Mark Corson

By D. Fasim. University of Maryland Eastern Shore.

The addition of the handle to the shaft makes it versatile purchase rumalaya liniment 60 ml online, with more than 30 blocking and striking techniques available to the officer buy discount rumalaya liniment 60 ml. Correct use in stressful and challenging situ- ations requires extensive and ongoing training generic 60 ml rumalaya liniment overnight delivery. It is carried unobtrusively on the belt and does not impede the general movement of the officer. This gives more weight distally, but it is prone to becoming flattened and rough over time because the baton is closed by striking this end against the ground. The acrylic patrol baton has a solid or hollow nylon shaft with a ring of rubber separating the shaft and handle. It is broader than the friction lock type and, therefore, less likely to cause injury because the imparted energy is spread over a larger area. The heavier weights of these types of batons are used in public order disturbances. In the United States, a 26-in hickory (wooden) straight baton is used (similar to group 3 in the previous list). The situation throughout the Austra- lian states is variable, with intrastate differences relating to specific police staff; for example, plain clothes staff may use an Asp-type baton, whereas uniformed officers are equipped with straight or side-handled batons. Strikes are made from an officer’s strong (dominant) or weak (nondominant) side, and clearly the potential for injury varies with the baton mass and velocity at impact, the target area, and to how much of the surface area the force is applied. Although no body area is absolutely forbidden to strike, an officer must use a proportionate response to the situation he or she faces knowing the potential to injure. Although target areas are divided into low-, medium-, and high-risk areas, maintaining a distinction between them can be difficult because strikes are made in dynamic situations where an initial target area may change as the potential detainee moves. Target areas with a low injury potential are the areas of the common peroneal, femoral, and tibial nerves on the legs and those of the radial and median nerves on the arms. There is a low probability of permanent injury, with the main effects being seen as short-lived motor nerve dysfunction, as in a “dead leg” and bruising. The medium injury potential areas involve bones and joints, including the knees and ankles, wrist, elbow, hands, upper arms, and clavicle. In these cases fractures, dislocations, and more extensive soft tissue injuries would be expected. Finally, those areas with the highest risk of injury include the head, neck and throat, spine, kidneys, and solar plexus. The most common injury is bruising, and this is often in the pattern of so-called “tramline bruising,” where two parallel lines of bruising are sepa- rated by a paler area. This is not unique to a baton injury but reflects an injury caused by any cylindrical hard object. The absence of bruising or other find- 200 Page ings does not mean that a baton was not used because, for example, a degree of cushioning can occur from clothing. It is possible for a detainee to have signs but minimal symptoms or even be unaware of being struck. Fractures need to be considered where there are the traditional clinical signs of local pain, swelling, and loss of function. Considering the forces that can be applied when necessary, there is the potential for significant injury with bruising and rupture of internal organs, including the heart, liver, spleen, or kidneys or a head injury. The forensic physician should refer suspected cases for hospital review without delay, es- pecially if a confirmatory history for events is unavailable. Particular care is needed in those who are intoxicated because they are difficult to assess. Because they cannot be released them- selves, snips to cut them are always available at the same time. Although quick and easy to apply, they have no way of being locked in position, so they can tighten in an uncontrolled manner, resulting in direct compression injuries. At least two ties are used on each detainee; one is placed on each wrist and then interlocked with the other. These plastic constraints are used in preplanned operations, where numerous arrests are expected or in special- ized operations. Excessive force, either directly applied by the officer or from a detainee continuing to move, can result in strains to joints, such as the wrist, elbow, and shoulder. Officers in the United Kingdom are not trained in any neck holds because of the high risk of serious injury or death as a result of large blood vessel or airway compression. Fatalities can occur quickly, and if a detainee complains of such holds being used, the neck should be examined carefully. Petechial bruising should be looked for in the face, particularly in and around the eyes, on the cheeks, and behind the ears. It is common for clothing to be held in a struggle to restrain, which may tighten it around the neck. Linear bruising Medical Issues of Restraint 201 may be seen at the site of tightening, as well as petechial bruising on the neck and above on the face. Clearly, the tactical firearms units are often required in these situations, but there is an increasing trend to look for other “nonlethal” options, which will incapacitate with a lower risk of serious injury. In the United Kingdom, the investigation of firearm inci- dents under the auspices of the Police Complaints Authority with its attendant recommendations is a major influence when looking at developments in this area (7). Different countries use different restraint equipment, such as water cannon or the firing of different projectiles (e.

The following method has (October 2003) been formulated by experienced forensic practitioners and forensic scientists in England to maximize the recovery of spermatozoa while considering these po- tential problems: 1 60 ml rumalaya liniment amex. Any external (sanitary napkins or pads) or internal (tampons) sanitary wear is collected and submitted for analysis with a note about whether the item was in place during the sexual act and whether other sanitary wear has been in place but discarded since the incident buy 60 ml rumalaya liniment with visa. Even though traditionally these swabs have been labeled “external vaginal swab cheap 60 ml rumalaya liniment overnight delivery,” they should be labeled as “vulval swab” to clearly indicate the site of sampling. However, if the vulval area or any visible staining appears dry, the double-swab technique should be used (28) (see Subheading 4. The labia are then separated, and two sequential dry swabs are used to compre- hensively sample the lower vagina. An appropriately sized transparent speculum is then gently passed approximately two-thirds of the way into the vagina; the speculum is opened, and any foreign bodies (e. Then, 88 Rogers and Newton two dry swabs are used to comprehensively sample the vagina beyond the end of the speculum (particularly the posterior fornix where any fluid may collect). At this point, the speculum may be manipulated within the vagina to locate the cervix. If doctors decide for clinical reasons to use a lubricant, then they should take care to apply the lubricant (from a single use sachet or tube) sparingly and must note its use on the forms returned to the forensic scientist. In the process of sampling the vagina, the speculum may accumulate body fluids and trace evidence. Therefore, the used speculum should be retained, pack- aged separately, and stored in accordance with local policy. If the speculum is visibly wet on removal, swabbing may be undertaken to retrieve visible material. In some centers, additional methods of semen collection are employed (5,63,103) in the form of aspiration of any pools of fluid in the high vagina and/or placing 2–10 mL of saline or sterile water in the vagina and then aspi- rating the vaginal washings. However, vaginal aspirates should not be neces- sary if dry swabs are used to sample the vagina in the manner described. Furthermore, there are no data to confirm that vaginal washings retrieve sper- matozoa more effectively than vaginal swabs. On these occasions, two dry swabs should be inserted sequentially into the vagina under direct vision, avoiding contact with the ves- tibule and hymen. An attempt should then be made to comprehensively sample the vagina by gently rotating and moving each swab backward and forward. Unfortunately, in such cir- cumstances, it is impossible to be certain that the high vaginal swab was not contaminated from semen in the low vagina, which could be there because of drainage from external ejaculation. Spermatozoa Some guidelines recommend that the forensic practitioner perform an immediate microscopic examination of a wet mount of the material obtained Sexual Assualt Examination 89 from the vaginal fornices to identify motile spermatozoa on the basis that the presence and motility of spermatozoa may help determine whether recent vagi- nal ejaculation had occurred. Forensic science laboratories have specialist extraction procedures, staining techniques, and microscopic equipment to maximize spermatozoa recovery and facilitate identification. A survey of 300 cases in which spermatozoa were eventually identified found that they were only detected in four of the cases in the native preparation (before the applica- tion of specialist stains) (105). Seminal Fluid If no spermatozoa are detected, an attempt is made to corroborate the allegation by the microscopic identification of seminal choline crystals. Semi- nal choline is present in high concentrations in seminal fluid, and the choline crystals can be precipitated by the addition of reagents (106). There are also electrophoretic techniques by which seminal fluid can be identified (107). This will be useful where the offender is suspected to be oligospermic or aspermic or when only minimal amounts of male epithelial cells have been deposited; Y chromosome-positive cells have been isolated from vaginal swabs taken immediately after intercourse where no ejaculation had occurred. Whenever bleeding is noted during the medical examination, the forensic practitioner should communi- cate to the scientist any possible source for the bleeding. In these cases, the presence of blood must be interpreted with caution, particularly if in small quantity, 90 Rogers and Newton because traces of uterine blood may be present at any time of the cycle (7) and, currently, there is no accepted method of differentiating between traumatic or uterine blood (111). Furthermore, even traumatic bleeding may result from con- sensual sexual acts (see Subheading 8. On rare occasions assailants injure their penises during a sexual act, and this may be the source of blood found in the vagina. The quantity of semen in the vagina will diminish progressively with time, usually as a result of drainage. The posture and activity of the complain- ant subsequent to the act are likely to affect this. Drainage of semen from the vagina may also result in soiling of intimate clothing items worn at the time, and these can prove valuable sources of body fluids. It has been observed that spermatozoa can be isolated for longer periods in the endocervix. Studies that compared paired swabs from the vagina and cervix have found that 2 days or more after vaginal ejaculation there is a larger quantity of spermatozoa on endocervical swabs compared with the vaginal swabs (115). Therefore, it is recommended that if a complainant presents 48 hours or more after alleged vaginal intercourse, an endocervical swab be taken in addition to the swabs from the vagina. There is interest in the possibility of determining the timing of inter- course by changes in spermatozoa. Spermatozoa may remain motile in the vagina for up to 24 hours and longer in the cervical mucosa (50,118,119), but the periods for persistence are extremely variable. For example, Rupp (120) observed that motile spermatozoa persisted longer in menstruating women but added that identification is hindered by the presence of red blood cells, and Paul (121) reported that the period of spermatozoa motility ranged Sexual Assualt Examination 91 from 1–2 hours at the end of the menstrual cycle to as long as 72 hours at the time of ovulation. However, the morphology of the spermatozoa does show more consis- tent temporal changes. In particular, the presence of large numbers of sperma- tozoa with tails is indicative of recent intercourse.

However generic 60 ml rumalaya liniment otc, at the present time generic rumalaya liniment 60 ml online, many hos- patients treated early with intravenous atenolol was 3 discount rumalaya liniment 60 ml line. This small absolute benefit was cases, since prevention of death and other serious complica- not maintained (there were more deaths in the atenolol group tions is directly related to the speed with which opening of than in the control group at one year) and does not warrant the infarct-related artery can be achieved, antithrombotic/ routine use of β-blockers for this indication (as opposed to fibrinolytic treatment should be instituted. Aspirin and throm- their use in secondary prevention, five days or more after bolytic therapy both reduce infarct size and improve survival – acute infarction, which is discussed below). Early fears about toxicity of almost universally been positive in this context, showing bene- the combination proved unfounded, so they are used together. Recent evidence suggests that the increases with increasing ventricular dysfunction, whilst there additional use of clopidogrel in the early course of myocardial is little or no evidence of benefit in patients with normal left infarction improves outcome further, over and above the bene- ventricular ejection post-infarct. Cardiac rehabil- itation includes attention to secondary prevention, as well as to Treatable complications psychological factors. A supervised graded exercise programme These may occur early in the course of myocardial infarction, is often valuable. Neglect of these unglamorous aspects of man- and are best recognized and managed with the patient in a agement may cause prolonged and unnecessary unhappiness. Transfer from the admission room should therefore not be delayed by obtaining x-rays, as a portable film can be obtained on the unit if necessary. Drugs are used prophylacti- cally following recovery from myocardial infarction to pre- vent sudden death or recurrence of myocardial infarction. It is generally best used trials of β-adrenoceptor antagonists have also demonstrated as ‘acute’ prophylaxis, i. It is usually given sublingually, thereby discussed under Management of stable angina above, because ensuring rapid absorption and avoiding presystemic metab- of their clear prognostic benefit in this situation. In addition, olism (Chapter 5), but in patients with unstable angina it may numerous trials have now demonstrated that long-term use of be given as an intravenous infusion. In patients whose pattern of aldosterone antagonist eplerenone, continued long term (at pain is predominantly during the daytime, it is prescribed to least 18 months), prevents development/progression of heart be taken in the morning and at lunch-time, thereby ‘covering’ failure and improves mortality. Longer-acting controlled-release preparations Consideration of surgery/angioplasty are available for once daily use, and these usually provide Ideally all patients who are potentially operative candidates nitrate cover during most of the day, but leave a small ‘nitrate- would have angiography at some stage, even if they have not free’ window of a few hours, thereby again preventing the undergone early angiography/angioplasty as an in-patient. Adverse effects can be minimized by swallowing the tablet after strenuous activity is Psychological and social factors completed (a more genteel alternative to spitting it out! The evidence suggests that any benefit under physiological conditions by a constitutive enzyme in is very small (or non-existent) in patients with completely nor- vascular endothelial cells and is Furchgott’s ‘endothelium- mal ventricular function, but that with increasing ventricular derived relaxing factor’. Treatment should be for the resting vasodilator tone present in human resistance started with small doses with dose titration up to doses that arterioles under basal conditions. They are partic- Reduced venous return reduces ventricular filling and hence ularly useful in patients in whom beta-blockers are con- reduces ventricular diameter. This drugs do not appear to act synergistically in angina and reduces cardiac work and oxygen demand. Coronary blood should not be routinely co-administered as prophylaxis to flow (which occurs during diastole) improves due to the such patients. They may be particularly useful in the rare decreased left ventricular end-diastolic pressure. Short-acting dihydropyridines Reduced arterial tone reduces diastolic blood pressure and should be avoided because they cause reflex tachycardia. Nitrates relax some non-vascular or a controlled-release preparation of nifedipine) are often smooth muscles and therefore sometimes relieve the pain of used in this setting. This can be min- and the antiplatelet uses of aspirin and clopidogrel are dis- imized by omitting the evening dose of isosorbide mono- cussed in Chapter 30. There is no evidence that the efficacy of nitrate (or by removing a patch at night). Accordingly, the lower Use in ischaemic heart disease dose should be used routinely for chronic prophylaxis. In practice, even much higher doses given once Key points daily or every other day achieve considerable selectivity for platelet vs. Organic nitrates, infarction, including streptokinase, alteplase, reteplase and 2 nicorandil and Ca -antagonists do this by relaxing tenecteplase. Streptokinase works indirectly, combining with vascular smooth muscle, whereas β-adrenoceptor plasminogen to form an activator complex that converts the antagonists slow the heart. Treatment using streptokinase (usually low-molecular-weight heparin nowadays), which improve outcome, and with intravenous glyceryl with aspirin is effective, safe and relatively inexpensive. It is treated cost than streptokinase, such drugs have been used increas- by early (primary) angioplasty where this is available; ingly over streptokinase in recent years, because of the where not available, fibrinolytic drugs (with or without heparin/low-molecular-weight heparin) should be occurrence of immune reactions and of hypotension with given. Being a streptococcal protein, individuals who and clopidogrel, inhaled oxygen and opoids. Individuals eplerenone) each improve outcome in patients with ventricular dysfunction; whether the use of all three of who have previously received streptokinase (more than a few these treatment modalities in combination confers days ago) should not be retreated with this drug if they additional benefit over maximal dosage with one of reinfarct. The situation regarding previous streptococcal infec- these agents remains a matter of debate. Such infections (usually in the form of sore • After recovery from myocardial infarction, secondary throats) are quite common and often go undiagnosed; the prophylaxis is directed against atheroma, thrombosis (aspirin) and dysrhythmia (β-adrenoceptor antagonists, impact that such infections (along with more severe strepto- which also prevent re-infarction) and in some patients coccal infections, such as cellullitis or septicaemia) have on the is used to improve haemodynamics (angiotensin- efficacy of streptokinase treatment is uncertain, but likely to converting enzyme inhibitors, angiotensin receptor be significant. He should con- symptoms of active peptic ulcer disease or evidence of severe tinue to exercise, but would be wise to switch to a less liver disease (especially if complicated by the presence of extreme form of exertion. A long-acting nitrate may improve his exercise severe uncontrolled hypertension, have a significant bleeding tolerance, and low-dose aspirin will reduce his risk of diathesis, have suffered recent substantial trauma (including myocardial infarction. In view of the history of ulcer and vigorous chest compression during resuscitation) or require indigestion, consideration should be given to checking for invasive monitoring (e. The position Helicobacter pylori (with treatment if present) and/or reinsti- tution of prophylactic acid suppressant treatment. If ophthalmological advice is locally and immediately despite his high alcohol intake and regular exercise. It will available, this is no longer universally regarded as an absolute almost certainly necessitate some form of drug treatment contraindication to fibrinolysis.