatherman Raptor Trauma Shears.  Not all trauma shears are created equal.  Over a span of 20 + years, I have used trauma shears extensively.  For many years, I used the standard issue cheap shears.  When the pair I was using started to fail, I would get another set.  It was incredibly frustrating to be directly in the middle of a critical call and have a piece of equipment fail on me.   

In 2013 I saw that a new product was coming to market directly addressing my frustration.  When I saw that the raptor shears were available at a store four hours from me, I made the drive and became one of the early adopters of this incredible multitool.  Unfortunately, two years ago, that initial set of raptor shears was dropped into a river (completely my fault) during a water rescue.  I went the very next day and bought a new set.  Below I will outline all of the different features of the Leatherman Raptor Trauma Shears, and why you should consider adding a pair to your first line equipment as an emergency services provider.  

1. Cutting – There are two pairs of shears on the market that I have personally used that cut exceptionally well.  I will cover the other set of shears later in the article.  All trauma shears have a blunt tip so that when you are cutting clothing from patients, you don’t accidently cut them.  These shears are no different in that aspect.  The cutting power from these shears are phenomenal.  For 6 years I used the same pair of shears cutting everything from fire hose, regular clothing, belts, leather coats, and in one instance, Kevlar.  I used the seatbelt cutter multiple times for cutting seatbelts, paracord, opening the tape on boxes etc. etc.  I never sharpened them, and they never failed.  The ring cutter on the shears is incredibly strong.  I rarely ever used the ring cutter to cut an actual ring (only once), but I used it multiple times to cut wires.  I used this particular feature to cut a chain link fence to free a trapped animal.  
2. Glass Breaker – I have used this feature multiple times for access into vehicles, and it works very well.  Pro tip: When striking the window, aim for the lower corner for best results.
3. Lanyard Hole – I obviously did not use this convenient feature and thus I lost my first pair in a river.  
4. Holster / Clip – The holster is included with the raptor tool and slides onto a belt or works with MOLLE.  The shears can be stowed in the holster in a folded-up configuration, or in an open configuration.  For daily use I simply utilize the pocket clip that is adhered to the shears.  I have never had the pocket clip bend or break, and they stay in my pocket with no issues.  
5. Measurement feature on the side of the cutting edge.  I believe that this is often overlooked, but I use it all of the time, mostly for measuring the length of a laceration, bruise, or anything else that I need to measure to annotate in my report.  
6. Oxygen Bottle Opener – This is a feature that I use daily on the ambulance and on the fire truck during my morning checkout of the apparatus as well as throughout the day when I have to switch out oxygen tanks.  
7. Prying – While definitely NOT designed for this particular task, I may have done some minor prying from time to time, and there was no issue.  
8. It may seem odd, but this makes the best back scratcher in a pinch!  
9. There are a multitude of handle colors available

Over the past several years that I have owned a pair of raptor trauma shears, I have used them daily in some form or fashion.  I use them far more than I use a pocketknife, which I also carry on a daily basis.  If there was one MAIN medical tool that I could recommend to my fellow emergency services Professionals besides a tourniquet and an IFAK, this would be it.  There are just too many uses, medical, and non-medical to not have a pair.

There is a vast array of trauma shears on the market.  Even on the high-end side of trauma shears, other manufacturers are coming out with new products.  SOG recently came out with their version of a trauma shear multi-tool.  I have handled a pair in person, but for ME, the raptor is a better tool.  Another company that has come out with a very high-quality trauma shear is X-Shear.  Their shears are excellent for cutting; however, they lack all of the other features.  For the X-Shear, and an X-Shear holster, they are only slightly cheaper than the raptors.  

If it is just too difficult to wrap your head around purchasing trauma shears that cost in excess of $60.00 (which I can completely understand) I STILL suggest finding a cheap pair that you can carry.  The cheap ones are better than nothing.  

As always, I am looking forward to any discussion or questions that you may have!  

I have no doubt that all of us have heard WAY more than we would like to about the COVID 19 Pandemic.  However, since so many officers have become infected, and sadly a couple of law enforcement officers have died because of COVID 19, I would feel remiss if I didn’t address this topic as the SCT medical representative.  In this medical Monday we will attempt to provide some preventative measures, some decontamination procedures, and address some misinformation that may be floating around.  I have two disclaimers before we get started. This is not intended to replace your specific department’s plans or protocols.  Information on how to best combat COVID-19 is literally changing by the hour.  (While working at the hospital on 04/03/2020 we had two policy changes within one hour.)

Allow me to begin by discussing preventative measures.  In a previous Medical Monday post talking about medical gloves (Pre COVID-19 days) I stressed the importance of proper hand washing.  This is not a new concept.  In 1846 a physician working in a labor and delivery ward in Vienna began an investigation as to why so many women were developing fevers and dying in the hospital as opposed to women that opted to have home births.  He discovered that doctors at the hospital were performing autopsies and then going directly to the labor and delivery floor to assist with the delivery of the newborn.  Women who delivered their newborns at home with the assistance of midwives on the other hand did not receive as much of an exposure to disease because the midwives were not performing autopsies.  Dr. Semmelweis implemented a new regulation that the physicians at the hospital begin washing their hands between procedures.  Doctors in 1846 and modern-day law enforcement have a lot in common because at the time, the physicians thought that this change was essentially a bunch of bullshit (the way LE reacts to change in general).  Long story short, eventually over time it was found that handwashing is the number one way to reduce catching and spreading disease.  This statement is true to this day.  With that being said, YOU HAVE TO WASH YOUR HANDS CORRECTLY!  This means wash them with soap and with water.  Let me further break this down:

Step 1.  Get your hands wet.

Step 2.  Put soap on your hands

Step 3.  Rub the soap over the entirety of the hands to include the fingernail areas and at least three inches above your wrists

Step 4.  SCRUB for TWENTY (20) seconds  

Step 5.  Rinse off the soap under running water 

Step 6.  Dry your hands

You need to wash your hands before and after eating, after coughing or sneezing, after handling garbage, after you use the bathroom, after handling a suspect, and any other time that you even remotely think that you may need to wash your hands.  Many of you may have the mindset that you will just use the hand sanitizer in your patrol vehicle.  That is fine as a temporary measure (if you can even find some), but you still need to wash your hands as soon as you are able to locate running water and soap.  Additionally, make sure that the hand sanitizer that you are using is at least 60% alcohol.   

The next preventative measure is…DON’T TOUCH YOUR FACE WITH YOUR HANDS!  Germs get onto your hands and as soon as you touch your face those germs or the virus is much closer to your airway where it can grow and cause infection.  

WIPE EVERYTHING DOWN WITH A DISINFECTANT WIPE!  If you do not have access to disinfectant wipes, you can make your own cleaning solution by placing 4 teaspoons of bleach in a quart of water, or 1/3 cup of bleach in a gallon of water.  When you go on duty, ensure that you spray and wipe down all surfaces.  Wipe down the steering wheel, seatbelt and buckle, headrest, and any other surfaces that you come into contact with.  As far as radios go, Motorola released guidance advising to apply rubbing alcohol with at least a 70% concentration to a cloth, and then use the cloth to clean the radio.  Do not forget about the radio and mic in your patrol car as well.  Make sure that you wipe down your duty gear.  

In our basic law enforcement training academy, we were taught that DISTANCE IS OUR FRIEND.  It seems as if that advice is more than applicable in this day and age.  I have seen many different policies that different departments have implemented to protect their officers.  Regardless of your specific department has implemented, try to stay SIX feet away from people on or off duty.  This obviously doesn’t apply when you are at your home although some healthcare professionals have gone to some extraordinary lengths separating themselves from their family through this crisis.  

Moving on to masks…This is where information becomes tricky.  According to the National Institute of Safety and Health, the N95 mask that you have been hearing so much about in the news is the minimum standard for contact with known COVID-19 patients.  It is named N95 because it filters out 95% of particles in the air that are 0.3 microns in size.  There are a couple of issues.  I strongly suspect that hardly any agencies are requiring an N95 fit test upon hiring of new officers.  To wear the N95 respirator, it needs to be fit tested to ensure that the mask will work correctly.  As I am also sure that you have seen in the news, N95 masks are difficult to come by.  

The CDC is now recommending that people wear a cloth mask when out in public.  The theory is that the cloth mask will reduce the chance of you passing COVID-19 to others in public.  It is possible to be infected with COVID-19 and only exhibit minor symptoms, or even no symptoms at all.  The issue that I have with the cloth mask is that there has not been nearly enough research done to see exactly how many particles that these masks will filter out.  There are varying types of fabric.  Some cloth masks have slots made for coffee filters, or other home-made options.  The surgical masks and or cloth masks are ok for filtering out the large airborne particles, or good for blocking the fingers touching a large area of the face.  Again, information is changing on a continual basis.  When it comes to wearing masks, follow your department’s guidelines.  

Decontamination is absolutely essential when you get off shift and go home.  I recommend that you think of all of the areas outside of your home as the hot zone (direct threat).  Think of your garage or if you don’t have a garage, your entry way in your home as the warm zone (indirect threat).  The interior of your home is the cold zone.   

 The first step to decontamination is that when you get off duty, you again wipe down all of your duty belt equipment.  Change into civilian clothes (I have been changing into sweats and a t-shirt).  If you have a washing machine and dryer at your department, I highly suggest washing it at work. If not, place your uniform into a plastic bag.  Place your uniform into the trunk of your personal vehicle, or if you have a take home car, place it in the trunk as well.  When you arrive home, place your uniform as well as your clothes that you wore home into the washing machine and start it.  Go directly to your bathroom and shower.  I suggest leaving your footwear in your garage or entry way.  Make sure to wash your boots (especially the soles with hot soap and water).  The last thing that you want to do is risk bringing any type of sickness into your home or to your family.   All of these steps are merely a suggestion.  If you have a more efficient option, I would love to hear about it in the comments.

The last topic I will address in relation to COVID-19 is mental health.  Mental health could be discussed in multiple Medical Mondays, but for now make sure that you are taking care of yourself.  While off duty, try to focus on something that is not law enforcement related.  Read a new book.  Watch a new show on Netflix.  Play a board game with your family.  Whatever you do, don’t go home and become vapor locked on the news.  By giving yourself a break, you will be more focused and present while you are on duty.  Try to exercise patience, understanding, and kindness not only to the public that we serve, but also to your colleagues and family.  

This may not have been the most earth-shattering post, but if it helps even a single officer, the time to put it together is well worth it.  I promise a much sexier Medical Monday post in the near future.  Please watch out for each other.  Please take care of yourselves and your families.  If you have any questions or comments, please reach out, or put them in the comments section below.  Stay safe, take care of each other, and WASH YOUR HANDS! 

It is practically guaranteed that when you become a law enforcement officer, you will undoubtedly witness some shocking events (pun intended) throughout your career.  Many of those events will involve some sort of medical element to it.  In this week’s Medical Monday, we will be breaking down the different types of shock, and some critically important first aid care that you can provide as an officer.  

The simplest definition of shock that I can come up with is that some type of event has happened to the body, and the body’s needs are not being met.  Initially in most cases the body will compensate or attempt to compensate.  Eventually if shock is not treated, the body will no longer be able to compensate, and the patient will die.   

To understand compensation and decompensation when discussing shock, I like to use the example of a city.  Imagine a large city such as Los Angeles.  The city government provides multiple services such as police, fire, ems.  They also provide electrical services, waste services, water services, etc.  In order for the city to run efficiently, each service must pull their fair share of the weight and perform their duties well.  For our example, imagine that the waste service workers go on strike and refuse to perform trash pick-up.  The first couple of weeks may not be too terrible, and the city would be able to compensate.  However, if the strike were to go on for months on end imagine the impact on the city that would have.  Fire departments would be running more fire calls, police would be running more calls, hospitals would be overcome with sick patients due to disease from the buildup of the trash.  The economy of the city would be negatively impacted.  If this crisis continued, the city would for all intents and purposes die off if no aid was given.  

The human body has a vast array of different systems, organs, and cells that need to work together toward the goal of living and being healthy.  If one system is affected significantly, all other systems become affected as well.  If not corrected, the body will eventually go into shock.  

There are four main categories of shock.  Each category breaks down into subcategories.  For our purposes today, we will focus on the four main types. They are as follows:

• Hypovolemic Shock – This is the type of shock that most officers will be the most familiar with.  This type of shock most commonly is the result from significant blood loss due to trauma to the body.  As many of us have learned, it is critically important to treat this type of shock by stopping the bleeding and covering the patient with a blanket.  We will discuss this point further into the article.  
• Distributive Shock – This is the most common type of shock.  This is the type of shock that a person who is severely allergic to bee stings or other allergens that produce a life-threatening reaction will experience.  A massive fluid shift occurs in response to the invading substance (such as a bee sting) that causes significant swelling to the airway.  Because the airway is being closed off, it obviously makes it a critical medical event. 

 The treatment for this type of emergency is administration of an EpiPen.  Most police departments do not have a policy in place nor provide an EpiPen for officers to administer.  For this type of shock, it is important to remove the substance causing the reaction.  In the case of the patient that has a stinger, it is important to remove the stinger using a scraping motion with a credit card or ID card.  Do NOT use tweezers as it could inject more venom into the patient causing a worse reaction.  Expedite EMS and allow the patient to position themselves to where it is easiest for them to breathe.     

This type of shock is also seen in very sick patients who become septic.  Sepsis is a subcategory of this type of shock.  

The last subcategory of this type of shock is neurogenic shock.  This could be observed in patients with a significant head, neck, or spinal cord injury.  The important treatment for a patient experiencing this type of shock is rapid transport to a hospital.

• Cardiogenic Shock – As the name implies, this type of shock occurs due to an issue within the cardiac system.  Quite simply, the heart is nothing more than a pump that circulates the blood throughout the body.  When the pump is not operating optimally, problems begin to develop.  For these patients, it is important to loosen restrictive clothing such as neck ties, shoes, belts, etc.  It is also important to allow them to get into a position of comfort.  Expedite EMS, and again, cover the patient with a blanket.  
• Obstructive Shock – This type of shock occurs when pressure is being exerted upon the greater vessels or upon the heart.  The most common example that law enforcement officers may have heard of before is tension pneumothorax.  If a hole has been made in the lung tissue, air will escape into the chest cavity causing a buildup of pressure.  This type of pressure could also be caused by a hemothorax which is blood that is collapsing the lung and placing pressure onto the greater vessels and heart.  If there is an open wound, it is absolutely vital to cover that wound with a chest seal.  Be sure to check for an exit wound as well.  Any hole found from the neck to the waist all around the body should be covered with a non-occlusive dressing.  

Another medical condition that obstructive shock falls under is pericardial tamponade.  The heart sits within a protective sac.  When the chest has been struck with a lot of force, that sac can fill with fluid and obstruct the heart from beating efficiently.  

With all of that being said, here are the main pearls of wisdom that officers can apply when treating patients prior to EMS arrival.  

1. Shock is way easier to prevent than to treat.
2. The two main indicators that a patient is experiencing shock are: altered mental status, and absent OR abnormal radial pulses.  
3. If the patient is another law enforcement officer and they are experiencing an altered mental status, you MUST disarm the officer!
4. PLACE A BLANKET ON THE PATIENT TO KEEP THEM WARM!!!!!  I cannot stress this enough.  I will do a future Medical Monday covering the Lethal Triad.  One of the elements of the lethal triad is hypothermia.  When a person goes into shock, the body loses the ability to conduct temperature regulation.  The outside ambient temperature could be 110 degrees, and the patient that is experiencing shock will become hypothermic if it is not treated.  If the patient becomes hypothermic, their blood will lose the ability to clot along with a host of other negative impacts.  Bottom line….COVER THE PATIENT WITH A BLANKET.  
5. It is immensely helpful to the EMS providers if you can keep them updated while they are responding to the scene.  The number of patients, what is generally wrong with the patients, and any scene hazards are a few great pieces of information to begin with.  

One last note before we conclude this Medical Monday.  It had been taught for many years to elevate the legs of patients in shock.  After many medical studies it was found that elevating the legs not only provided no benefit to the patient, in some cases it caused a medical complication called pulmonary edema.  

As always, I hope that you enjoyed this installment of Medical Monday.  If you have any questions or if you would like to provide further discussion, comment below.  

Yesterday marks the 25^th anniversary of the Oklahoma City bombing that occurred on 04/19/1995.  This Medical Monday installment is dedicated to the victims, the families, and the first responders (many of whom I currently serve with) who answered the call in one of the most iconic moments in our nation’s history.  The topic for this week is blast injuries.  We will be discussing different types of injuries sustained from a blast and treatment for those types of injuries.  We will also discuss some safety considerations for response to events that have an explosion potential.  In addition to serving as a tactical paramedic for our SWAT team, I am also assigned to our agency’s bomb squad.  This assignment has allowed for unique training opportunities as well as a more in-depth perspective when it comes to blast injuries.

We will start out by addressing the four different mechanisms of injuries that occur from a blast event.  

• Primary – Primary injuries are caused by the pressure wave generated by an explosion.  The injuries from this mechanism of the explosion mostly involve hollow organs.  Your lungs, intestines, stomach are some examples of hollow organs.  The primary phase of the blast can also cause a ruptured ear drum as well as a concussion / traumatic brain injury.  
• Secondary – Secondary injuries are caused by shrapnel and any other type of flying debris.  Any part of the body is susceptible to this type of injury.  
• Tertiary – Tertiary injuries stem from the body being thrown by the wave of the blast.  For example, if you are thrown by the blast against a wall and break your arm, this would be considered a tertiary injury.  
• Quaternary – This type of injury encompasses any type of injury or illness that is not covered by the aforementioned mechanisms.  The quaternary mechanism also includes any complications from any of the injuries or illness that occur because of the blast.  For example, if you receive a bad cut because of something that struck you (Secondary Injury) and that cut becomes infected, the infection is considered a quaternary injury.

You may be wondering how difficult it is to treat all of these different types of injuries.  Now is a good time to point out that trauma is trauma.  With few exceptions, you treat blast injuries that you encounter just as you would with any other type of trauma that you might come across in the performance of your regular duties.  Stop any massive bleeding.  Make sure that the patient’s airway is open.  Place a chest seal over any holes between the neck and the stomach all of the way around the patient’s body.  Evaluate again for any ongoing bleeding.  Cover the patient and keep them warm to prevent or to treat shock!!!  Evaluate the patient in more detail to see if anything has been missed.  Reassess your interventions.    

Now for the exception!  If you notice that you or someone else that has been involved in a blast event has developed even a minor cough, it is critical that you or they be evaluated at an emergency room.  It is easy to think that the cough is because of the dust particles that have gotten into the airway, however the lungs may have incurred an injury called blast lung.  An x-ray will show if this injury has occurred and allow for the hospital staff to begin treatment.  

In responding to a scene where the potential of an explosion exists, it is critically important to remember that time, distance, and shielding are our friends.  It is obvious that the further you are from an explosion, and the more protection that you have between you and the explosion, the better off you are.  Be mindful of reflective pressure.  Imagine that you are on scene of a potentially explosive incident, and you take cover behind your patrol car that is parked next to a building.  The pressure of the explosion will go over the patrol car, hit the building, and the energy will be reflected onto you.  It is something to consider when arriving onto the scene.  Another thing to be acutely aware of is secondary devices that may be in the area.  Even if the response does not include a terrorism aspect, many times the likelihood of additional explosions is still present.  Do not become complacent.  

A special note for members of a bomb squad or SWAT team…It is a good practice to have a medical information form on file and readily available for each member of the team.  This form should be updated yearly at minimum.  The information on this form should include the team member’s following information:

• Full name
• SSAN
• Emergency contact information
• Drug allergies
• Current medications to include supplements
• Past surgical history
• Pertinent medical history (High blood pressure, cardiac issues, high cholesterol, etc.)
• Special notes (Power of attorney, Advanced directive, etc.)

It is also important to have a rehabilitation plan in place.  This will keep members hydrated, warmed up or cooled down depending on the season, and rested during extended events.  For most agencies, a conversation with your local fire department or EMS agency can help organize the rehabilitation plan before an event occurs.  

One last point before we wrap up this installment.  The Murrah Federal Building bomber was captured by an Oklahoma State Trooper by the name of Charlie Hangar.  Trooper Hangar conducted a traffic stop on the suspect due to the vehicle he was driving having no license plate.  While Trooper Hangar was conducting his investigation, he observed that the suspect was concealing a handgun underneath a windbreaker.  Trooper Hangar made the arrest having no idea that he had just arrested the most wanted man in America.  I have had the privilege of attending Trooper Hangar’s account of the events of that fateful day.  I believe that Trooper Hangar exemplified the type of attention to detail police work that SCT tirelessly promotes.  

As always if you have any questions or comments, please leave them below.  If there is a topic for Medical Monday that you would like to see addressed, please let me know!

Whether you have dealt with someone who is intoxicated or have come across someone who seems…off after hitting their head in a traffic accident, chances are you have had to assist someone presenting with an altered mental status.  In this Medical Monday, we are launching a series that specifically addresses different causes of why a person might have an altered mental status.  For the first part of the series, we will address stroke signs, symptoms, and treatments.  

Firstly, it is important to understand that there are two separate types of strokes (also known as cerebrovascular accidents).  They are as follows:

Ischemic Stroke – This is the most common type of stroke.  It is caused by a blockage either from fatty build up in the vessels blocking blood flow, or blockage from a clot that has formed.  To paint a simple picture as an example, imagine the brain as a small city in a mountainous area.  If a large avalanche is triggered and blocks the major pass or road into the city, all aspects of the city will suffer a major disruption if the blockage is not cleared.  The brain is no different.  If the patient does not receive the treatment that they need in a fairly small amount of time, it will be too late, and the patient will either end up with irreversible damage, or they will die.  As an interesting side note, heart attacks happen much the same way, just in a different part of the body. (The heart) 

Hemorrhagic Stroke – This type of stroke is less common.  In this type of stroke, a blood vessel in the brain has begun to leak, or it has ruptured causing the vessel to bleed into other areas of the brain.  The space between your cranium (the nugget holder) and the brain (the nugget) is very minimal.  With bleeding occurring from the vessel, pressure is created which essentially suffocates the brain cells.  Back to our small mountain city and the avalanche comparison.  Instead of the avalanche blocking the major road, the avalanche has fallen directly onto the small city smothering it.  It was taught in paramedic school that if a patient exclaims to you that they are having the absolute worst headache of their life, consider this type of stroke as a possible cause.      

Now that we know what the two different types of stroke are, we will discuss what kind of assessment that you can perform to assist with determining if the altered mental status patient is suffering from this condition.  It is called the BE FAST assessment.

B – Balance.  Does the patient have trouble maintaining their balance?

E – Eyes.  Does the patient have blurred vision in one or both eyes?

F – Facial Drooping.  If you observe facial drooping on either side of the patients face, you should request an EMS response.  

A – Arm Drift.  Direct the patient to hold both of their arms out in front of them and to keep their eyes closed.  Look for one arm that appears weaker, or that drifts.  

S – Speech.  Is the patient aphasic (unable to speak at all), or are they presenting with slurred speech or saying random words that have no order or make no sense?

T – Time.  It is critically important to note the time that you observed the person with ANY of the above symptoms, and ALSO make every attempt to find out what time it was that they were last seen normal.  This is so important because if the patient is having an ischemic stroke they only have 3 hours (in the vast majority of cases according to 2018 American Heart Association guidelines) to receive the drug (clot buster) used at the hospital to treat these patients.  

With all of that being said, most every single drunk person will exhibit one or more of the above traits.  While good common sense along with experience plays a strong role, it is very important to note that it is absolutely possible that a person who is intoxicated is ALSO experiencing a stroke.  It has been highlighted in the medical world that intoxicated patients who are actively having a stroke have delayed diagnoses and treatment.  If there seems more to the scene than someone just being drunk, I urge you to request an EMS response.  

Another medical condition I will address is a transient ischemic attack (TIA).  This is a medical event where a person may experience stroke like symptoms, but they resolve over a fairly quick amount of time.  If a person has experienced a TIA, the chance that they will eventually experience a full-on stroke increases significantly.  

Lastly we will cover Bell’s Palsy.  Bell’s Palsy is a condition where the facial nerve (one of your 12 cranial nerves) becomes compressed or inflamed which causes one side of the face to droop.  This condition obviously mimics a sign of a person having a stroke, however a person with bell’s palsy typically does not have a fast onset.  Also, in the case of a stroke there will likely be many more signs and symptoms that present with the patient.  

Key points to remember:

Stroke = Bad

Use the BE FAST mnemonic as an assessment guideline.  

Request EMS early on.

Note the time you found the patient and how they presented

Find out when they were last seen normal

If you believe that the patient is having a stroke, it is critical to get the patient to a hospital that has a stroke center capability!!

I hope that you learned something from this down and dirty stroke episode of Medical Monday.  If you have something to add, or if you have any questions or comments, please leave them below.  As always, I look forward to hearing from you.  

When interacting with a person who has an altered mental status (just not acting right) it is very commonplace in the law enforcement community to come to the conclusion that the person that we have made contact with is either drunk, high, or both.  For this Medical Monday we are going to discuss diabetes (another cause of altered mental status), what it is, and how to treat it.  We are also going to examine a case that made it all the way to the supreme court in regard to use of force by law enforcement.  

Before we go into what exactly diabetes is, it is important to go over a couple of quick definitions.  

• GLUCOSE – Sugar 
• PANCREAS – A gland / organ that sits behind the stomach that produces the hormones insulin and glucagon.  It also secretes stuff (enzymes) that helps break down food.  
• INSULIN – The key (hormone) that unlocks the cells allowing glucose to enter which creates energy.  Insulin also has the ability to store glucose for future use.  

Now that we have those definitions out of the way, we can begin to explain diabetes.  Diabetes is a condition where the amount of glucose in the body is being poorly regulated because of the amount of insulin being released by the pancreas.  There are a few different types of diabetes.  

Type I – This type of diabetes occurs typically at an early age.  It is a condition in which your body does not produce any insulin.  These patients typically have a small device that they used called an insulin pump.  It is a small computer device that is worn on the belt with a tube that goes into the body to supply the insulin.  The other option for diabetics is an insulin pen.  The person must inject a set amount of insulin throughout the day.  

Type II – In this type of diabetes (typically found in adults) the body has developed either a resistance to using the insulin it produces, or the body does not produce enough insulin for the amount of glucose in the body.  This type of diabetes is managed by the person being prescribed an insulin pen as well as following physician recommended lifestyle changes.  

Gestational Diabetes – Due to hormonal changes, some women will experience incurring diabetes while they are pregnant.  After the woman has delivered their baby, their glucose levels will return to normal.  There is research that shows women who experience gestational diabetes have a higher risk of developing type II diabetes.  

Now to the point of what all of this has to do with altered mental status and us as cops… A person with blood sugar that is too high (HYPERglycemia) or blood sugar that is too low (HYPOglycemia) can present with an altered mental status.  To give some sort of frame of reference, think about a time where you were not able to eat for a long period of time.  You were most likely hangry.  After you were able to eat, you felt better.  You become hangry because your glucose level is too low.  After you eat, it rises back to a normal level.  With people who are diabetics they will often be very slow to respond and appear that they are under the influence of either drugs or alcohol.  There are several diabetic calls that I have responded to where the patient is being combative and acting erratically.  In general, it is definitely a great idea to have an EMS unit respond.  Every ambulance is equipped with a glucometer (a device that can measure blood glucose). If the person is experiencing HYPOglycemia, they need a medication (D10 preferably or D50) that can be given intravenously, or a different medication (glucagon) that can be given as a shot so that their glucose level can rise back to a normal level.  If the person is experiencing HYPERglycemia the person will need to be transported to a hospital where their glucose level can be lowered safely in a monitored environment.  It is important to note that people that are breathing deeply and rapidly (Kussmaul respirations), complaining of extreme thirst, urinating frequently, and have a dry mouth are most likely experiencing HYPERglycemia.  

On November 12^th, 1984, a person experiencing a drop in his blood sugar asked his friend to drive him to a convenience store so that he could purchase some orange juice to raise his blood sugar back to a normal level.  When he went into the store, he encountered a long line, so he decided to exit the store, get back into his friends car and ask his friend to drive to another friends residence where he hoped to find something to eat or drink to get his sugar back into a normal range.  The trip to the store was observed by Officer Connor.  It appeared suspicious to Officer Connor that the subject entered and then exited the convenience store so quickly, so Officer Connor conducted a traffic stop.  Officer Connor directed the subjects to stay in the vehicle, however one of the subjects, Mr. Dethorne Graham exited the vehicle, ran around the vehicle and then passed out.  Officer Connor placed Mr. Graham in handcuffs.  Mr. Graham woke up and reportedly plead with the officers on the scene to get him some sugar.  The officers ignored the requests believing that the suspect was intoxicated.  During the encounter the suspect sustained multiple injuries including a broken foot.  When it was determined that the suspects had not committed any crimes, Mr. Graham was released.  This case wound up in the supreme court known as Graham VS Connor.  It is a landmark case dealing with reasonableness when it comes to use of force.  The good news for us is that the actions of the officer must be judged from the perspective of a reasonable “officer” and not from that of a responsible “person.”  

Here are the key take-aways from this Medical Monday:

• Hypoglycemia & Hyperglycemia can both become life threatening medical conditions.
• Keep an open mind as to what the underlying cause of the altered mental status is.  
• 1 out of every 10 Americans is affected by diabetes. 
• Consider an EMS response early when encountering any type of altered mental status.
• In some areas of the country a person with diabetes will tell you that they have “the sugars.”  
• The normal range for blood glucose is 80-120 milligrams per deciliter.  
• Do not attempt to give any sugary food to anyone who is not conscious, breathing deeply and rapidly, or who is complaining of severe thirst, a dry mouth, and needing to urinate frequently.  

I hope that you were able to take away something from this Medical Monday.  As always if you have any comments or questions, I would love to hear them in the comment section below.  

This week we are continuing our series on causes of altered mental status.  A very common police response involves interaction with elderly persons whether it involves shoplifting, abuse or neglect, wandering, or wellness checks.  In this Medical Monday we will talk about dementia.  We will explore what dementia is, the progression of dementia, and how to best interact with people affected by dementia.  

Many people think that dementia is a disease experienced by elderly people before it progresses into Alzheimer’s disease.  That thought process is incorrect.  Dementia is NOT a disease, but rather a generalized term that is commonly used to describe deficits in how the person communicates, thinks, and how they remember things.  It is important to note that dementia is not a normal process of aging.  Dementia occurs because of damage to brain cells.  Not all elderly people will experience dementia.  

Dementia is generally split up into four different phases.  They are:

• Mild Cognitive Impairment – Most of us experience this anyway.  This is characterized as general forgetfulness.  Just because you experience this does not mean that it will develop into full blown dementia in all cases.  
• Mild Dementia – With this phase people will occasionally experience memory loss, getting lost, and confusion.  
• Moderate Dementia – In this stage people will need assistance with simple items such as getting dressed.  These people can also be easily agitated and be overly suspicious.  (I guess this could also be most cops!!)
• Severe Dementia – The people in this phase will need full time care.  They are typically unable to control bladder function, cannot speak, and have difficulty with even holding their head up.  

It is common in a person with early onset dementia to have difficulty in finding the right words.  It is also common for them to become easily confused, disoriented, and oftentimes they will be repetitive.  The best advice that I can offer all law enforcement officers is to be patient.  This can be difficult at times for us for a myriad of reasons.  Just think of the phrase “slow is smooth, smooth is fast.”  This phrase definitely applies here.  Here are some additional tips for interacting with people with dementia:

• If feasible, approach from the front and attempt to avoid startling the person.
• Explain who you are and that you are there to help.
• Maintain a calm and friendly demeanor and voice. Remember to smile. 
• Speak slowly and allow around 15-30 seconds for a response.  
• If the person becomes agitated, try changing the subject.  This distraction technique is very beneficial in establishing a rapport as well as keeping the person calm.  
• Do not automatically assume that because they are elderly, they are hard of hearing.  
• Ask simple questions.  Yes or no questions are optimal.
• Avoid correcting the person or “reality checks.”  This will most likely lead to the person becoming more confused or aggravated.

I hope that you were able to gather some useful information from this Medical Monday.  As always, if there is something that you would like to add, or if you have any questions, please let me know in the comments below.  I look forward to hearing from you!

Yesterday marked the beginning of the 46^th Annual Emergency Medical Services week instated by President Gerald Ford in 1976.  Because we commonly interact with and have the potential to be treated by an EMS practitioner, I thought it would be an interesting Medical Monday to outline the different certification levels as well as the skill sets practiced by EMS professionals.  

The National Registry of Emergency Medical Technicians is the national level certifying body of EMS certification applicants.  The NREMT, or “National Registry” as it is commonly referred to offers four separate certification levels.  Two important points to mention.  In addition to having an NREMT certification, you must also have a license from your state’s department of health as well as a medical director to practice under before performing any type of medical procedures outside of what would fall under good Samaritan laws.  

In the class that I developed for SCT, I mention that it is GENERALLY ok to put something ON somebody, and it is GENERALLY NOT ok to put something IN somebody.  The second point is that in order to perform advanced medical procedures, I must be in an on-duty status.  The instant that I am not on duty, I do not fall under the license of my medical director.  To give a quick example:  If I witness a vehicle accident on my day off and I stop to assist, if the person needed to be intubated, I could NOT perform that skill.  If I did so, even if it meant that it would save that person’s life, I would be at risk for losing my paramedic license as well as my certification.  With that being said, keep in mind that laws, regulations, and medical protocols will vary from state to state, and agency to agency.  Without going too much further down that rabbit hole, here are the levels of EMS certification:

Emergency Medical Responder:  This is the entry level certification.  Professionals that are certified to this level are considered trained to perform immediate lifesaving care with basic treatments and with little equipment.  Most fire service organizations around the country require their firefighters to be certified to at least this level.  The EMR equivalent in the law enforcement world would be an police recruit.  

Emergency Medical Technician – Basic:  This is the minimum level of certification that you must have to work on an ambulance in a paid status in most states.  EMTs are trained in basic trauma care and other basic lifesaving and first aid interventions.  At the college that I instruct for, an EMT-Basic course takes place over one semester.  The semester encompasses both classroom hours and clinical hours on an ambulance putting into practice what they have learned.  The EMT-B equivalent in the law enforcement world would be a first-year rookie officer.  

Emergency Medical Technician – Advanced:  In addition to all of the previous skills mentioned, this practitioner is also able to begin utilizing some of the more advanced equipment on the ambulance such as limited use of the cardiac monitor as well as limited administration of medications outside of Aspirin, Glucose, and Nitroglycerin.  The EMT-A candidate is allowed to test after successful completion of the first two semesters of paramedic school in the paramedic program that I am involved with.  In addition to the classroom hours and ambulance clinicals, these candidates must also participate in hospital based clinicals.  While performing hospital clinicals, the candidates intubate patients in the operating room as well as perform a wide array of other emergency skills in the emergency room under the guidance of a physician.  The EMT-A equivalent in the law enforcement world would be a field training officer.  

Paramedic:  At this level, the paramedic is certified to do a myriad of advanced medical procedures such as intubation, cricothyroidotomy, and needle chest decompression.  When it comes to the heart, we do interpretation of 3 lead, 4 lead, 12 lead, and 15 lead ECGs (the squiggly lines on the paper that comes out of a machine).  From our interpretation of those rhythms we can perform cardiac pacing, synchronized cardioversion, unsynchronized cardioversion, (Edison medicine as we call it) or treat the rhythm with a medication.  Speaking of medications, the paramedic is also trained on when, where, who, and how to administer multiple different medications.  In addition to four semesters (two years) of classroom instruction, the paramedic candidate in our program must complete 560 clinical hours.  These hours include time on an ambulance to include a paramedic internship, time in a behavioral health center, time in an operating room, clinical hours in an emergency department of a hospital, and a physician internship.  At the conclusion these educational programs for all levels of certification you must take and pass a difficult written examination.  You must also pass multiple skill stations in a psychomotor examination.  The paramedic level equivalent in the law enforcement world would be a detective or investigator.      

I have held each of these certifications over the course of my career for the exception of Emergency Medical Responder.  In my experience, the biggest difference between any of the previous certification levels and being a paramedic is the level of critical thinking and ultimate responsibility involved.  (Just like law enforcement)

After gaining some experience as a paramedic, there are a myriad of options to continue to grow professionally.  Paramedics can gain additional certifications as critical care paramedics, community medicine paramedics, flight paramedics, and of course the most awesome, tactical paramedics!  From our program, you can either obtain your Certificate of Mastery, or you have the option of completing a few more classes to earn an Associate Degree in Emergency Medical Sciences.  The latter was the option that I selected.   

I am incredibly thankful for the opportunities that I have been presented in becoming an instructor for our college’s Emergency Medical Sciences Program as well as becoming an instructor for SCT.  Just as in law enforcement, EMS is certainly a career where the learning never stops.  Serving as an instructor not only allows me to help others grow in their careers, but I also get to learn or refresh on topics and skills that I may not have used in a while.  There is no better reward than knowing that something that I have taught to a student of mine has saved a life.  

I will wrap this Medical Monday up with a shout out to my fellow medics in the Street Cop Training community.  HAPPY EMS WEEK!  Thank you to those who have added something to the Medical Monday posts, and to those who have reached out via private message.  If anyone has any questions or comments about this or any other Medical Monday, please comment below.  

Trauma care is no doubt the most intriguing subject to law enforcement officers when it comes to medically related topics.  In this Medical Monday we are going to discuss the topic of the lethal triad.  We will talk about what the lethal triad is, what components make up the lethal triad, and what you the officer can do to prevent a trauma patient from slipping into the lethal triad which can cause a much higher mortality rate.  

The lethal triad is a combination of three components that if not treated correctly and immediately will raise the chances of a severe trauma patient’s chances to dying significantly.  Those three components are:

Coagulopathy: Very simply put, it is a condition where the blood is not clotting optimally.  The clotting ability is impaired.  Clearly, this is a major issue for patients that are severely bleeding internally or externally.  Think of your blood as a pitcher of Kool-Aid.  When you were growing up, the more sugar that was in the Kool-Aid the better.  Most likely, if you were the one making the Kool-Aid, your mother made you dilute it down with more water which made the Kool-Aid taste not nearly as good.  The same theory applies in the trauma patient that is massively bleeding.  If that blood is replaced with Saline Solution by an untrained medic, the blood and the clotting factors in the blood are becoming diluted which presents a serious problem when it comes to stopping the massive bleeding.  The reason that there is such a significant push to train law enforcement officers on stopping the bleeding is due to this portion of the lethal triad.  The speed at which we can stop the bleeding can have a very large impact on the patient’s survival.  The skills of tourniquet application, wound packing, and application of pressure dressings are essential officer survival skills as well as essential first aid skills that we may be called upon to provide to the general public.  

Acidosis:  You most likely have experienced sore muscles after a strenuous workout.  A partial reason for the soreness is that the lactic acid buildup in the muscle group has not had a chance to fully dissipate.  When the body experiences a massive trauma, the vessels throughout the body constrict (narrow) to attempt to keep the blood pressure within the body up as well as attempting to keep the body from going into a hypothermic state.  Because the vessels are narrowed, oxygen molecules have a more difficult time reaching the tissues throughout the body which results in an incredible amount of lactic acid beginning to accumulate.  Through a complex set of systems in the body, the normal pH balance in a person is between 7.35 and 7.45.  Once the patient’s pH drops below 7.35 the patient is considered acidic.  To further complicate the issue, Saline Solution that is administered by an untrained medic will increase the severity of the acidosis because the pH of Saline Solution is 5.5, well below the body’s normal pH of 7.35.  If I have completely lost you by now, just think of it this way.  Think of the soreness that you felt in your muscles after the most vigorous workout that you have ever done and multiply that by 1,000.  Obviously, that would be bad.  The treatment that you can do as a law enforcement officer is to again control the bleeding effectively AND KEEP THE PATIENT WARM!!  

Hypothermia:  It is very easy to believe that hypothermia is a condition that only occurs in colder temperature conditions.  Interestingly, hypothermia occurs in just over half of ALL severe trauma patients regardless of climate conditions.  As mentioned previously in the article, the body is made up of several complex systems that work together to keep the body in a state of homeostasis (everything working together in harmony).  When the body sustains major trauma, and especially when the body enters into the phases of going into shock, the body loses the ability to sustain temperature regulation.  A multitude of medical studies have proven that as the body’s temperature drops, the body’s ability to form clots drastically reduces as well.  If a person is experiencing massive bleeding, this is clearly a major issue.  The body’s coagulation system in part relies on a series of complex actions performed by enzymes to form clots.  Those enzymes only work optimally in temperatures that do not involve a hypothermic state.  To make this simple, the body has to stay warm to form clots.  To make this very easy, make every effort to cover any massive trauma patient and keep them warm.  When doing your assessment on a trauma patient as an example, once you examine the chest and back, cover them before moving to another body part.  It is a very good idea to carry a blanket in your patrol vehicle.  In addition to keeping trauma patients warm, it can serve as a vast array of other uses as well.  

In conclusion, stop massive bleeding, and cover the trauma patient up keeping them warm.  Do not forget to ensure that there is also a layer between the patient and the ground, especially in colder environments.  I hope that you took something away from this Medical Monday.  If you have any questions or anything to add, make a comment below.  Happy Memorial Day!!

One of the most difficult types of calls that we can respond to as emergency services providers is a call involving a critically injured or ill child.  In this Medical Monday we will discuss the Pediatric Assessment Triangle.  This tool is used by EMS professionals as a step by step guide that will assist with forming a general impression of what exactly is wrong with the child.  In my experience, I have found that the Pediatric Assessment Triangle helps to keep me focused during a high stress event (responding to help a very sick kiddo whether trauma or medically induced) as well as helping to guide me to a fast differential diagnosis so that I can begin accurately treating what is going on.  

As the name implies, the Pediatric Assessment Triangle consists of three components.  They are: Appearance, Work of Breathing, and Circulation to the Skin.  Allow me to break these components down individually.  

Appearance – I have always preached that 90% of emergency medicine at the street level is common sense.  My personal belief when it comes to the appearance of anyone whether a child, or an adult is that if they truly look “bad” then they ARE “bad” until proven otherwise.  To simplify this, if they look really sick, move urgently.  If they don’t look that sick, you have a little time to do a more detailed assessment.  Now for the technical answer.  For the appearance section of the triangle, we use the mnemonic TICLS.  

• T – Tone (Muscle Tone) Is the child limp?  Are they rigid?  Are they moving normally for their age?
• I – Irritability Is the child crying?  Is their airway blocked to the point that they can’t cry?  Are they unresponsive?  I have always believed as a paramedic responding to a call involving a baby or a child that it is a wonderful thing to hear them crying loudly.  This means that their airway is open, and they are alert to the fact that they are in pain.  
• C – Consolability Is the child able to be comforted by their parents / guardians?  Does the child withdraw or act fearful of their parents / guardians?  Are you able to calm the child down with a distraction such as a toy?  
• L – Look or gaze Does the child have a fixed and vacant stare?  Is the child looking around normally? If the child has a vacant stare, ask about seizure activity or any possibility of a head injury.  
• S – Speech Is the child able to express themselves at an age appropriate level?  If it is an infant, are they crying, and if they are, is it a normal type of cry?

Work of Breathing – This portion of the triangle measures how hard the child or infant is working to breathe.  Are they breathing normally?  Are they using accessory muscles to breathe?  Do you see retractions (the skin between the ribs being sucked in)?  Do you see nasal flaring?  Do you hear any abnormal noises such as snoring, wheezing, or a high-pitched bark?  In infants specifically, grunting noises are a sign of respiratory distress. Most generally, when pediatric patients are experiencing a serious medical issue, the issue is respiratory in nature.  If you can begin to fix the respiratory issue, the patient in most cases will begin to improve.  

Circulation to the Skin – This segment of the triangle covers obvious blood loss.  Mottling (a marbled appearance), cyanosis (bluish coloring around the face, or tips of fingers and toes), and pallor (paleness of skin) all point to a decrease in circulatory function and or a lack of oxygenation.  An important note:  CAT Tourniquets WILL work in any age of patient.  It used to be taught that this was not the case, but a study was conducted and showed that to be inaccurate.  With that being said, pediatric patients have lower blood pressures, so direct pressure is more effective when it comes to stopping blood flow.   

Here are a few tips that have worked well for me over the years of responding to emergencies involving children:

On the way to the scene make sure that you are taking deep breaths and focus on being / remaining calm.  This may sound cliché, however oftentimes these calls can quickly become overwhelming and people are looking to you to make solid and urgent decisions.  Once you have arrived on the scene, our inclination is to immediately rush to the patient.  I make it an absolute point to stop at the doorway for approximately 10 seconds and survey the big picture of the scene before I enter.  Once you are beside the child, it can be very easy to be overcome with tunnel vision and miss something such as an empty pill bottle nearby, or other clues that can guide you to what is going on.   

If the parent / guardian / caregiver is available, not panicking, and remaining somewhat calm, allow the child or baby to be held by them while you perform your assessment.  Generally, the child will remain calmer, the parents will be calmer, and you can get a more accurate assessment.  When it comes to calls involving pediatrics, it is very important to remember that the parents are a patient also.  Communicate calmly, and clearly.  Avoid phrases such as “everything will be fine.”  A great replacement phrase is to assure them that you are doing everything possible for their child.  Generally speaking, the parents or caregiver of the child will be a great resource for gathering the health history of the child.  Important questions include but are not limited to:  What kind of medical problems does the child have?  Have they had any recent complications?  Is the child taking any medications?  Does the child have any allergies?  Have they been peeing / pooping normally?  How many wet diapers has the infant had today?  When was the last time they ate or drank anything?  What led up to this medical event today?

When assessing a responsive child, make sure to lower yourself to their level, and then begin at the feet and work your way up.  This will allow the child to be more comfortable.  I highly recommend carrying a couple of small stuffed animals in your patrol car to give to pediatric patients.  They can be used as a distraction, but they can be used as a great assessment tool.  If the child is age appropriate, you can ask the child to point on the stuffed animal where they are hurting.  Another strategy is to see if you can track down their favorite toy or blanket.  

When other responders arrive, whether it be firefighters, medics, or other officers, refer to them as your friends.  Use calm and reassuring voice levels.  It is very helpful once a rapport has been established to try your best to remain with the child for as long as possible before they are transported.  

When it comes to cardiac arrest in pediatrics remember these three things:

• The SINGLE RESUCER chest compression to ventilation ratio remains the same for adult, child, and infant.  That rate is 30 compressions to 2 breaths.  
• For SINGLE rescuer use the two-finger method for infants.  Many responders have stated that the thumb encircling the hand method seems more effective, and more comfortable.  The problem is that it takes too much time to get back into position after delivering the ventilations.  Once TWO rescuers are on scene, the thumb encircling the hand method is preferred.  Once TWO rescuers are on scene, the compression to ventilation ratio for CHILD AND INFANT changes to 15 compressions to 2 breaths.    
• When opening the airway, it is very important to remember that extending the head too far can cause hyperflexion which can also block the airway.  Primarily in infants, the best way to get their head into a neutral in line position is to place a towel or sheet, or whatever you have available that you can manipulate between their shoulder blades.  This will naturally raise the torso allowing their head to get into the optimal position for their airway to be open.  

I have no doubt that there are several of you out there who have your own tips and tricks that have worked well for you when it comes to responding to calls involving children.  I would love for you to share them in the comments.  As always, if you have any questions, please let me know in the comments section as well.  

A couple of weeks ago I had the privilege attending a meeting with a few representatives from the company QuikClot.  QuikClot is one of a few different manufactures that produces impregnated gauze that is used for wound packing.  In this Medical Monday we will discuss the correct way to perform wound packing as well as the areas in which wound packing can be performed.  

One thing that sets QuikClot apart from other manufactures is that QuikClot is impregnated with kaolin as the agent that assists with faster clotting of blood.  The Committee of Tactical Combat Casualty Care also recognizes QuikClot as a superior product.  An long conversation ensued discussing the two methods approved by QuikClot when using their product.  One theory is that if you have used an entire roll of QuikClot inside of a wound, and the wound is still bleeding, you pull all of it out and place a fresh pack of QuikClot into the wound.  

The rationale behind that theory is that the fresh kaolin will make contact with the blood and provide a better clot to slow down and stop the bleeding.  In my entire career I have always been taught that you should never remove gauze from the wound once the wound is packed with gauze.  

If the bleeding continues, add fresh gauze on top of the existing gauze and hold pressure.  I brought this point up to the QuikClot representatives who after a long discussion agreed that EITHER method would be acceptable.  The tactical physician in the room advised that he personally would just add gauze, he would not remove what was already in place.  This is what I recommend as well.  My thought process says that if you remove the gauze that has already become soaked, you are removing any clot, or beginning of a clot that has already formed, and you are starting back at square one.  

This brings me to my next point.  When you encounter a wound with a large amount of bleeding in a place that is not amendable to tourniquet use, it is imperative to try to pinpoint exactly where the bleeding is coming from.  To do this, if blood has pooled within the wound, use your hand and “scoop” the blood out to assist you with finding the source.  Once you find the source, begin packing the wound using your finger to hold pressure directly on the source of the bleeding.  Ensure that you fill ALL of the voids of the wound cavity.  Especially in the case of a gunshot wound, the energy that enters into the body with the bullet will cause tissue to expand and tear.  It is important to pack all areas of the wound that were affected.  

Let me clarify a few things.  Wound packing is most generally performed in the junctions of the body.  Your arm pits, groin, and the base of your neck are a few examples.  Do NOT put QuikClot or any other type of gauze into major head trauma, the chest, or the abdomen.  

QuikClot offers several different sizes of gauze for different applications.  The packaging will look different, but the product itself is the same.  No longer is quikclot the granules that used to cause burns.  I have used the current quikclot product and it is absolutely incredible how well it works.  A friend of mine took a sim round to the nose during SWAT school last year and his nose would not stop bleeding.  I used a small piece of the QuikClot gauze to place into his nose, and the bleeding stopped immediately.  If you have any questions or comments, please let me know.