Blood Spatter Research Articles

The currently available possibilities for the application of photogrammetry in the forensic medical expertise of the blood stains at the scene of the crime

The study of blood stains retained at the scene of the crime is of crucial importance for the preliminary inquiry. The present article is focused on the analysis of the possibilities and prospects for the use of photogrammetry (PM) as exemplified by the foreign expert practice of the blood stains examination at the site of the event. It is shown that the results of the application of digital photogrammetry in addition to the traditional methods of morphological investigations enables the forensic medical experts to reconstruct a number of unique features and circumstances that accompanied the commission of a crime at the site of the event. Such PM techniques supplemented by the ballistic analysis of the blood splatter and droplet trajectories provides additional evidence that allows the forensic medical experts to reconstruct the scene of the crime including the pose and position of the victim at the moment of causing injury. Moreover, these data make it possible to determine the maximum number and the sequence of injurious impacts (blows). The authors discuss the advantages and relative disadvantages of the application of the photogrammetric technique in the routine practical expert work. It is emphasized that the published decision making algorithms provide the specialists in various disciplines and professional experts with the ready-made technological tools for obtaining the additional criteria for the objective improvement of the quality of the studies they carry out and for the enhancement of the value of expert conclusions. It is concluded that the application of the modern photogrammetric technologies can be recommended for the solution of the applied forensic medical problems and conducting the relevant expert research.

The Spanish Tragedy

Reviewed by: The Spanish Tragedy Elizabeth Zeman Kolkovich The Spanish TragedyPresented by The Broccoli Project at the Black Box Theater, University of Texas at Austin, TX. 04 20– 23, 2017. Directed by Who Ray and David Higbee Williams. Music and puppeteer training by James Smith. Lighting by Laura Nagy. Tech by Dana Moore. With Kat Agudo (King of Spain/Isabella/Lorenzo’s Page/Watchman), Casey Allman (Balthazar/Ambassador/Serberine/Hangman/Jacques), Gabe Colombo (Ghost of Andrea), Laura Doan (Bel-Imperia/Spanish General/Bazardo/Watchman), Patrick Greer (Duke of Castile/Horatio/Pedringano/Ambassador), Austin Hanna (Hieronimo/Ambassador), Nicole Harrison (Revenge), and Bryson Kisner (Lorenzo/Pedro/Watchman). On opening night of a student production of The Spanish Tragedyat the University of Texas at Austin, its directors warned the audience about a “blood splatter zone” and “puppet sex.” Although these two delightful spoilers accurately previewed its most memorable parts, the performance was still filled with surprises. This swiftly moving and thoroughly enjoyable puppet version of Thomas Kyd’s revenge tragedy demonstrated the value of creative approaches to Renaissance drama. Conceived and executed by a student group called “The Broccoli Project,” the performance began with a man singing the Muppets theme song. The company members and their friends had made all the puppets, and indeed many recalled Jim Henson’s style. Lorenzo’s dimwitted Page, not quite a frog but resembling Kermit, was a small green puppet with googly eyes and curly hair. Some puppet choices were irreverent, [End Page 703]such as Balthazar as an alligator and Jacques as a blue squid who gurgled in place of his lines, whereas others shaped characters purposefully. The most human-seeming puppets were Hieronimo, Horatio, and Isabella, whose simple dress of white shirts or blue overalls represented them as humble country folk (fig. 4). Although most puppets were about the size of the actors’ torsos, the King of Spain puppet was an enormous head worn over the actor’s own, and she needed to move his mouth with both hands. The King became a ridiculous, out-of-touch ruler who towered over his subjects and stood apart from them. Only six puppeteers dressed in black played almost all of the characters, and they brought out the humor in the play’s lines and situations. Deaths were funny when puppets awkwardly stabbed each other and released red string when they died. Two characters played by humans framed the action: Revenge as a pale woman with green-streaked hair in a black dress and Andrea as a thin man in a tie. Both sat in chairs on stage during the performance, as Andrea watched with worry and Revenge appeared bored and insolent. Otherwise, the black box stage featured only a giant cardboard tree (where Horatio would later hang), and the puppets sometimes held small props: letters, handkerchiefs, a knife, and a rope. The directors judiciously streamlined the text to a running time of two hours. Many cuts were practical: to enable a small cast to use few props and to eliminate dense lines or ones in Latin or Italian. The production cut Hieronimo’s masque of knights and kings, the dumb show with Hymen, a slew of minor characters, and the subplot featuring the Viceroy of Portugal and Villuppo, whose ambitious plotting nearly kills Alexandro. The Broccoli Project’s version became not a political drama about competing nations, but an interpersonal one about a few major characters at a single court. The small stage and few actors contributed to the sense that this Spain was an isolated, intimate place, not one positioned internationally. Three aspects of the performance deserve further discussion: the characterization of Bel-Imperia, the representation of Hieronimo’s grief, and the concluding play-within-the-play. This Bel-Imperia was no submissive virgin, but a bold, independent woman. She wore a red velvet lowcut dress and had huge red lips, spiky multicolored hair, and enormous breasts. She spoke fewer lines than in the playtext but delivered them with defiant conviction. Although the production retained enough lines to indicate that her family arranged her marriage to Balthazar to strengthen peace and produce an heir, it included less conversation about her being a valuable commodity...

Risk of blood splashes in otorhinolaryngology surgery: do we really require protection?

<p class="abstract"><strong>Background:</strong> Surgeons are particularly at risk from blood borne pathogens like hepatitis and HIV during interventions or surgeries. They do take precaution to avoid the needle stick injuries but few pay attention on blood or body fluid splashes into eye. The main aim of the study was to know the risk of blood splashes in glass, gown and mask during ENT –HNS (ear, nose and throat and head and neck surgery).</p><p class="abstract"><strong>Methods:</strong> The prospective study conducted in Department of ENT-HNS of Dhulikhel Hospital, Kathmandu University Hospital from 1<sup>st</sup> July 2016 to 30<sup>th</sup> September 2016. All the elective cases were included for study. Surgery was performed by the single surgeon. The surgeon wore the glass and mask during the surgery. At the end of the surgery, the glass, mask and gown was inspected by the surgeon for any blood splashes and information was recorded<span lang="EN-IN">. </span><span lang="EN-IN"> </span></p><p class="abstract"><strong>Results:</strong> There were total 62 patients with male 30 and female 32. Regarding the age, most of the patients lie between 20-50 years. The amount of blood splatter in glass, mask and gown is most common in modified radical mastoidectomy surgery. Likewise, the blood splatter is most common in tonsillectomy in throat surgery and in head and neck surgery, the blood splatter is common in all head and neck surgery.</p><p class="abstract"><strong>Conclusions:</strong> The blood splashes is high even in various ENT surgeries. So it is important to take precaution by surgeon like protective mask and glass worn during surgeries to protect from various blood-borne infection transmissions<span lang="EN-IN">. </span></p>

Periampullary Diverticula: A Potential Source of Upper GI Bleeding

Background: The duodenum is the most common location for small bowel diverticula. These diverticula are typically asymptomatic, and are often found incidentally or during post-mortem evaluations. When symptomatic, most periampullary diverticula result in pancreaticobiliary obstruction. We present a rare case of a periampullary diverticulum as a cause of upper GI bleeding, treated successfully with endoscopy. Case: A 69 year-old-male on dual antiplatelet therapy was admitted for an acute heart failure syndrome 2 weeks following a 4-vessel coronary artery bypass graft. During his hospitalization, he developed melenic stools with a subsequent drop in hemoglobin from 10.0 to 7.1 g/dL. Esophagogastroduodenoscopy (EGD) revealed a periampullary diverticulum that was found to be actively bleeding. Using a side-viewing endoscope, a vessel with visible arterial spurting was identified consistent with a Dieulafoy lesion. Hemostasis was achieved via combination therapy of endoscopic hemoclip and epinephrine injection at the site of the Dieulafoy lesion. His post procedural course was uneventful, and the patient was discharged within 48 hours of his procedure on a proton pump inhibitor.Figure 1Figure 2Discussion: Two to five percent of patients undergoing barium swallow studies, and up to 7% in patients undergoing endoscopic retrograde cholangiopancreatography, are found to have duodenal diverticula. Duodenal diverticula are not an uncommon finding, however they are generally asymptomatic. Most complications from these diverticula result in pancreaticobiliary pathology. This case demonstrates the ability of these more proximally located diverticula to cause upper GI bleeding, as with colonic diverticula. Whereas previous case reports describing treatment of diverticular bleeding have highlighted the ease of administering treatment with a forward-viewing scope, this case highlights the improved visibility and utility of the side-viewing endoscope. In the past, surgical diverticulectomy had been the main treatment for this pathology, however recent advances in endoscopic technique have made endoscopy the treatment of choice.Figure 3

Prediction of blood back spatter from a gunshot in bloodstain pattern analysis

Theorists propose a model for predicting and interpreting blood spatter patterns resulting from gunshot wounds. The atomization process, the trajectories of the backspatter drops of blood from the wound to the ground, the impact angle and the impact Weber number on the ground, as well as the distribution and location of blood stains and their shape and sizes are predicted.

Incidence and risk factors of blood splatter in dermatologic surgery: Need for facial protection

Incidence and risk factors of blood splatter in dermatologic surgery: Need for facial protection

FORENSIC MEDICINE: THE STORY, CLINICAL NEXUS AND CHALLENGES OF THE PRACTICE IN NIGERIA

The synonym of forensic medicine is forensic pathology1,2. Also called legal medicine or medical jurisprudence3. Forensic medicine is a field that involves collection and analysis of medical evidence (samples) to produce objective information for use in the legal system2,3. It can therefore be aptly summed as the science that deals with the application of medical knowledge to legal questions. It is also extremely useful in cases where a patient dies without having made a definitive diagnosis2. The primary tool of forensic medicine has always been the autopsy2. Frequently used for identification of the dead, autopsies may also be conducted to determine the cause of death2. In cases of death caused by a weapon, for example, the forensic pathologist - by examining the wound - can often provide detailed information about the type of weapon used as well as important contextual information. In a death by gunshot, for example, he can determine with reasonable accuracy the range and angle of fire. Forensic medicine is a major factor in the identification of victims of disaster, such as landslide or plane crash4. In cause-of- death determinations, forensic pathologists can also significantly affect the outcome of trials dealing with insurance and inheritance5. Though the autopsy is performed by a forensic pathologist or a medical examiner, particularly during the investigation of criminal law cases and civil law cases in some jurisdictions2, Coroners and medical examiners are also frequently asked to confirm the identity of a corpse. The scope of modern day forensic medicine has expanded far beyond autopsies to include exciting subjects of anthropology; forensic odontology; forensic entomology; ballistics, fingerprint, crime scene and blood spatter analysis; toxicology; DNA; arson and fire investigation; evaluation of the sexual assault victim; forensic psychiatry (which is used to determine the mental health of an individual about to stand trial, and thus, his blameworthiness) and more1,2. It is therefore instructive that the forensic medical services cut across all specialities of medicine with the primary areas of medicine that are commonly involved and harnessed in forensic medicine practice being anatomy, pathology, and psychiatry. To render efficient and effective forensic services in any setting, the forensic pathologist works with a number of support staff including: accident scene investigator; autopsy technician; coroner; forensic investigator; legal consultant; trauma, emergency medicine or psychiatric nurse; sexual assault nurse examiner; social services investigator and/or advocate and more2 .

Rapid DNA analysis for automated processing and interpretation of low DNA content samples.

BackgroundShort tandem repeat (STR) analysis of casework samples with low DNA content include those resulting from the transfer of epithelial cells from the skin to an object (e.g., cells on a water bottle, or brim of a cap), blood spatter stains, and small bone and tissue fragments. Low DNA content (LDC) samples are important in a wide range of settings, including disaster response teams to assist in victim identification and family reunification, military operations to identify friend or foe, criminal forensics to identify suspects and exonerate the innocent, and medical examiner and coroner offices to identify missing persons. Processing LDC samples requires experienced laboratory personnel, isolated workstations, and sophisticated equipment, requires transport time, and involves complex procedures. We present a rapid DNA analysis system designed specifically to generate STR profiles from LDC samples in field-forward settings by non-technical operators. By performing STR in the field, close to the site of collection, rapid DNA analysis has the potential to increase throughput and to provide actionable information in real time.ResultsA Low DNA Content BioChipSet (LDC BCS) was developed and manufactured by injection molding. It was designed to function in the fully integrated Accelerated Nuclear DNA Equipment (ANDE) instrument previously designed for analysis of buccal swab and other high DNA content samples (Investigative Genet. 4(1):1–15, 2013). The LDC BCS performs efficient DNA purification followed by microfluidic ultrafiltration of the purified DNA, maximizing the quantity of DNA available for subsequent amplification and electrophoretic separation and detection of amplified fragments. The system demonstrates accuracy, precision, resolution, signal strength, and peak height ratios appropriate for casework analysis.ConclusionsThe LDC rapid DNA analysis system is effective for the generation of STR profiles from a wide range of sample types. The technology broadens the range of sample types that can be processed and minimizes the time between sample collection, sample processing and analysis, and generation of actionable intelligence. The fully integrated Expert System is capable of interpreting a wide range or sample types and input DNA quantities, allowing samples to be processed and interpreted without a technical operator.

透析支援現場での血液飛散の現状の把握

透析支援現場での血液飛散の現状の把握

Periesophageal Pseudoaneurysms: Rare Cause of Refractory Bleeding Treated with Transarterial Embolization.

A 43-year-old female with history of systemic lupus erythematosus, prior cytomegalovirus esophagitis treated with ganciclovir, and long segment Barrett's esophagus (Prague class C8 M9) with high grade dysplasia treated with radiofrequency ablation presented to the hospital with hematemesis. An upper gastrointestinal endoscopy showed multiple esophageal ulcers with active arterial spurting which could not be controlled with endoscopic interventions including placement of hemostatic clips. An emergent angiogram demonstrated actively bleeding saccular dilations (pseudoaneurysms) in the esophageal branches of the lower thoracic aorta as well as left gastric artery for which gelfoam and coil embolization was initially successful. Due to recurrence of massive bleeding, she subsequently underwent emergent esophagectomy and bipolar exclusion. Pathology demonstrated submucosal hemorrhage, esophagitis with dysplastic Barrett's mucosa, and an ulcer containing cytomegaloviral inclusions. We report the first case of arterial bleeding from periesophageal pseudoaneurysms as well as use of angiographic embolization for arterial bleeding in the esophagus.

An Impact Velocity Device Design for Blood Spatter Pattern Generation with Considerations for High-Speed Video Analysis.

A mechanical device that uses gravitational and spring compression forces to create spatter patterns of known impact velocities is presented and discussed. The custom-made device uses either two or four springs (k1 = 267.8 N/m, k2 = 535.5 N/m) in parallel to create seventeen reproducible impact velocities between 2.1 and 4.0 m/s. The impactor is held at several known spring extensions using an electromagnet. Trigger inputs to the high-speed video camera allow the user to control the magnet's release while capturing video footage simultaneously. A polycarbonate base is used to allow for simultaneous monitoring of the side and bottom views of the impact event. Twenty-four patterns were created across the impact velocity range and analyzed using HemoSpat. Area of origin estimations fell within an acceptable range (ΔXav = -5.5 ± 1.9 cm, ΔYav = -2.6 ± 2.8 cm, ΔZav = +5.5 ± 3.8 cm), supporting distribution analysis for the use in research or bloodstain pattern training. This work provides a framework for those interested in developing a robust impact device.

Risk of ocular blood splatter during oculofacial plastic surgery.

To assess intraoperative blood splatter to the ocular surface and adnexa during oculofacial surgery. Four surgeons and multiple assistants at three separate locations wore a total of 331 protective eye shields during 131 surgeries. Postoperatively, a luminol blood detection system was used to identify blood splatter on the shields. In the event of positive blood splatter, the total number of blood spots was counted. Controls were used to verify the blood detection protocol. A postoperative questionnaire was given to all surgeons and assistants after each case, and they were asked whether intraoperative blood splatter was noticed. Blood was detected on 61% of eye shields and in a total of 80% of surgical cases. However, only 2% of blood splatters were recognized intraoperatively by the surgical participants. There was no significant difference in the splatter rate between surgeons (64%), assistants (60%), and surgical technicians (58%) (p = 0.69). Shields worn during full-thickness eyelid procedures, direct brow lifting, orbitotomy with bony window, and orbital fracture repairs were more likely to be splattered (p = 0.03), and there was a significant difference between splatter rates among different surgeons (range, 29-90%; p = 0.0004), suggesting that blood splatter rate may be both procedure dependent and surgeon dependent. Mucocutaneous and transconjunctival transmission of human immunodeficiency virus and viral hepatitis has been documented. These results suggest that oculofacial plastic surgeons should consider eye protection for patients with known blood-borne diseases and in cases where blood splatter is expected. This precautionary practice is supported by the high incidence (98%) of undetected, intraoperative blood splatter.

Fluid dispersal from safety cannulas: An in vitro comparative test

We report a comparative laboratory study between 2 peripheral intravenous catheters equipped with a passive fully automatic safety mechanism to assess generation of blood droplets during withdrawal. One presented no fluid droplets, whereas the other presented droplets in 48% and 60% for the best and worst case, with analysis of variance showing positive effects on the number of droplets generated (P < .001). Safety devices can introduce hazards if health care workers are at risk from blood splatter.

Calculating point of origin of blood spatter using laser scanning technology.

The point of origin of an impact pattern is important in establishing the chain of events in a bloodletting incident. In this study, the accuracy and reproducibility of the point of origin estimation using the FARO Scene software with the FARO Focus(3D) laser scanner was determined. Five impact patterns were created for each of three combinations of distances from the floor (z) and the front wall (x). Fifteen spatters were created using a custom impact rig, scanned using the laser scanner, photographed using a DSLR camera, and processed using the Scene software. Overall results gave a SD=3.49cm (p<0.0001) in the x-direction, SD=1.14cm (p=0.9291) in the y-direction, and SD=9.08cm (p<0.0115) in the z-direction. The technique performs within literature ranges of accepted accuracy and reproducibility and is comparable to results reported for other virtual stringing software.

A prospective study of blood splatter in ENT.

Surgeons face an occupational risk of daily exposure to blood and body fluids. Potential sources of infection include sharps injuries and mucocutaneous contact. The transmission of blood-borne viruses, in particular human immunodeficiency virus (HIV), Hepatitis B and Hepatitis C from the patient to healthcare workers is well documented in the literature. We studied the incidence and degree of blood splash in all otolaryngology (ENT) procedures undertaken in a single unit over a 12 week period. In addition, we investigated which intraoperative factors might predict the degree of splash. We undertook a prospective, non-blinded study of 102 patients undergoing a range of 'routine' elective ENT within one department over 12 weeks. A surgical mask with visor attached was worn in all procedures. Following each procedure, all splatter masks were collected and examined macroscopically and microscopically for blood splash. In addition, the procedure performed, technique used, total blood loss, operating time and grade of surgeon was noted. 54% of procedures resulted in splash mask contamination. The median number of splash spots per mask was 4.7 (range 0-63). Tonsillectomy was the most commonly performed procedure, accounting for over one-third of total procedures investigated. Each mask had an average of 8.2 splash marks. Tonsillectomy had a splash rate of 76.9%. Although the risk of developing HIV is low the operating surgeon has a duty to take all precautions to protect themselves during a procedure and therefore a protective mask and visor or suitable goggles must be worn.

Puncture decompression technique used in clipping intracranial large and giant aneurysms

Objective To explore the role of puncturing the aneurysm to decompress in clipping intracranial large and giant aneurysms.Methods Different methods were used according to the different location of 25 cases of large and giant aneurysms.Cervical carotid internal artery was exposed and the pterional craniotomy was used for carotid-ophthalmic aneurysm,and direct pterion craniotomy used in the carotid-post communicating artery aneurysm.Temporary occluded the exposed the cervical internal carotid artery or the intracranial proximal segment of parent artery and distal segment of parent artery and its branches,then punctured aneurysm body and suck gushing blood with suction.When aneurysm body collapsed,remodel the parent artery and clipped aneurysm.As a thrombotic giant aneurysm which was incised then removed thrombus and clipped aneurysm after parent artery and its branches have been occluded provisionally.Microvascular doppler (MVD) was used to monitor before and after clipped aneurysms.Results The time of temporary occlusion vessels was 9-15 minutes.,the average time was 11 minutes.MVD monitor showed vortex flow disappearance of aneurysm and the bloodstream amplitude of the parent artery and its branches were not changed before and after clip.Postoperative DSA or CTA showed aneurysms disappeared and the bloodstream of the parent artery and its branches were normal after operation.Conclusions The temporary occlusion of the parent artery and its branches and the direct puncture of aneurysm body (or incise aneurysm and remove thrombus) to decompress are indicated for the most large and giant aneurysms (including thrombotic aneurysm).MVD is of benefit in providing operative safe and improving treatment effects in aneurysm surgery. Key words: Large and giant aneurysm; Puncture; Incision; Decompression; Clip

RISCOS OCUPACIONAIS DURANTE O REPROCESSAMENTO DE HEMODIALISADORES

Backgound and Objectives: The observation of hazards during processing of hemodialyzers showed the need to study these events. The aim of the study was to identify occupational accidents and hazards recognized by nursing professionals in the reprocessing of hemodialyzers. Methods: It was performed an exploratory-descriptive study in a haemodialysis unit of a university hospital using recall. Six nurses and fifteen nursing technicians answered the questions about risks in re-processing dialyzers. Results: 44 occupational hazards were reported: 30 (70%) with the participant and 14 (30%) with colleagues. Eleven (25%) were touching clean surfaces with blood visible on gloves and ten (23%) direct contact with blood. Disinfectants appeared in fifteen (34%) cases: five contacts with the skin and mucous membranes, six to toxic fumes and three unspecified. Two reports about touching surfaces possibly contaminated but no visible blood. Conclusion: The risks reported were those that could be seen or felt, such as blood spatter and germicides, strong odors. Risks not visible were rare. KEYWORDS: Occupational risks. Occupational health. Renal Dialysi. Nursing.

THE TRINITY KILLER, THE DOOMSDAY KILLERS AND ‘DEXTER’ AS SUBURBAN GOTHIC

The city of Miami seems an unlikely setting for the Gothic. Like the global capital that has made Florida the fastest growing US state, it is all ephemeral present, with glittering surfaces that reflect appear to be too new to harbour the ghosts of the past. This is the setting for Showtime’s television series ‘Dexter’ (2006-2013) about a blood spatter analyst who works for the metropolitan police and is a serial killer. This paper explores two key story-arcs in the series. Punter (1998) argues that ghosts arise on the site of vanished cultural territory, and in ‘Dexter’Miami’s extraordinary growth has left many such spaces behind, but what kind of ghosts are possible here? Nelson (2012: xi) claims that gothic narrative in the 21st century has outgrown its ‘heritage of dark supernaturalism’, and yet the trimmed lawns and flowerbeds of season 4 hide a monster known as the Trinity Killer, who forces Dexter to confront his own horrific past in a devastatingly literal bloodbath and by season 6, in the story arc of the Doomsday Killers, Dexter’s monstrous double life is exposed to the one person he loves and fears above all others: his sister Debra. A complex series of doppelgangers, characteristic of high gothic narrative, concludes with Dexter’s attempts to lay to rest all the ghosts of the past that torment him, and to save the remains of his family by constructing his own death.

The Ditch

The Ditch Paul Ruffin (bio) I’ll begin by telling you outright that I am not a violent man. But there are times when all the talk and reason in the world won’t address a threat that’s coming at you. When I was younger, I didn’t mind getting into scrapes when some kid messed with me. My philosophy was to walk softly and carry a big fist to knock the shit out of my opponent—not exactly an acceptable political slogan—which meant to conduct the fight, if it had to come, with one swift blow to the nose. If you do it right, all the lights in the house will come on in your adversary’s head when your fist strikes, and he will be blinded to the point of buckling to the ground, wondering what universe all those new stars are from, and generally the lights will dim real low or go completely out. The first time it happened, second grade maybe, a much older boy on the schoolbus kept turning around in his seat and poking me in the shoulder, and all I wanted was for the bus to get me home and away from him. But as the bus ground up the long gravel road toward our mailbox, it seemed forever in making the grade, so I just flung a fist as hard as I could at the kid’s nose, and when it smacked home, it didn’t hurt me at all, but he slid down off his seat onto the floor, with blood spurting all over. The driver knew that he was a bully and didn’t say anything to me. But he winked at me as I left the bus. It happened again three years later, when a kid stole my bike and messed up the chain. One blow to the nose. The thing about going after the nose is that you don’t come away with skinned knuckles or broke fingers—the nose just caves in, flattens. No bone there. Nothing but soft nose. You can hit a guy all day in the mouth or upside the head, [End Page 535] and likely as not, he’ll keep coming at you, and you’re gonna end up hurting your fist on teeth or bone. Land your fist dead-on on the nose, and all he wants is to shake those stars out of his head, forget the pain, and breathe again or go to sleep. And if you do it properly, his nose will swell up like a damned ripe tomato and both his eyes will go black, and you are not likely ever to have to deal with him again. What I’m saying is, it beats the shit out of any other kind of blow that you can deliver. A couple of years after that bike incident, I did it again when I hammered the boy next door for accusing my daddy of poisoning dogs, even when he was telling the truth. It wasn’t nice, I told him as he cupped his bleeding nose and tried to get to the safety of his house before I followed up the blow. If you do it right the first time, there is no need to follow up. My childhood confrontations were always conducted the same way with the same effect. After the age of fifteen or so, I never fought again. For one thing, my reputation was such that most kids wouldn’t dare mess with me. For another, I became more tolerant of the dumbasses of the world. I figured that most of them didn’t have the sense to breathe and stayed alive only because Nature made it impossible for them to die from not taking a breath. I always thought it was a shame that Nature had to fling that wide a net. I mean, dogs and cats and horses and cows and the wilder animals, sure, it’s OK for them to do dumb shit from time to time, but lots of people I knew didn’t deserve that kind of break. I’m telling you, there are some dumbass people out there, and...

Control of immediate post-EMR bleeding by using monopolar hemostatic forceps

A 58-year-old patient with hypertension was referred for EMR of a large flat polyp in the ascending colon. Colonoscopy revealed a Paris IIa lesion measuring roughly 3 cm in diameter. The polyp was removed by first injecting diluted indigo carmine to achieve an adequate submucosal lift. A 25-mm snare (Snaremaster Spiral; Olympus America Inc, Center Valley, Pa) was used to capture the lifted polyp. Using a blended cut current (Endocut; ERBE USA, Inc, Marietta, Ga), we removed the polyp en bloc. Immediately an arterial bleed was identified with brisk spurting of blood from the submucosa.