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The Misadventures of an 18D

The Misadventures of an 18D

The misadventures of an 18D across the world.

It’s easy to forget that between the cool guy pics and polished image of many social media accounts, we’re all just normal humans. Nobody is perfect, least of all the 18D medics here at Ready Warrior LLC. We’ve done and experienced some things that will make you probably wonder how we ever made it to a team in the first place, let alone stayed on one. So, let’s hit just some of the lowlights of times where we had some misadventures or just sucked at life. What follows is a collection of short stories that highlight the stuff that never makes it into the books or media.

The Rooster that had to Die

On our first trip to the Philippines, our team was assigned a training mission in a small town on the island of Mindanao. When we arrived, it was exactly what you’d imagine a jungle camp to look like. Bamboo hunts, thatched roofs, and minimal security. If you’ve ever been to the Philippines, you know they love cock fighting (roosters—not…never mind). The camp had dozens and dozens of roosters. Some were roaming free, but the prized ones they used for cockfighting and guard duty were kept in small basket cages outside the soldier’s quarters. Okay, we thought, whatever works for them.

Only problem was…unlike in cartoons where a rooster crows a few times early in the morning to wake you up and then shuts up, these annoying bastards never stopped. Ever. Cockledoodledoo all !&#&@* night. What was worse, someone in the camp kept their rooster directly outside my window. After two nights of horrible sleep, I asked the soldier if he would mind moving his rooster somewhere else. He just laughed and replied ‘No’. Earplugs didn’t work, and I wasn’t about to wear Peltors to bed.

By night 5 I was at my wits end. We were working 16hr days, and the lack of sleep was getting to me. At approximately 3am on the 5th night, I snapped. I took my knife out, walked outside, and shanked that stupid rooster to death. I walked back into the team hut and saw my Team Sgt, who shared the room next to me, staring at me from outside his door. I still had the knife still out and had blood and feathers on my hand. I was one of the newer guys on the team, and I was worried that he was going to send me back home the next morning for this stupid act. He simply replied “If you hadn’t done it, I would have” and went back to his room.

 The next morning, the soldier who owned the rooster was PISSED. I thought we were going to get into a rumble, but after some back and forth, I offered him $80 to replace the rooster, under the condition that he no longer keep the rooster anywhere near our hut. He was more than happy to take that deal. I finally got a decent night sleep for the first time that night..but that didn’t last long, because I got sick…really sick. To be continued in….

The Balut that got me

Not long after the rooster episode, myself and a teammate were invited to try an Asian delicacy called Balut. Some of you may know what that is already, and have already gagged a little. For those of you who do not, it is a duck egg. Let me be more specific. It is a duck egg, that has been fertilized, and the baby duck is 14-21 days gestation when its development is stopped and it’s sold. You buy the duck egg, poke a hole in the top of the egg, dunk it in a vat of vinegar, and then suck the partially developed duck and yolk down. Depending on the stage of development, a feather may tickle your throat on the way down. See below for an example:

Surprisingly enough, I found them to be delicious in a weird, scrambled egg type way. I ended up eating two of them during that short break in training we had, each time dunking them in the pitcher of vinegar and spices with everyone else. By now you're probably seeing where I went wrong. 

It was later that night the trouble started. I shot out of bed like a bolt of lightning at 1am with huge stomach aches. Yep-bathroom time. Then again at 2am, 3am, 3:30am, 3:45am. After 5 nights of barely sleeping because of a now-dead rooster, I was awaked again because my insides had decided to set themselves on fire. Without exaggeration it was the most violent stomach pains I’ve ever had in my life.  All caution was thrown to the wind and doors were thrown nearly off their hinges as I made the mad clench-scramble in an effort to not shit myself en-route. 

The next day I came out of my room and felt better. It was my day to teach TCCC, and I was a Green Beret. I could make it through the day on barely any sleep again. I didn’t even make it to noon. I spent the next 3 days alternating between sprints to the bathroom 20 times a day and bouts of fitful sleep. Rather than get better, I was getting worse. By the 4th night, I had a temperature of 104.8. My junior medic and I decided that if it hit 105, we’d have to enact our MEDEVAC plan, which let’s just say was not ideal. That night I had a fever of 105 exactly, but convinced my junior to wait it out until the morning before I gave up.

I don’t remember what time I woke up that night, but instead of making a mad dash to the bathroom, I was now laying in a pool of water. My first thought was that it was raining and my roof had sprung a leak. I realized after becoming more awake, that what had really happened was that my fever had broken, and my sleeping bag was waterlogged in my own sweat. I felt almost completely fine the next day, minus being a little weak and severely dehydrated. Having been absent for a few days and our soldiers we were training being told I was sick, they brought me food upon seeing me for the first time in days. It was Balut. FML

To be continued with more stories............

 

Managing Junctional Hemorrhage

Managing Junctional Hemorrhage
We are honored to share a guest write-up by Rob, @rob_o_medic, Senior 18D and instructor on the treatment of junctional injuries! 

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The hemorrhage that takes place when a main artery is divided is usually so rapid and so copious that the wounded man dies before help can reach him- Colonel H. M. Gray 1919

Hemorrhage in junctional areas, such as inguinal (groin), pelvic, and under the arms can take more time and expertise to control. These areas can and often should have junctional tourniquets added for additional hemorrhage control. Most medics should know or have heard of junctional tourniquets. However, improvised tourniquets of this nature may be unfamiliar to new medics or civilians who come across an injury that needs one, so we will lay out information as outlined through various reference materials available to service members and civilians alike.
As we all know hemorrhage is the leading cause of preventable death on the battle field. 90% of combat fatalities occur forward of a medical treatment facility. 75% of combat fatalities have non survivable injury and 25% have potentially survivable injury. Of those with potentially survivable wounds, 90% die from hemorrhage. Although bleeding is a main cause of death, the vast majority of wounds do not have life-threatening bleeding. 
 

 

Massive hemorrhage tends to fall into two distinct categories:

 

- Compressible
- Non-compressible

 

Tourniquet use is great for extremities (compressible) wounds, but as IED's dominate the recent wars, an increasing percentage of casualties present with poly-trauma from blast related injuries rather than bullet or direct fire weapons. Recent statistics show a breakdown of casualties as: 60.5% from Boobytrap/IED and 19.2% from bullet. High junctional wounds (high femoral/pelvic and axillary wounds) do not allow the standard use of a tourniquet. So further considerations must be made to control blood loss to these areas. 

 

Treatment
Initial treatment should always be direct pressure and wound packing. There are various hemostatic agents available for use, such as Combat Gauze, Chito Gauze, Celox, and Nu-Stat. Its really shooter preference and what is readily available from your supply folks (what works better can be saved for another conversation). Remember to always find the SOURCE of the bleed and apply direct pressure. 

 

Attempting Junctional TQ
A transition to a junctional TQ should be considered after manual pressure and wound packing has been attempted and successful. Due to the sometimes long and difficult set up of either deliberate or improved TQ's, the provider should make initial attempts at wound packing, manual pressure at identified pressure points, and if possible, clamping damaged vasculature when readily identified. Be sure to clamp proximal and distally to the damaged vasculature. Use of a Debakey peripheral vascular clamp preferable if you have access to one. 
 
Managing Junctional Hemorrhage

 

Background
Generally speaking if you arrive to find ongoing junctional hemorrhage and your patient is alive, you are already ahead of the power curve. We had an incident at Fob Shank in 2014. Some regular army platoon was training at the range. A young soldier got hot brass down his back. Being the undisciplined soldier he was, he freaked out, jerking his arm about with his weapon on fire. He shot his battle buddy in the hip right next to him. The soldier died before he made the 3 min drive to the FST located on base. The point of that story is if the major vasculature of the pelvis is hit, (iliac/femoral arteries) and there is complete dissection of those vessels, there is little you can do about it.
There are three major sources of pelvic bleeding: arterial, venous, and cancellous bone. 70% of the time, blunt pelvic trauma causing fracture is venous and may be controlled with pelvic stabilization. 

 

Arriving at the patient:

 

(Pelvic and LE Junctional Bleeds/injuries)
I recommend applying pressure to high femoral with your fingers. It takes little to no pressure to achieve hemorrhage control this way. Medicine is generally not done in a vacuum, so utilize the people around you and replace your hands with theirs so you can control the chaos of treating the casualty.
Once hemorrhage control is confirmed, take a moment take a breath. Release some stress and think about what you are going to do next. Continue your blood sweeps of the patient and then begin exposing so you can visualize what you are dealing with. In training we generally don't make our patients completely trauma naked, but in actual trauma, you need to suspend modesty if it's the difference between life or death. This is important so you can identify what you need to pack or clamp etc... 

 

Wound Packing-
Choose your hemostatic agent of preference. Pack as much as you can into the wound. Be sure to hold direct pressure for at least 3-5 minutes after application. This is often not done in training, yet is essential in a real life patient. (Training, especially at the school house, is often done on the clock so it creates bad habits). 
Clamping- can be done and should if the major vasculature can be visualized.

 

Types of Junctional TQ's
SAM JTQ is my absolute favorite for a deliberate TQ.
I love the SAM for many reasons. It has so many uses and provides me with peace of mine that it will remain effective once applied, even after significant jostling of the patient. I am fortunate to have a giant patient population that we can try this on, and I have had the most success with the deliberate SAM. This will always be the one I carry until something else I find works better. 
Pros-
  1. Works as a pelvic binder
  2. Can be used bilaterally with both bulbs inflated over right and left femoral arteries
  3. The auto stop buckle ensures proper slack is taken out before application of bulbs
  4. Can be used for Axilla/subclavian injuries
  5. Has an auxiliary strap for additional support in pelvic use
  6. Extremely easy to use
Con-
  1. It's bulky- (I would hardly consider this a con as I am making sure I have room for this. But many people want to streamline their kits)

Go out and make sure you train with this device and become familiar with it. Common issues I see is applying this device to high. It must lie over the greater trochanter on both sides to effectively bind the pelvic and allow proper placement of the bulbs to gain hemorrhage control. You may need to tie the ankles with a cravat in internal rotation to provide further stabilization.

 

Improvised JTQs
I have seen many types of improvised TQ's made with the SOFTT-W TQ's. I will lay out a few of them below. I will say these TQ's have a pretty high failure rate, at least from what I've seen in training at the school house. They do not provide me the piece of mind I once had when I first learned these years ago. Failures are commonly seen after patient movement due to it being improvised in nature. Be sure you have proper placement over high femoral area. Take out as much slack as possible and be sure to have the windless directly over where you are trying to provide direct downward pressure. With some of the larger implements used below, there is no pelvic instability, and if the patient permits, some external rotation of the LE may be needed to gain better purchase on the desired pressure point.

 

Best-
SOFT-W with a grenade pouch under the windless and a lacrosse ball secure inside. it provides pretty good direct pressure on the the high femoral area.

 

Better- 
SOFT-W with a tightly rolled SAM splint preferably with all slack taken out and taped as to make it as rigid as possible

 

Good-
SOFT-W with a Nalgene bottle underneath

 

There are other ways to attempt JTQ's as well, such as using cravats! See pic below courtesy of the Special Operations Medical Coalition:
One last note. I am not a fan of placing a knee in pelvis for hem control. If you must and are a lone provider, a knee to the abdomen would be preferred over pelvis. We (the medical community) have also talked about using an AAJT (aortic TQ) as a very temporary stop gap so you can work through your procedures and then take it off. Most folks don't carry these and they are incredibly uncomfortable for the pt. 

 

Axilla/ Subclavian vessel injuries  
- I won't go into as much detail here as some of the same principals apply when managing this type of hemorrhage. As with above if you can visualize the bleeding utilize manual pressure to gain control of the bleeding. Pressure points are quite difficult in this area especially for the subclavian artery. You have the clavicle in the way of providing adequate pressure. I have seen it done but it takes an incredible amount of pressure and is extremely uncomfortable for the pt. 

 

Wound packing- Same principals apply from above. If the wound is big enough,  try to pack as much hemostatic gauze as possible and hold pressure for 3-5 minutes to achieve control. If there is no cervical involvement you can perform an X wrap around the body with a large 6in ACE wrap to provide external pressure to the injury. 

 

SAM JTQ
Axilla wound- 
Wound pack and take an additional roll of kerlex and place it in his armpit. Use the SAM TQ to secure his arm down to his side. With the added piece of kerlex you will provide adequate pressure to the Axilla to control any hemorrhage. More secure than just trying to use ACE wrap. It's difficult to provide direct pressure. 

 

Subclavian-
The SAM works great but you need to take an additional step. The SAM comes with this wedge device, and it's not ideal. Instead, take a golf ball sized roll of Coban and use that in place of the plastic wedge. Have the pt turn their head and you will see the notch/crease made by the proximal portion of the clavicle. Place the ball there underneath the balloon and you can achieve relatively comfortable hemcon of the subclavian vasculature. 

 

Squashing a myth
-Subclavian tie off using IV tubing. This has been going around for a while and there are rumors it has been successfully done in the field. This is simply wishful thinking. With right-sided subclavian injuries a median sternotomy can be performed. For Left-sided injuries the use of a median sternotomy is inappropriate. The left subclavian vessels are posterior and cannot be reached through an incision alone. There is a procedure called a trapdoor incision or "book" thoracotomy. These procedures should be left to professionals. Utilize wound packing or a urinary catheter to gain hemorrhage control.
Don't cause more harm to a patient by attempting these procedures.

 

Pelvic Injury Notes: 

 If time permits, a thorough examination of the pelvis and perineum is required to rule out associated injuries to the rectum and GU/GYN systems which may render FX open. Open injuries have a mortality rate of >50% due to hemorrhage and late sepsis.

Signs and Symptoms to look out for: 

 Length discrepancies, scrotal hematoma, and ecchymosis raise suspicion for pelvic ring injury. Bi-lateral lower leg amputations have a high association with clinically significant pelvic fracture and instability. Don't even waste time checking for stability. If the MOI correlates with associated injuries, go ahead and provide immediate pelvic stabilization. 

 

Final notes:

 

Dropping a knee:
I am personally not a fan of dropping a knee into the pelvis. With the types of injuries we generally see that cause pelvic involvement, there is a high index of suspicion that there is pelvic instability. Dropping a knee into a patients pelvis is not good medicine. You are more than likely not actually getting any sort of occlusion to the underlying vasculature.

 

Use of X-Stat:
Lots of people ask about X-stat. Frankly I don't have any experience using this nor have I gotten much feedback in the positive about that device. I am not ruling it out, but as of right now its not finding a place in my aid bag.

 

My favorite- I think every medic should carry a Foley catheter in either their pocket or readily accessible on their med kit. you can use if for small wound tracks and stick it in directly into the wound. using saline flushes (preferred over air) fill the bulb  to create a tamponade. Its important to clamp the proximal end of the catheter so as to not allow blood to flow through. 

 

All treatment considerations come from an operator and instructors perspective. Supplementary information was gathered through Emergency War Surgery book as well as Joint Trauma Service CPG's. 

FAQ About Special Forces Assessment and Selection

FAQ About Special Forces Assessment and Selection

Every day we receive numerous emails and messages on our page regarding questions about SF Selection (SFAS), the 18D course, and more. We love hearing from you all, but it is impossible to respond to every question directly, so we've taken these great questions and attempted to assemble them into one page!

FAQ about Selection (SFAS)

What if I have a disciplinary record? Will that stop me from being SF?           

Depends. SF isn’t made up of saints, but it’s wise to ask an SF recruiter whether your previous history will prevent you from going.

Do you have to be big to make it through selection?

No, absolutely not. SF guys come in all sizes. A snapshot of the 18D’s who work for Ready Warrior--one is 5’7” and 170lbs, one is 6’0, 210lbs, and one is 6’3” and 235lbs. The great equalizer is fitness, rucking, and drive.

How do I prepare for selection?                                                                     

Be well-rounded. Don’t be a linebacker who can’t run, or a runner who can’t handle a heavy rucksack. We hesitate to use the example of Crossfit, because people either swear by it or despise it, but the all-around fitness it encourages is close to what you’ll need to be successful. 

How do I mentally prepare for selection?                                                          

To quote Eric Thomas: "When you want to succeed as bad as you want to breathe, then you’ll be successful." There is no magic pill to take or book to read in order to be successful. You have to accept that selection will suck, and that you will have to have a laser-like focus an believe that you want nothing more in life than to succeed at this to get through each day. 3 weeks seems like a long time, but the pride of getting selected lasts forever.  

Can we bring any Motrin or Vitamins to Selection?

No. Non-essential medications are strictly forbidden. Prior approval must be attained before bringing any medication for illnesses.

What are some good standards to shoot for in preparation for selection?     

A general guideline is to be able to run 5 miles in an average of 35-37 minutes. Ruck should be 11-13 min/mile indefinitely. Rule of thumb is do your absolute best, all the time. Faster is always better. Ruck tips in our blog post here.

Best way to get an 18x contract? 

Talk to a recruiter. Don’t think that you HAVE to do your time in the regular army if your only goal is to get to SF anyway. Everyone is at different stages of their life, maturity level, and career goals. If you aren’t sure…spend some time in the military first and then go talk to an SF recruiter.  

Boots for selection and training? 

Everyone has their own favorites. There was something called the SOPC soles that we put on our boots that were softer and were supposed to help with the ruck distances. They also burned up on the rope climbs. You don’t need some fancy pair. The standard Bellevilles will be just fine. We didn’t use any other pair of boots (except in Garrison) throughout the entirety of my SF career. Just spend enough time in them that they are thoroughly broken in before going to selection. Don’t be the guy in the selection class who busted out a brand-new pair of boots on the first day and then had to tough out some of the most incredible blisters we’ve ever witnessed. 

Does my age have any bearing on me getting selected? What is too old?

We’d be lying if we said age was not a factor in selection. It is. Regiment has to consider how many years you will be able to give them for the $ they spend on you and the time it takes to get you to a team. Consider too that most people take from 18 months to nearly 30 months (18D’s and 18A’s) to pass the Q from the time they go to selection to the time they graduate, and that’s just to get you to the bare minimum to join a team. Now the goal Is to get through the Q course in 12 months (not including medics), but you still have even more training once you get to a team, which means you are an unproven rookie!

That being said, we don’t know you…or your ability level. If you are late 20’s, you’re fine. No question. If you are early 30’s, decide quickly, but that it’s entirely possible if you perform well and have something they are looking for. We’re not selection cadre, so don’t ask us what that is! Mid-late 30’s……eh……you’re pushing it. We had a 38-ish guy in my selection class that made it all the way to the end, and was a non-select. We also had some early 30’s guys who did get selected.  

We’re never going to tell you NOT to go to selection if you’re older. You just need to honestly ask yourself if you truly want to endure what it takes to get to SF for up to 30 months, and where you see your life during that time. If you think you’re physically and mentally ready, then you don’t need us to tell you that you should go for it.  

Getting Ready for Selection. Any tips?

Get ready for the suck!!! We have all heard the horror stories about how bad selection sucks and blah blah blah. There is no way to sugarcoat it. It does. But it’s also a defined period of time that ends. To make the most out of your experience, we’d suggest the following:

1) Don’t pace yourself too much. Lots of guys don’t give 100% on the individual portions of selection because they want to make sure they have energy left for team week. Guess what? Cadre notice when you aren’t giving it everything you have. Remember, selection is a tryout. If you’re not giving everything you have, what are you even there for? You’d be surprised at the kind of physical and mental reserves you can access when you get closer to the end. There will be times where you can pace yourself, and those times will be obvious. For every other time, give it 100% of your effort.

2) Try and be the gray man. If you can excel at the individual events, do it. Excel at the PT test, excel during the runs or rucks. Don’t stick out for the wrong reasons though. Don’t be the guy who spotlights himself by being overly loud during team week. Don’t be last, don’t even be second to last in any event.

3) Shake it off. If you have a bad event, or spotlight yourself for the wrong reason, don’t take yourself out of the game. Too many people self-select out because they feel like there is no way they will ever pass after “x” happened. Not true. We had a former selection cadre on my team in group, and he used to say that guys who were very likely to get selected would quit all the time because they failed an event and spotlighted themselves in a negative way once.

4) Don’t quit. I know what you’re thinking. I’ll never quit! Well we’ll let you in on a little secret. Everyone thinks of quitting. We sure as hell did. Selection sucks! Have your little pity party, take a deep breath, and find a reason to keep going. For me, we felt sick as a dog during the Star Course. We were dizzy, nauseated, felt like we couldn’t concentrate, etc. In our delirium we went to the side of the road and convinced ourselves that If the cadre just took me back to get checked out, we’d be fine and could rejoin selection afterwards. Part of us must have known that it meant quitting, because as we sat on my ruck on the side of the road waiting to be picked up, we snapped out of it just as a cadre’s truck came around the corner, and sprinted back into the woods with our ruck. We came THAAAAT close to wiping out our dreams because we let misery and mild illness distract us.

5) Be a team player. There was a physically small guy on our team in team week. Our event was pushing a contraption that needed someone to steer it from the top. Because he was the smallest guy, he was asked to do it. He saw it as him not getting to participate and us trying to make him look bad, and threw a fit about it. Unfortunately for him, the cadre aren’t assessing your strength at that point. It’s called team week for a reason.  Find a way to be helpful. If it makes the most sense for you to be in a certain spot for a certain amount of time, accept that role.

What is life like during the SOPC course before selection? 

I can only speak to what I went through. We woke up each day super early, worked out, spent the day learning about various topics pertinent to bringing us up to speed on soldiering, such as land navigation techniques, had an afternoon session of working out, and everyone pretty much passed out from sheer exhaustion after dinner. Repeat daily. It was an incredible course and taught you a ton of great skills, as well as getting you in incredible shape for selection. 

I’m 17. Any advice on becoming an 18D? 

Finish school. Stay out of trouble. 

Any ways to guarantee getting the 18D MOS after Selection?

Short answer, no guarantees. You will be assigned an MOS based off the needs of the regiment. However, having a 4-year degree, any sort of medical background including EMT, scoring a 120 or above on your GT and simply requesting the 18D MOS will all help your cause. While there is no guarantee, SF always seems to need 18D’s, so your chance of getting it is pretty good if you have at least some of the above qualifications. 

What was your favorite part of the 18D course?
Rotations. Your experiences at the Hospitals you get to work at on rotation are some of the best hands-on experiences you’ll ever have in your life.

 

FAQ about the 18D MOS/course

I’m a civilian paramedic, do I stand a better chance of passing the 18D course? 

Mixed. Civilian paramedics either perform extremely well in the 18D course, or they can’t unlearn some of the stages of care they learned as paramedics that are different from the military, and subsequently fail. The only civilian paramedic certified classmate I had in the SOCM course failed out because he couldn’t unlearn some of the ingrained steps of medicine he had been taught, and reconcile them with TCCC. 

 

How do I prep for the 18D course? Any reading material you recommend?

The 18D course is self-contained, which means you can be like me and have had exactly 0 days of formal medical training on your first day of class and still do fine. If you really want to get a jump on the material though, I’d highly recommend getting to know Anatomy and Physiology. This firehose of information is a wrecking ball to poor students without really good study habits. I’d recommend picking up literally any basic book on A&P and get to know the PRIMARY muscles, nerves, arteries, veins, bones, etc. No matter how much you learn, prepare to study at least 2-3hrs per night during that phase to make sure you get it all. 

 

How do I prep for the 18D course?  Any hands-on training you recommend?

Memorize and practice the steps of TCCC and the MARCH algorithm of care. Getting that ingrained in your memory and practicing it will help.

 

What was the hardest topic to grasp in the SOCM/18D course? 

Everyone in the course struggled with different phases, which is one of the reasons why the attrition rate is so high. Personally, I had more trouble with the hands-on material than with the book material. Anatomy and Physiology is extremely book intensive, but if you put in the hours you can pass. The hands-on material takes the ability to really think critically and adjust as necessary to innumerable what-if’s, which means quick thinking and applying relevant algorithms of care. Even to this day, practicing and hands on is a key component of training.

 

Besides the 18D course, what is the toughest part of the SF pipeline? 

Small Unit Tactics. It’s invaluable, but it’s a suck fest. 

 

What are the primary differences between an 18D and a PJ?

I get this question a lot. Besides the obvious answers that Google and 5 minutes of research on your own can provide, there is this. 18D’s are 100% members of an SF team. This means conducting UW, FID and everything else SF teams are tasked with. This also means that they are fully integrated into the entire training cycle of their ODA, including ranges, demo, CQB, airborne ops, and pretty much everything else non-medical you can think of. An 18D often has to find their own training opportunities for rehearsing, practicing and staying proficient in all facets of medical care. You become an extremely well-rounded soldier in every aspect of what it means to be an SF guy. That’s the super short answer. A PJ is the finest combat rescue professional on the planet. While I do not speak for PJ’s, their job centers around medicine and the vast majority of their training is designed for them to be able to get to their patient. A PJ’s job is not to conduct a shura, or train a foreign military in CQB.

 

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