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Featured Articles

Winter 2013

Drug-Induced Liver Injury Secondary to Testosterone Prohormone Dietary Supplement Use

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Hoedebecke KL, Rerucha C, Maxwell K, Butler JN. 13(4). 1 - 5. (Journal Article)

Abstract

Dietary supplementation has become progressively more prevalent, with over half of the American population reporting use of various products. An increased incidence of supplement use has been reported in the military especially within Special Operations Forces (SOF) where training regimens rival those of elite athletes. Federal regulations regarding dietary supplements are minimal, allowing for general advertisement to the public without emphasis on the potentially harmful sideeffects. Subsequent medical care for these negative effects causes financial burden on the military in addition to the unit's loss of an Operator and potential mission compromise. This report reviews a case of an Operator diagnosed with drug-induced liver injury secondary to a testosterone prohormone supplement called Post Cycle II™. Clinical situations like this emphasize the necessity that SOF Operators and clinicians be aware of the risks and benefits of these minimally studied substances. Providers should also be aware of the Human Performance Resource Center for Health Information and Natural Medicines Comprehensive Database supplement safety ratings as well as the Food and Drug Administration's MedWatch and Natural Medicines WATCH, to which adverse reactions should be reported.

Keywords: liver injury; prohormone; testosterone; supplement

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Identification and Management of Bed Bug Infestations in Austere Environments

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Amodt ZT. 13(4). 6 - 11. (Journal Article)

Abstract

Military forces have missions that send them all over the globe. With the reemergence of bed bugs worldwide, the possibility of Servicemembers encountering them has increased. Special Operations Forces are often sent to locations that may not have integrated pest management support. Knowing how to identify and manage a bed bug infestation, with and without proper equipment and supplies, may become necessary in the very near future. It is also important that Servicemembers are aware of how bed bugs travel, to prevent their dispersal back to the United States and into their barracks and homes.

Keywords: bed bugs; bat bugs; infestations; austere environments; pest management

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Rice-Based Electrolyte Drinks More Effective Than Water in Replacing Sweat Losses During Hot Weather Training and Operations

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Gerold KB, Greenough WB, Yasar S. 13(4). 12 - 14. (Journal Article)

Abstract

Heat-related injury presents significant threats to the health and operational effectiveness of Soldiers and military operations. In 2012, active component, U.S. Armed Forces experienced 365 incident cases of heat stroke and 2,257 incident cases of "other heat injury." Most of these occurred among recruit and enlisted personnel and most were under the age of 30. In conditioned military personnel, a rice-based oral rehydration solution was superior to water alone at maintaining body weight and, by inference, enabled Soldiers to better maintain their the state of hydration during prolonged exercise in high ambient temperatures. In view of the health risks associated with dehydration and their effects on training and operations, this study suggests that the consumption of beverages containing electrolytes and a rice-based carbohydrate is superior to the consumption of water alone in preventing dehydration and heat related illness.

Keywords: heat-related illness; dehydration; oral rehydration; water

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Tactical Lighting in Special Operations Medicine: Survey of Current Preferences

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Calvano CJ, Enzenauer RW, Eisnor DL, LaPorta AJ. 13(4). 15 - 21. (Journal Article)

Abstract

Success in Special Operations Forces medicine (SOFMED) is dependent on maximizing visual capability without compromising the provider or casualty position when under fire. There is no single ideal light source suitable for varied SOFMED environments. We present the results of an online survey of Special Operations Medical Operators in an attempt to determine strengths and weaknesses of current systems. There was no consensus ideal hue for tactical illumination. Most Operators own three or more lights, and most lights were not night vision compatible. Most importantly, nearly 25% of respondents reported that lighting issues contributed to a poor casualty outcome; conversely, a majority (50 of 74) stated their system helped prevent a poor outcome. Based on the results of this initial survey, we can affirm that the design and choice of lighting is critical to SOFMED success. We are conducting ongoing studies to further define ideal systems for tactical applications including field, aviation, and marine settings.

Keywords: lighting; tactical; dark adaptation; contrast sensitivity; illumination

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Filling in the Gaps of Predeployment Fleet Surgical Team Training Using a Team-Centered Approach

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Hoang TN, Kang J, LaPorta AJ, Makler VI, Chalut C. 13(4). 22 - 33. (Journal Article)

Abstract

Background: Teamwork and successful communication are essential parts of any medical specialty, especially in the trauma setting. U.S. Navy physicians developed a course for deploying fleet surgical teams to reinforce teamwork, communication, and baseline knowledge of trauma management. Method: The course combines 22 hours of classroom didactics along with 28 hours of hands-on simulation and cadaver-based laboratories to reinforce classroom concepts. It culminates in a 6-hour, multiwave exercise of multiple, critically injured victims of a mass casualty and uses the "Cut Suit" (Human Worn Partial Task Surgical Simulator; Strategic Operations), which enables performance of multiple realistic surgical procedures as encountered on real casualties. Participants are graded on time taken from initial patient encounter to disposition and the number of errors made. Pre- and post-training written examinations are also given. The course is graded based on participants' evaluation of the course. Results: The majority of the participants indicated that the course promoted teamwork, enhanced knowledge, and gave confidence. Only 51.72% of participants felt confident in dealing with trauma patients before the course, while 82.76% felt confident afterward (ρ = .01). Both the time spent on each patient and the number of errors made also decreased after course completion. Conclusion: The course was successful in improving teamwork, communication and base knowledge of all the team members.

Keywords: fleet surgincal team predeployment training course; fleet surgical team; Cut Suit; human worn partial task surgical simulator; trauma team training; educational gap in teamwork and communication; teamwork-centered training; military trauma training

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The Correlation of Early Hyperglycemia With Outcomes in Adult Trauma Patients: A Systematic Review

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Peffer J, McLaughlin C. 13(4). 34 - 39. (Journal Article)

Abstract

Background: Hyperglycemia is often treated in both acute and long-term settings and has recently garnered attention for its utility as a prognostic marker in traumatic injury. This could be of vital importance in Special Operations, as triage and disposition of trauma patients are often accomplished under less-than-ideal conditions. Blood glucose levels are easily obtained, require inexpensive instruments, but are likely not routinely taken in the field for trauma patients. Objective: The objective of this review was to systematically search available medical literature for early (within 48 hours of presentation) hyperglycemia in trauma patients and present the relevant data regarding prognosis in a qualitative fashion. Sources: A systematic review was conducted of published Englishlanguage articles using PubMed/MEDLINE in addition to searching bibliographies. Search terms included hyperglycemia, trauma, and prognosis. Study Eligibility Criteria: Eligible analytical studies had an adult population, who had experienced a traumatic injury, with blood glucose measurements within the first 48 hours of care, and had prognostic end points such as morbidity measures (intensive care unit time, infection, length of stay, etc.) and/or mortality. Study Appraisal and Synthesis Methods: Studies were appraised according to their design, size, population characteristics, definition of "hyperglycemic" and "normoglycemic," and morbidity and mortality outcomes. Results: We reviewed 104 studies. Ninety-five were identified from a PubMed/MEDLINE search, and an additional nine were from relevant citations and bibliographies. Eighty-seven studies were excluded; 17 articles met inclusion criteria and were analyzed for the review. Five were prospective in nature and 12 were retrospective reviews. Five studies analyzed patients with traumatic brain injury, and one study exclusively concerned burn patients. Sixteen of the studies found negative outcomes with early hyperglycemia. One study found no significant relationship between serum glucose measurements and mortality. Limitations: Limitations of this review included the use of one database and articles available online and in English. Conclusions and Implications of Key Findings: There is strong evidence that early hyperglycemia is correlated with a worse prognosis in trauma patients. Providers at all levels could potentially use this information to aid in the triage and disposition of traumatic injury victims.

Keywords: trauma; hyperglycemia; prognosis; mortality

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Cutaneous Leishmaniasis: The Efficacy of Nonantimony Treatment in the Austere Environment Using Cryotherapy, Thermotherapy, and Photodynamic Therapy as an Alternative Method of Treatment

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Kunzler B. 13(4). 40 - 45. (Journal Article)

Abstract

The author provides a retrospective review of clinical trials evaluating cryotherapy, photodynamic therapy (PDT), and thermotherapy in the treatment of cutaneous Leishmania infestations. Current cutaneous leishmaniasis (CL) treatment is based primarily on antimony compounds such as meglumine antimoniate, sodium stibogluconate, ketaconozole, amphotericin B, and other similar compounds. All have potentially severe sideeffects and relatively narrow therapeutic windows (i.e., the minimum doses that are therapeutic and do not cause harm). Investigational modalities using heat and cold therapies were shown to have similar results compared with current treatment regimens. Combination therapies have also been investigated and are the standard of treatment in the United States. Although the current therapies are effective in the treatment of the trypanosomatid protozoan Leishmania parasite, some effective alternative modalities have been shown to have fewer serious side-effects compared with current medications. Investigational studies that were reviewed showed that whether used individually or as an adjunct to traditional therapies, alternative treatment methods proved to be equally efficacious in treating CL. Some investigational therapies, such as cryotherapy as the sole modality, approached 92% cure rate. Any of the three investigated alternatives (i.e., heat, cold, or photodynamic) are techniques that could be readily used by Special Operations Forces (SOF) medics during their operations in remote and/or austere regions of the world.

Keywords: cutaneous leishmaniasis; cryotherapy; thermotherapy; diathemy; SOF medics; photodynamic therapy; Leishmania

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Use of the LMA Supreme in the Special Operations Environment: A Retrospective Comparison of the LMA Supreme and King LT-D

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Hamilton TJ, Maani CV, Redman TT. 13(4). 46 - 52. (Journal Article)

Abstract

The purpose of this study is to evaluate the use of the LMA Supreme® (LAM) as a combat supraglottic airway for U.S. Special Operations Forces (SOF). It is imperative to continuously evaluate and compare existing management options for airway control as requirements and technologies change. Providing our Special Operators with the most advanced and reliable medical equipment is of the utmost importance, and it is our intention here to compare the LMA Supreme with the currently fielded King LT-D® (King Systems) to determine whether the LMA Supreme may be a viable alternative supraglottic airway.

Keywords: supraglottic airway; LMA Supreme; King LT-D

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Needle Thoracentesis Decompression: Observations From Postmortem Computed Tomography and Autopsy

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Harcke HT, Mabry RL, Mazuchowski EL. 13(4). 53 - 58. (Journal Article)

Abstract

Background: Needle thoracentesis decompression (NTD) is a recommended emergency treatment for tension pneumothorax. Current doctrine recognizes two suitable sites: the second intercostal space in the midclavicular line and the fourth or fifth intercostal space in the anterior axillary line. Methods: A review was conducted of postmortem computed tomography and autopsy results in 16 cases where NTD was performed as an emergency procedure. Results: In 16 cases with 23 attempted procedures, the outcome was confirmed in 17 attempts. In 7 placements, the catheter was in the pleural cavity; in 7 placements, the catheter never entered the pleural cavity; and in 3 placements, cavity penetration was verified at autopsy even though the catheter was no longer in the cavity. Success was noted in 6 of 13 anterior attempts and 4 of 4 lateral attempts, for an overall success rate of 59% (10 of 17). In the remaining 6 attempted procedures, a catheter was noted in the soft tissue on imaging; however, presence or absence of pleural cavity penetration was equivocal. All placements were attempted in the combat environment; no information is available about specifically where or by whom. Conclusion: NTD via a lateral approach was more successful than that via an anterior approach, although it was used in fewer cases. This supports the revision of the Tactical Combat Casualty Care Guidelines specifying the lateral approach as an alternative to an anterior approach.

Keywords: needle thoracentesis decompression; Tactical Combat Casualty Care guidelines; tension pneumothorax

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Point-of-Care Coagulation Testing for Trauma Patients in a Military Setting: A Prospective Study

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Cotte J, d'Aranda E, Chauvin V, Kaiser E, Meaudre E. 13(4). 59 - 62. (Journal Article)

Abstract

Background and Objective: Almost 50% of military trauma patients who need transfusions develop a coagulopathy. Immediately treating this coagulopathy improves the patient's prognosis. Field military hospitals often lack laboratory devices needed to diagnose a clinically significant coagulopathy and have limited blood product resources such as plasma. Point-of-care (POC) devices for the measurement of prothrombin time (PT) are available and have been tested in a variety of situations, including hemorrhagic surgery. The authors compared a POC device, the Coaguchek XS Pro (F. Hoffmann-La Roche Ltd., Basel, Switzerland), with laboratory measures for determining the PT in military trauma patients in a field hospital. Methods: This single-center prospective study was designed to compare POC coagulation monitoring with traditional laboratory testing. It was conducted at the French military hospital located at Kabul International Airport. All patients with trauma injuries resulting from war operations were included. A blood sample was drawn immediately on admission. PT was determined both in the laboratory and with use of the Coaguchek XS pro. Results: Forty patients with war trauma were enrolled during a 3-month period. The authors recorded 69 measurements. The two methods were correlated with a correlation coefficient of 0.78 (ρ < .001). The Bland- Altman plot showed a mean difference of 5.8% (95% confidence interval -14.9% to 26.6%). Using a PT cutoff of 60%, POC had a sensitivity of 77.1% and a specificity of 94.1%. Results from POC PT measurement were available within a mean of 25.8 minutes before laboratory measures. Conclusions: The Coaguchek XS Pro device can be used successfully in an austere environment without compromising its performance.

Keywords: point-of-care; coagulation; prothrombin time; military trauma

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Cessation of Vital Signs Monitored During Lethal Hemorrhage: A Swine Study

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Bodo M, Pearce FJ, Tsai MD, Garcia A, vanAlbert S, Armonda R. 13(4). 63 - 75. (Journal Article)

Abstract

Introduction: Two challenges of trauma triage are to identify wounded who are in danger of imminent death and to enable medics to determine if resuscitation is possible when making "dead or alive" decisions on the battlefield. Hemorrhagic shock is the leading cause of death in combat injuries. The purpose of this study was to establish the sequence of vital sign cessation during lethal hemorrhage in swine. Our hypothesis was that brain electrical activity (electroencephalography [EEG]) and respiration are earlier indicators of imminent death than traditional modalities measured during triage, such as heart electrical activity (electrocardiography [ECG]) and blood pressure. Methods: Lethal hemorrhage was induced in anesthetized Yorkshire pigs. Vital sign modalities measured were respiration, heart electrical activity (ECG), heart sound, blood pressure (systemic arterial pressure), and brain electrical activity (EEG). Results: The sequence of vital sign cessation was (1) respiration, (2) brain electrical activity (EEG), (3) heart sound, (4) blood pressure, and (5) heart electrical activity (ECG). Cessation of respiration occurred at approximately the same time that brain electrical activity stopped ("flatlined") for 2 seconds and then resumed briefly before cessation; cessation of heart electrical activity occurred almost 8 minutes later. Conclusions: A 2-second EEG flatline and final respiration are useful event markers to indicate an opportunity to prevent irreversible brain damage from lethal hemorrhage. Since the 2-second EEG flatline and final respiration occur about 8 minutes before cessation of heart electrical activity (ECG), EEG and final respiration are earlier indicators of imminent death. The use of deployable noninvasive brain monitors implementing these findings can be live-saving on the battlefield as well is in civilian environments.

Keywords: lethal hemorrhage; vital sign monitoring; EEG; respiration; event marker; data processing; swine

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U.S. Military Experience With Junctional Wounds in War From 2001 to 2010

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Kragh JF, Dubick MA, Aden JK, McKeague AL, Rasmussen TE, Billings S, Blackbourne LH. 13(4). 76 - 84. (Journal Article)

Abstract

Background: In 2012, we reported on junctional wounds in war, but only of the few injuries that were critically severe. Objective: The purpose of the present study is to associate a wide range of junctional wounds and casualty survival over a decade in order to evidence opportunities for improvement in trauma care within a large healthcare system. Methods: We retrospectively surveyed data from a military trauma registry. We associated survival and injuries at the junction of the trunk and appendages in the current war (2001 to 2010). Results: The junctional injury rate rose 14-fold from 0%, its minimum in 2001, to 5%, its maximum in 2010. Of the 833 casualties with junctional injury in the study, the survival rate was 83%; its change was not statistically significant over time. Most casualties had severe extremity injuries and associated injuries of other body regions such as the face and head. Conclusions: Junctional injury is common, severe, disabling, and lethal. The findings of this study may increase awareness of junctional injury. Opportunities for improvement which we identified included further research on the future addition of junctional codes (such as neck diagnoses) in order to align research methods to clinical care.

Keywords: tourniquet; trauma; resuscitation; injuries; wounds

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Management of Junctional Hemorrhage in Tactical Combat Casualty Care: TCCC Guidelines-Proposed Change 13-03

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Kotwal RS, Butler FK, Gross K, Kheirabadi BS, Billings S, Dubick MA, Rasmussen TE, Weber MA, Bailey JA. 13(4). 85 - 93. (Journal Article)

Abstract

The vast majority of combat casualties who die from their injuries do so prior to reaching a medical treatment facility. Although most of these deaths result from nonsurvivable injuries, efforts to mitigate combat deaths can still be directed toward primary prevention through modification of techniques, tactics, and procedures and secondary prevention through improvement and use of personal protective equipment. For deaths that result from potentially survivable injuries, mitigation efforts should be directed toward primary and secondary prevention as well as tertiary prevention through medical care with an emphasis toward prehospital care as dictated by the fact that the preponderance of casualties die in the prehospital environment. Since the majority of casualties with potentially survivable injuries died from hemorrhage, priority must be placed on interventions, procedures, and training that mitigate death from truncal, junctional, and extremity exsanguination. In response to this need, multiple novel and effective junctional tourniquets have recently been developed.

Keywords: junctional hemorrhage; Tactical Combat Casualty Care guidelines

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Tactical Emergency Casualty Care-Pediatric Appendix: Novel Guidelines for the Care of the Pediatric Casualty in the High-Threat, Prehospital Environment

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Bobko JP, Lai TT, Smith R, Shapiro G, Baldridge T, Callaway DW. 13(4). 94 - 107. (Journal Article)

Abstract

Background: Active shooter events and active violent incidents are increasingly targeting civilians, placing children at heightened risk for complex and devastating trauma. The U.S. Department of Homeland Security has identified as a priority preparing domestic first responders to manage complex mass casualty incidents as a primary step in strengthening our medical system. Existing literature suggests that many prehospital providers are uncomfortable treating critically ill or injured pediatric patients and that there is a gap in the consistent provision of high-quality trauma care to these patients. The success of threat-based care developed by the military has led to an exponential rise in the familiarity and utilization of these concepts within certain specialized elements of civilian care. Evolution of these concepts is accelerating to meet the demands of the nonmilitary civilian environment through the formation and subsequent work of the Committee for Tactical Emergency Casualty Care (C-TECC). However, a gap remains in the available literature describing the application of these principles to specialized populations. Methods: In the absence of an evidence-based set of guidelines for prehospital care of the pediatric casualty, the C-TECC sought to establish a set of peer-reviewed guidelines to serve as a foundation describing current best practices. The Pediatric Working Group (PWG) utilized the adult TECC guidelines as a starting point and identified a series of key questions regarding trauma interventions. The PWG conducted a standard PubMed search to identify key relevant or potentially relevant literature. The literature review was presented to the C-TECC Guidelines Committee for review and approval of recommended principles. Recommendations: Given the dearth of supporting literature on the subject, the TECC committee was purposefully conservative in the adaptation of the adult TECC guidelines to a pediatric standard. The guidelines highlight information tailored to the pediatric population and were designed to be a resource for individual agencies seeking guidance for high-threat operations. To our knowledge, the TECC Pediatric Appendix is the first published recommendation for the widespread use of tourniquets in pediatric hemorrhage. In addition, the Guidelines are meant to highlight gaps in trauma literature and stimulate discussion regarding future research in the area of prehospital care of the pediatric casualty.

Keywords: TCCC; pediatric hemorrhage; pediatrics; C-TCCC

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Tactical Medicine in Response to Acts of Terrorism

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Tang N, Kelen GD. 13(4). 109 - 110. (Journal Article)

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The Application of Regional Anesthesia by the Special Forces Medical Sergeant

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Ho TT, Hall C. 13(4). 111 - 111. (Letter)

Pertussis

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Burnett MW. 13(4). 113 - 114. (Journal Article)

Abstract

Background: Pertussis, a disease that has been well described since the Middle Ages, has a worldwide distribution and can infect all ages. It is caused by the gram-negative, pleomorphic bacillus Bordetella pertussis, which is transmitted from human to human via aerosolized droplets at close range. Descriptions such as the one-hundred day cough in Chinese and whooping cough in English, describe the severity of this disease seen in both the developed and the developing world.

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Erythema Ab Igne

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Gregory JF, Beute TC. 13(4). 115 - 119. (Journal Article)

Abstract

Erythema ab igne is a reticulated, erythematous, hyperpigmented dermatosis resulting from chronic mild to moderate heat exposure. The authors present two cases of erythema ab igne, one from a hot water bottle to treat chronic low back pain and another from a heated automobile seat. They review other reported etiologies and highlight scenarios in which military medical providers may encounter erythema ab igne.

Keywords: erythema ab igne; thermal injury; heating blanket; heated seat; reticular dermatosis; hyperpigmentation

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The Twilight War: The Secret History of America's Thirty-Year Conflict With Iran

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Farr WD. 13(4). 121 - 122. (Book Review)

Abstract

David Crist. New York, NY: The Penguin Press; 2012. 638 pages. ISBN: 1-59420-341-1. $36.00.

"My name, F., just that one letter."

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Kragh JF. 13(4). 127 - 127. (Interview)

Abstract

SGM F. Bowling on Being a Special Operations Medic and Leader Today