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June 01, 2007
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Winning Over Injury - A Tactically Oriented Approach to Treating Injured Officers

By Matthew D. Sztajnkrycer, MD, PhD
    David W. Callaway, MD
    Sgt. Jeff Stilwell
    Amado Alejandro Baez, MD, MS, MPH

Law enforcement is a dangerous job. In 2005, there were over 50,000 assaults on officers, resulting in 15,763 injuries and 153 felonious line-of-duty deaths.2  Scores of officers were also inured in the line-of-duty as a result of automobile accidents, heart attacks, falls, etc. As part of a societal mandate to protect and serve, all officers undergo formal emergency medical training, typically at the Department of Transportation First Responder level. This training is based upon the principles of Basic Life Support (BLS). Unfortunately, such training is not law enforcement specific and, is inherently limited. Though adequate for the officer responding to a routine EMS medical assistance call, BLS does not address the challenges of an officer caring for an injured colleague in the presence of an active threat. Under these circumstances, medical care must be thought of as a tactical decision and training programs must appropriately address this concept.

Historically, the civilian approach to prehospital trauma management has emphasized the principles of Advanced Trauma Life Support (ATLS).1,3  The military experience in Somalia highlighted deficiencies in the application of this medical model to a tactical setting.4,5  Out of this conflict was born the modern doctrine of tactical combat casualty care (TCCC). TCCC focuses on three simultaneous goals; treating the casualty, preventing further casualties and completing the mission.6,7 The military currently trains all forward-deployed soldiers in the concepts of TCCC. Within the civilian setting, such training has been limited to specially trained medics supporting law enforcement special operations units. In contrast to the military, this knowledge has not made it to those who arguably need it the most, officers in the field. 

This article attempts to demonstrate, through scenario-based discussions, the application of modern Tactical Combat Casualty Care to the civilian law enforcement setting. The objective is to provide a tactical framework from which to approach medical care while under conditions of actual or perceived threat. Each scenario contains critical actions, which are meant to illustrate principles for approaching difficult operational challenges; they are by no means the only solution. The usual disclaimers apply: These discussions are for illustrative purposes only, and should not supersede your current operational guidelines.

Case 1
You’re assisting in the arrest of a suspected drug dealer during a buy-bust operation. As your partner attempts to cuff the suspect, he slashes your partner’s hand with a razor. You see a large amount of dark red blood streaming from the wound. Your partner is screaming. What can you do to help?

Unfortunately, this straightforward case is not far-fetched. Even with cover-contact drills, physical assault and injuries happen quickly and unexpectedly. The conventional medical response would be to immediately stop any active bleeding with direct pressure. However, what about the suspect? By focusing upon your partner and the blood streaming from his wound, you risk losing situational awareness. Accordingly, the suspect may escape or continue the assault, resulting in further injury to both of you. 

In the combat setting, the best medicine is fire superiority.1,6 Similarly, in the tactical setting, the best initial medicine is threat neutralization. Tactically assess the situation, prevent further injuries and call for assistance. Eliminate the threat, secure the suspect, then focus on hemorrhage control. If immediate medical care is needed, the injured officer should be capable of administering it as self-care (apply pressure) in order to allow his partner to concentrate upon the threat (Figure 1).
   
When giving first aid to the injured officer, body substance isolation (BSI) precautions are critical. While this may be a fellow officer rather than a drug-abusing prostitute, he could have been stuck by a needle while patting down a suspect six months ago and currently have hepatitis C or HIV. Make it a habit of carrying gloves, and double-glove when managing an actively bleeding wound. Better safe than sorry. Gloves in the squad car are no more useful than a shotgun in the trunk. If you routinely carry them on your body, you will have them when it matters.
   
The primary lesson is to start thinking about the “what-ifs” of routine patrol. Blood is scary. In fact, large amounts of unanticipated blood may make your mind stop working. You will simply fall back upon habit, whether good or bad. This is the basis for the oft-quoted mantra “Train how you fight, fight how you train.” How often do you train for a scenario like this? Even mental rehearsal for situations like these will condition your mind to react appropriately during unanticipated, dangerous circumstances.8

Key Actions: Case 1
1. Tactically assess medical situation and prevent further injuries.
2. Manage/control any immediate threat:
   A. Call for assistance and activate EMS as soon as tactically feasible.
   B. Secure suspect.
   C. Secure primary and secondary weapons.
3. Medical Assessment/interventions
   A. Body substance isolation precautions.
   B. Control bleeding by direct pressure.
4. Initiate transport to medical care if appropriate and safe.

Case 2
You’re backing up your SWAT team during a high-risk warrant, providing outer perimeter security. A vehicle pull is used to breach the metal bars on the door. Unseen by the entry team, the breacher is struck by the metal bars as they are pulled from the door. He falls from the porch. As you approach, you find him sitting on the ground, cradling his assault rifle and looking dazed. Blood is coming from a gash in his forehead. What do you do?

First, are you in the hot or warm zone? Depending upon the raid, the location may not be secured. Tactically assess the situation, prevent further injuries and summon assistance/inform command. Because the breacher may have had another mission-critical role on the entry team, command will need to know that he is out of the stack. Given the presence of the tactical team, there are likely sufficient resources to allow you to aid the officer. However, you need to be specifically tasked to do so, as the perimeter will no longer be secured. Once on scene, secure all weapons. Despite the absence of an obvious suspect, this is still a hot zone because the casualty is armed, potentially dangerous and in close proximity to you. A head injury and an assault rifle are a bad combination, as is a head injury and a pistol.

From a medical needs standpoint, this patient has altered mental status and obvious injury from blunt trauma above the level of the collarbones. Bleeding from a scalp wound may be brisk and heavy, but should respond to local pressure or pressure dressing. Always consider c-spine (neck) injuries, even if the patient is moving all four limbs. If you decide to move him, remember to maintain c-spine precautions if tactically possible.  The data suggesting a lack of benefit for such precautions in the military setting is based upon penetrating trauma (gunshot wounds), not blunt trauma.9
 
Key Actions: Case 2
1. Tactically assess medical situation and prevent further injuries.
2. Manage/control any immediate threat:
   A. Call for assistance and activate EMS as soon as tactically feasible.
   B. Secure primary and secondary weapons. 
3. Medical Assessment/interventions
   A. Body substance isolation precautions.
   B. Control bleeding by direct pressure.
C. C-spine precautions as tactically appropriate.
4. Initiate transport to medical care if appropriate and safe.

Case 3
You are part of an entry team which is training for a no-knock warrant. The breacher, armed with a 12-gauge shotgun firing frangible ammunition, has an accidental discharge while pivoting. The round strikes the point man in the mid right thigh. The officer immediately goes down. There is heavy, pulsatile, bright red blood spraying from a large gaping wound. What do you do?

This is a potentially catastrophic injury likely involving the femoral artery. If not rapidly controlled, the officer will bleed to death in minutes. While this is a training accident, it is still important to ensure tactical awareness and scene safety prior to concentrating on the wounded officer. All live weapons should immediately be rendered safe and secured to prevent further injuries.

In the military setting, uncontrolled extremity bleeding is the leading cause of preventable combat death.10, 11, 12  A quick way to remember this is a mnemonic used by Naval Special Warfare operators: BATS (Bleeding – Airway – Tension Pneumothorax – Shock). In contrast to conventional medical training, which focuses upon the ABCs and emphasizes resuscitation from shock, tactical medical care focuses upon circulation (bleeding) before airway and emphasizes prevention of shock. According to TCCC guidelines, the only treatment appropriate while under effective fire (or the threat of effective fire in the civilian arena) is control of life-threatening bleeding.7

The tactical management of extremity hemorrhage is a vital skill. In managing this injury, direct pressure will probably be inadequate and will be difficult to maintain while under threat. (Figure 1, Figure 2)  As part of the TCCC approach to hemorrhage control, a tourniquet would be the most appropriate medical action. Although there is a lot of fear in the medical community about tourniquets, the experience in Afghanistan and Iraq indicates that tourniquets clearly save lives.13, 14, 15  There are some excellent modern one-handed tourniquets available and routinely included in the individual first aid kits issued to all US ground forces.16, 17, 18  Unfortunately, for civilian law enforcement officers, you will not likely have access to these as part of your duty kit unless you buy your own. Accordingly, preplanning and training is critical. Think about field-expedient tourniquets–your duty belt, your rifle or shotgun sling, even a cloth rag with your baton as a windlass.  Securing a windlass is difficult and requires practice. Forward thinking departments should consider developing “blow out” kits for their officers. These kits provide  necessary tools to manage immediate life-threatening emergencies. Most importantly, these kits must be available when needed, not left in the squad car. Consequently, these kits need to be compact, lightweight, and easy to use. Moreover, the simple existence of such kits is not enough. Training is essential.

And, if all of this fails, there are some new blood stoppers out there.19, 20, 21, 22, 23   

These compounds were developed to treat the so-called Blackhawk Down scenario–a groin shot with a femoral artery bleed too high up the leg for a tourniquet. Currently, the US Marine Corps uses QuikClot® as its hemostatic agent, while the US Army and the US Special Operation Command utilize HemCon®. Each product has benefits and drawbacks (ease of use, cost, potential tissue damage, etc.). Although there is limited data on the use of these agents, they are another potential tool to be used to address the rare, but catastrophic arterial bleed (Figure 1).

KeyActions: Case 3
1. Tactically assess medical situation and prevent further injuries.
2. Manage/control any immediate threat:
   A. Call for assistance and activate EMS as soon as tactically feasible.
   B. Secure primary and secondary weapons. 
3. Medical Assessment/interventions
   A. Body substance isolation precautions.
   B. Control bleeding by direct pressure, tourniquet, hemostatic agents.
4. Initiate transport to medical care if appropriate and safe. Consider use of helicopter evacuation.

Case 4
You and three other officers have just finished a one-mile foot pursuit of a felony suspect. As the suspect is arrested, the last officer to arrive on scene stops short. He looks at you, grabs his chest, makes a gurgling sound and collapses. What do you do?

Due to occupational stress and lifestyle issues (poor diet, lack of exercise, etc) police officers have heart disease and die from heart attacks on the job. This officer has suffered sudden cardiac death. The medical management of this case is no different than the management of any other medical assistance/cardiac arrest call. This officer needs immediate CPR and an automated external defibrillator (AED) as soon as one can be retrieved.

There are still some very important tactical issues with this case. Is the suspect secured and under control? Even if handcuffed, if no one watches him, he may a) run away, b) assault the officers caring for the downed officer, or c) all of the above. Tactically assess the medical situation and prevent further injuries. Call for immediate assistance, secure the suspect and assign an officer to maintain security of the suspect. Secure any primary and secondary weapons.

TCCC guidelines discourage CPR in the hot zone (under effective fire). This recommendation addresses “traumatic cardiac arrest” for which survival is dismal.  In the civilian setting, CPR may be permissible, provided it does not expose the caregivers to further risk. In this case, leadership is critical. You should quickly assign responsibilities; one officer to the suspect, one to call for assistance and one to assist with scene security or medical care as needed. You should immediately call for EMS, assess the ABC’s and initiate CPR once the scene is secure. It is extremely difficult for a single provider to perform CPR while maintaining situational awareness.

Key Actions: Case 4
1. Tactically assess medical situation and prevent further injuries.
2. Manage/control any immediate threat:
   A. Call for assistance and activate EMS as soon as tactically feasible.
   B. Secure suspect.
   C. Secure primary and secondary weapons. 
3. Medical Assessment/interventions
   A. Body substance isolation precautions.
   B. Check for a pulse. If absent, initiate CPR/Basic Life Support.
   C. Immediate defibrillation when available.
4. Initiate transport to medical care if appropriate and safe.

Case 5
While on routine foot patrol, you and your partner attempt to question a suspicious individual. When ordered to stop, he turns, raises a small handgun and fires a single shot. After neutralizing the threat, you check on your partner. He is wearing his duty vest, but has been struck in the right armpit. He complains of trouble breathing, which is getting worse. He looks pale and has a weak, thready pulse. As he speaks, he coughs up some frothy blood. Removing his ballistic vest, you notice that although there is little bleeding, the right side of his chest does not rise and fall as well as the left when he breathes. You also notice that his Adam’s apple is shifted over to the left. What do you do?

Once again, tactically assess the situation. Prevent further injuries and immediately call for assistance. From a tactical standpoint, become comfortable activating your radio one-handed without taking your eyes off the threat and become comfortable calling on the radio while using your weapon. Secure the suspect and then secure weapons. To a certain degree this scenario is unfair from a medical standpoint (certainly beyond the typical first responder law enforcement training program) but whoever said life was fair? The injured officer has a tension pneumothorax (the T in BATS). This happens when a hole is made in the lung that allows air to enter into the chest cavity but not to leave again. With each breath, more air fills the chest cavity, further collapsing the lung. As time goes on, so much air accumulates in the chest cavity that it pushes upon critical chest structures (the heart, the great vessels, the trachea) and forces them over to the other side (hence the Adam’s apple being pushed over from midline). When this happens, the chest structures are under tension, preventing blood from returning to the heart. Shock and eventually death ensue.

Why is this important? Tension pneumothorax is the second most common cause of preventable death on the battlefield.10, 12  Also, it is simply and effectively managed with treatment that can be taught in minutes. The treatment, called needle decompression, involves pushing a large bore needle (10 or 14 gauge IV needle/catheter) into the chest cavity, venting out the trapped air and converting the tension pneumothorax to a simple pneumothorax (Figure 3). This is a temporary but lifesaving solution; the injured officer still needs immediate transportation to a hospital. Needle decompression has traditionally been viewed as beyond the typical scope of police practice. However, given current threat levels, this philosophy should change. Advanced medical training for non-medical personnel is effective in the military in the form of combat lifesavers. These non-medical personnel have additional training beyond the basic medical skills taught to all soldiers, including the ability to perform needle decompression. Such training is simple, tactically oriented, and ideally suited in a modified format for use by police officers (Table 1).

Key Actions: Case 5
1. Tactically assess medical situation and prevent further injuries.
2. Manage/control any immediate threat:
   A. Call for assistance and activate EMS as soon as tactically feasible.
   B. Secure the suspect.
   C. Secure primary and secondary weapons. 
3. Medical Assessment/interventions
   A. Body substance isolation precautions.
   B. Control bleeding by direct pressure.
   C. Needle decompression.
4. Initiate transport to medical care if appropriate and safe.

Case 6
You respond to an armed robbery-in-progress call at a local bank. As you approach, a suspect emerges and opens fire with an assault rifle. A round strikes you in the left upper arm as you seek cover. Your arm instantly feels numb and as you examine the wound, you notice brisk, dark red bleeding. You feel lightheaded and think you might pass out. What should you do?

To a certain degree, this is a replay of the first case, but now requires knowledge of self-care. The response to this situation should be reflexive. Blood is a powerful stimulus, and if mentally unprepared, has a bad habit of making us either shut down or revert to more primitive and typically less useful actions. You need to overcome these emotions, and maintain a will to live and to fight.8 Even a gunshot wound to the head or chest is not necessarily fatal. Take some deep breaths, calm down and re-oxygenate the brain. Analyze the situation tactically and prevent further injury (Am I safe here? If not, where should I go? Am I in a position to immediately engage the suspect or should I seek cover and concealment?).

Call for immediate assistance, especially if you believe you might pass out. Then, when tactically feasible, assess wounds (Where am I hit? How bad is it? What can I do to make it better?) and control any bleeding. This is where a modern one-handed tourniquet will come in. Otherwise, a field-expedient tourniquet or direct pressure are your primary options. What else can you do medically, while waiting for extraction? In addition to hemorrhage control, lie down if tactically appropriate. This action theoretically allows gravity to keep blood in the core, (chest and brain) rather than in the lower body. If still feeling woozy, raise your legs slightly to get more blood into the core. Get angry, and stay determined to live. Help will arrive soon–keep fighting until it gets there.

Key Actions: Case 6
1. Tactically assess medical situation and prevent further injuries.
2. Manage/control any immediate threat:
   A. Call for assistance and activate EMS as soon as tactically feasible.
   B. Engage threat if tactically feasible.
3. Medical Assessment/interventions
   A. Control bleeding–self-care.
4. Initiate transport to medical care if appropriate and safe.

This article highlights important and inescapable interaction between good tactics and sound medical care during threats. For law enforcement leaders, medical response should be viewed primarily as another tactical decision. It affects manpower, operations, tactics, strategy and morale. Current first responder training should not be abandoned. Such training provides an essential framework of medical knowledge. However, we recommend a second tier of medical training based upon the principles of TCCC that emphasizes a sound tactical approach to medical emergencies.

Military leadership has long viewed over-reliance on highly-trained combat medics as an operational weakness that may negatively impact the care of wounded soldiers. Medics are expensive to train and are often early casualties in conflict.  Accordingly, the Naval Special Warfare Command advocates that every SEAL team leader is trained in tactical medical care.1  More recently, the US military has developed and fielded the concept of combat lifesavers (CLS) (Table 1). Combat lifesavers currently provide nearly one quarter of all combat casualty care.

The TCCC and CLS programs have proved so successful that the US is reportedly training the entire Iraqi police force to the combat lifesaver level.24 While the current situation in Iraq is not comparable to that in the US, if the training is deemed important enough for the Iraqi police force, might it not be useful for US law enforcement? Placed in perspective, a recent survey of law enforcement in one geographic area indicated that 41% had responded to the scene of a seriously injured officer, and that 29% had arrived prior to EMS [Personal Data, MDS]. Yet no civilian analog to the combat lifesaver program exists, resulting in an inescapable reliance on non-tactically aware civilian EMS for medical care.

We have developed a tactically-oriented medical algorithm for law enforcement which integrates the key actions discussed, while achieving the three goals of TCCC: prevent further injury, care for the wounded officer and allow successful completion of the mission. Given the effects of stress on the brain, actions must be kept safe and simple. 

The key element in developing tactically-oriented medical skills is appropriate, scenario-based training. Such training should be kept simple and build upon the medical skills officers already possess. The training does not need to be expensive nor does it need to be time-consuming. However, similar to a martial arts technique, it needs to be done with a degree of repetition which will allow it to be instinctive. If not, it will be forgotten during times of stress. While no training can account for every contingency, realistic training should be accessible, modular and capable of being integrated seamlessly into current departmental policies, providing an internally consistent approach to any scenario.

Coupling tactical medical training with use-of-force and defensive tactics training is one logical solution. This pairing allows the maintenance of a tactical mindset and the application of this mindset to medical and enforcement problems. Medical trauma response should be viewed as a mission-critical skill, similar to the ability to recover a dropped weapon while maintaining tactical awareness, the ability to change magazines with a wounded arm or the ability to call for assistance over the radio without taking eyes off the threat. All components of a tactical decision are intimately linked. Proper training requires realistic training with integrated medical and tactical scenarios. From an institutional health perspective, the military experience has suggested that first aid instruction is an excellent way to improve and maintain morale in combat arms, presumably by empowering personnel, giving them the knowledge to approach potentially dangerous circumstances with increased confidence. Under these conditions, medical care cannot occur in a vacuum, and must account for tactical considerations. Specific, integrated training of these two interrelated topics is key in developing a new paradigm in officer survival strategies. 

Table 1
Core Competencies of the US Combat Lifesaver Medical Curriculum

1. Perform Tactical Combat Casualty Care
2. Evaluate a Casualty
3. Open and Manage a Casualty’s Airway
4. Treat Penetrating Chest Trauma and Decompress a Tension Pneumothorax
5. Control Bleeding and Apply a Tourniquet
6. Initiate an Intravenous Line and Infusion
7. Initiate a Field Medical Card
8. Request Casualty Evacuation
9. Evacuate a Casualty Using a Litter

Table 2
Tactically Appropriate Medical Responses Based Upon Location of Care

Hot Zone - Threat of Effective Fire
• Manage/Control Immediate Threat–Fire superiority
• Stop life-threatening bleeding
• Protect yourself
• Protect the casualty
• Scoop and Go

Warm Zone - Care within the Inner Perimeter, but in a location of relative cover/concealment.
• Airway Management
• Clear Airway Obstruction - Chin Lift or Jaw Thrust
• Nasal Airway
• Advanced Airway Techniques Depending Upon Level of Training
• Breathing
• O2
• Needle Thoracostomy
• Bag-Valve Mask Ventillation
• Circulation
• Control Hemorrhage
• Intravenous/Intraosseus Access Depending Upon Level of Training

Cold Zone - Threat No Longer Exists. Care is Analogous to Routine EMS Care.
• Recheck Vital Signs and Patient Condition
• Perform Secondary Survey
• Expose and Dress all Wounds.
• Splint Fractures
• Pain Control
• CPR
• Evacuation and Transport

BSI: Body Substance Isolation
C-spine: Cervical Spine
LSI: Lifesaving interventions eg. tourniquet, hemostatic agent, needle decompression
RAM Algorithm: Remote Assessment  

Methodology, a field triage algorithm developed by the Counter Narcotics and Terrorism Operational Medical Support Program (CONTOMS) and designed in part to assess the risk of attempting rescue under fire.

References

1. Butler FK Jr. Tactical Medicine Training for SEAL Mission Commanders. Mil Med 2001; 166: 625 – 631.

2. Uniform Crime Reporting Program. Law Enforcement Officers Killed and Assaulted 2005. Federal Bureau of Investigation. US Department of Justice. November 2006.

3. American College of Surgeons: Advanced Trauma Life Support, 7th ed.  2003.

4. Butler FK and Hagmann JH. Tactical Management of Urban Warfare Casualties in Special Operations. Mil Med 2000; 165 (suppl 1): 1 – 48.

5. Mabry RL, Holcomb JB, Baker AM, Cloonan CC, Uhorchak JM, Perkins DE, Canfield AJ, and Hagmann JH. United States Army Rangers in Somalia: An Analysis of Combat Casualties on an Urban Battlefield. J Trauma 2000; 49: 515 – 529.

6. Butler FK Jr, Hagman J, and Butler EG. Tactical Combat Casualty Care in Special Operations. Mil Med 1996; 161 (Suppl 1): 3 – 16.

7. Committee on Tactical Combat Casualty Care. Military Medicine. In Prehospital Trauma Life Support, Military Edition, Revised 5th Edition, eds McSwain NE, Frame S, and Salomone JP. Mosby, St Louis, MO, 2005, pp 374 – 408.

8. Blum LN. Force Under Pressure: How Cops Live and Why They Die. Lantern Books, New York, NY. 2000.

9. Arishita GI, Vayer JS, and Bellamy RF. Cervical Spine Immobilization of Penetrating Neck Wounds in a Hostile Environment. J Trauma 1989; 29: 332 – 337.

10. Bellamy RF. The Causes of Death in Conventional Land Warfare: Implications for Combat Casualty Care Research. Mil Med 1984; 149: 55 – 62

11. Champion HR, Bellamy RF, Roberts P, and Leppaniemi A. A Profile of Combat Injury. J Trauma 2003; 54: S13 – S19.

12. Bellamy RF. Death on the Battlefield and the Role of First Aid. Mil Med 1987; 152: 634 – 635.

13. Walters TJ and Mabry RL. Issues Related to the Use of Tourniquets on the Battlefield. Mil Med 2005; 170: 770 – 775.

14. Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M, and Ben-Abraham R. Tourniquets for Hemorrhage Control on the Battlefield: A 4-Year Accumulated Experience. J Trauma 2003; 54: S221 – S225.

15. Cloonan CC. Treating Traumatic Bleeding in a Combat Setting. Mil Med 169: 2004; S8 – S10.

16. Calkins MD. Evaluation of Possible Battlefield Tourniquet Systems for the Far-Forward Setting. Mil Med 2000; 165: 379 – 384.

17. Wenke JC, Walters TJ, Greydanus DJ, Pusateri AE, and Convertino VA. Physiological Evaluation of the US Army One-Handed Tourniquet. Mil Med 2005; 170: 776 – 781.

18. Walters TJ, Wenke JC, Kauvar DS, McManus JG, Holcomb JB, and Baer DG. Effectiveness of Self-Applied Tourniquets in Human Volunteers. Prehosp Emerg Care 2005; 9: 416 – 422.

19. WedmoreI, McManus JG, Pusateri AE, and Holcomb JB. A Special Report on the Chitosan-Based Hemostatic Dressing: Experience in Current Combat Operations. J Trauma 2006; 60: 655 – 658.

20. Pusateri AE, Holcomb JB, Kheirabadi BS, Alam HB, Wade CE, and Ryan KL. Making Sense of the Preclinical Literature on Advanced Hemostatic Products. J Trauma 2006; 60: 674 – 682.

21. Alam HB, Burris D, DaCorta JA, and Rhee P. Hemorrhage Control in the Battlefield: Role of New Hemostatic Agents. Mil Med 2005; 170: 63 – 69.

22. Pusateri AE, Delgado AV, Dick EJ Jr, Martinez RS, Holcomb JB, and Ryan KL. Application of a Granular Mineral-Based Hemostatic Agent (QuikClot) to Reduce Blood Loss after Grade V Liver Injury in Swine. J Trauma 2004; 57: 555 – 562.

23. Heiskell LE, Olesnicky BT, and Vail SJ. Blood Clotters. Police. 2004; 28: 52 – 59.

24. Tilghman A. Iraqi Police Study the Basics of Medical Aid. Stars and Stripes, 10 April 2006 






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