# Tactical Assesment for Non medical personnel



## Armymedic (23 Mar 2005)

I developed this protocol in response to the request of my team here in Afghanistan. All 13 other mbrs completed the Cbt First Responder course, and asked for more medical training and specific direction towards exactly when and why each of the skill are to be used. I developed it in coordination with our team SOP and then tailored it towards a completely generic protocol for any nonmedical pers who do not have medical assets with them, or if it is the medical assets which are the casualties. It is also designed so that at the end of the Tactical Fd care stage for all casualties to be handed over to med pers. I hope it will be eventually adopted for the CF wide new tactical casualty course.

I have 12 Cbt arms Snr NCOs and officers on the team, about half of which had input to the final draft which I have below. I have also credited the sources in which I have taken ideas from to complete the protocol.

Feel free to comment below, or pm me with thoughts. Remember, its meant for all deployed army pers who have taken the Tactical Combat Casualty courses less qualified medical pers.






> *Tactical Assessment for Nonmedical Personnel*
> 
> Care Under Fire
> 
> ...


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## Armymedic (22 Apr 2005)

Survey awaiting approval, before possibly becoming TF SOP for TCCC qualified pers.


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## slim300 (22 Apr 2005)

This is well thought out.  The only thing I can think of to add is in step 4 of care under fire, add actions on for compromised airway.  This would likely be as simple as putting the casualty in the recovery position or repositioning the head.

I expect you'd agree that a basic airway intervention like that is worthwhile in the care under fire phase... rolling someone into the recovery position is all to easy, and a casualty can only go 4 minutes without an airway before brain damage starts.

Again, good work. BZ.


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## Armymedic (23 Apr 2005)

Care under fire is just that, quick care you do while doing your best to not be killed.

While it may be noble to roll the possibly unconscious cas to the recovery position, by doing so you will expose yourself to greater danger and going against the principle of having the cas lay flat to avoid being a target.

By log rolling the cas, you mark him to the enemy...at that would be all bad.


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## TCBF (23 Apr 2005)

"By log rolling the cas, you mark him to the enemy...at that would be all bad."

I am confused.  If you are a medic, you don't "Return to the fight as required"

If you are not a medic, you should be laying down fire and clearing the position, not laying out bandages.

No point saving one life, if only to have him bayonetted by the enemy as they roll over your position because some guy(s) put down their weapon(s) to patch a buddy.

We have a Battle Drill for re-org, do we not?


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## Armymedic (24 Apr 2005)

TCBF said:
			
		

> If you are not a medic, you should be laying down fire and clearing the position, not laying out bandages.
> No point saving one life, if only to have him bayonetted by the enemy as they roll over your position because some guy(s) put down their weapon(s) to patch a buddy.
> We have a Battle Drill for re-org, do we not?



Exactly my point....as this is an assessment for NONmedical personnel qualified tactical casualty care.


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## Fraser.g (24 Apr 2005)

TCBF said:
			
		

> "By log rolling the cas, you mark him to the enemy...at that would be all bad."
> 
> I am confused.   If you are a medic, you don't "Return to the fight as required"
> 
> ...



By utilizing the TCCC there will be an established drill as to when you can and should come to the aid of a buddy. Yes We have a Battle Drill for the Re-Org (Consolidation) but the only time during that drill that wounded were addressed was in the Ammo Cas State.

For the first time in the Battle Drill this acknowledgesthat casualties happen during the fire fight (Surprise!) and not at the end just before the re-org.

It is human nature to go to the aid of a buddy in pain. The only way to combat that urge is to drill an SOP into the combat arms.

All this does is set up an SOP for when you start to take casualties in an operational environment.

GF


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## slim300 (24 Apr 2005)

Armymedic,

It sounds like you are contradicting your own SOPs in your reply.  I fully understand the concept of care under fire.

Your SOPs:
4. *Once casualty is in safe area*, assess LOC / Airway by asking â Å“Where are you hit?â ?
   a. if not alert, disarm

If you already have the casualty in a safe area and are close enough to assess airway and LOC and disarm if necessary, how does it put anyone at greater risk to put someone in the recovery position, which is very close to the prone position anyway.  I would have to say that in such a circumstance, leaving someone asphixiate on their tongue is more dangerous than the 2 sec of _slightly_ greater exposure to enemy it takes to roll a supine casualty.


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## TCBF (25 Apr 2005)

When do you treat the cas?      When the enemy are dead.

Exceptions:   When there is nothing else (shooting, moving, communicating) that you should be doing at that moment, and as long as treating the cas will not impinge on your ability to move, shoot, or communicate the INSTANT you need to do so.

Otherwise, you take needless casualties.

Kill the enemy, then treat the cas.


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## Armymedic (25 Apr 2005)

Actually it is covered...
both points by TCBF and Med eh!



> 7. Take casualty with you or position casualty when you leave
> a. place in a fire position with weapon if able
> b. recovery position if decreased LOC
> 
> 8. Return to fight as required


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## TCBF (26 Apr 2005)

"1. React to fire
   a. seek cover
   b. return fire as trained
   c. attempt to neutralize threat.

2. Contact casualty
   a. direct the casualty to perform self aid
   b. direct the casualty to return fire if able
   c. if casualty is unable to return fire, tell them to lie still

3. Protect casualty from additional wounds
   a. if casualty is able to move direct them to cover
   b. if casualty is unable to move, attempt to recover casualty to safe area"

OK, my bad, I have not clearly posed my question.All of the above, up to sub para 3a, can be done while you are fighting.  To go from 3a to 3b is a major shift in your main effort.  You now have someone who should be paying attention to the enemy directing his attention to a casualty.  

TO ENSHRINE THIS AS AN SOP AS WRITTEN IS IRRESPONSIBLE.

It is up to the commander on the ground to decide at what point casualty care (saving individuals) takes precedence or effort away from destroying the enemy (saving the unit).  It is not up to an SOP.  

The local commander - fire team leader and up - has to decide at what point fighters (not medics) will treat cas rather than fight.


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## slim300 (26 Apr 2005)

Armymedic,
Fair enough... my original point was just to lay it out more clearly.  If you lay it out as IAs like rifle drills, I believe the SOP would be more user friendly.  As in, assess airway--> if compromised, put cas in recovery position.  Certainly not that big a deal.

In response to TCBF:
Of course caring for casualties should be under the direction of leadership, as should just about anything a soldier does during combat.  However, the notion that such an SOP is irresponsible is naive.  First of all, not all combat casualties are taken in the midst of a section attack on a lone enemy trench, we don't practice war by attrition so waiting until all the enemy are dead is a flawed point of view to start with.  I can think of several situations where a single rifle could be spared for a matter of 30 sec to care for buddy.

Secondly, assuming all casualty care should wait until reorg entirely ignores the human factors: casualties have a devastating impact on the morale of a unit, having a practiced drill to perform when your commander tasks you to care for the downed man can help maintain the effectiveness of your whole section/unit.  There are enough clichés in the movies about the reason we fight being the buddy in the next trench that you'd think that people would have figured out that it's a bad idea to let buddy die unnecessarily.

This kind of SOP just serves a guideline for commanders and soldiers-alike to know how to respond.

Cheers.


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## Armymedic (26 Apr 2005)

TCBF said:
			
		

> OK, my bad, I have not clearly posed my question.All of the above, up to sub para 3a, can be done while you are fighting.   To go from 3a to 3b is a major shift in your main effort.   You now have someone who should be paying attention to the enemy directing his attention to a casualty.
> 
> TO ENSHRINE THIS AS AN SOP AS WRITTEN IS IRRESPONSIBLE.
> 
> ...



To not have any SOP at all is also irresponsible.....

you speak of only one small section of our doctrine, I am looking at guidance for all of the army in all its roles and tasks. And in direct response to your points, nowhere does it say that the person who takes this action has to be the subunit in direct contact...it could be the follow on sections, platoons or even companies who take care of the casualty....that is still care under fire.
To directly address your concern;
To "attempt to recover cas to a safe area" maybe to pull him forward a few feet to an area where he can not be hit again, and the key word is "attempt". I leave it with that word because it allows for the flexibilty where the mission dictates whether that "attempt" can be safely made.

By taking the actions I outline in the Care Under Fire Phase, you can save 30% of all battlefield casualties from dying.....to not make that attempt at all, would also be irresponsible.

And let me reemphasise, this is for the nonmedical people...medics are usually back a bound from the contact, so it WILL be the leaders who will decide the actions that must be undertaken. I didn't just pull this out of my hat, it was done with the consultation of 3 Infantry Sr NCOs and 2 Infantry officers as well. The primary one being named above as a reference....it will fit into doctrine.

again, my main point in rebuttal....

To not have any SOP at all is also irresponsible.....


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## Grunt_031 (26 Apr 2005)

> When do you treat the cas?    When the enemy are dead.



Remember Somalia, US Rangers. Your *Care under fire * can last hours and hours.


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## JANES (26 Apr 2005)

"Any casualty management plan should be considered advisory rather than directive in nature"
Capt (N) Frank Butler


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## TCBF (26 Apr 2005)

"we don't practice war by attrition"

Wanna bet?  Stay in your arcs, now...

 "so waiting until all the enemy are dead is a flawed point of view to start with." 

 Depends on the sit, obviously, if I CAN do something about cas, I will - believe me, I will - , ASAP, for all of the good reasons you guys have listed above.  BUT, "Mission First" sometimes actually means "Mission First".  If we teach , practice, and assess our soldiers in scenarios where there will ALWAYS be someone who will be able to assist the cas before an engagement is finished, we will be doing them a dis-service.

I agree, an SOP will be handy, but we need a BATTLE oriented SOP, not a CASUALTY oriented SOP.

  "I can think of several situations where a single rifle could be spared for a matter of 30 sec to care for buddy."

I agree.  Perhaps even in a majority of situations.  And you can bet we will all try and find a way to make that happen.   But to enshrine it as an SOP gives it the authority of a DRILL.

"Any casualty management plan should be considered advisory rather than directive in nature"

There we go.  Words to the effect that  " re-deploying combat power from the battle to casualty care is a command decision, not a medical one" may be usefull between para 3a and para 3b.


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## JANES (26 Apr 2005)

Let's see here...

According to TCCC guidelines:

"Objectives of tactical casualty managment:  Treat the casualty, prevent additional casualties, complete the mission - not necessarily in that order."

"The priority of the mission may take precidence over the welfare of the casulaty"

"Care Under Fire phase:  'Firepower may be the best medicine'"

"Drills" need to be in individual skill, such as recognition of life threatening  bleeding, and tourniquet apllication, casualty rescue should not be an SOP, but rather a TT&P.  You need to practice casualty rescue to have the skills in your tool box, as stated prior - if the commander on the ground deems it appropriate to perform a rescue given the situation, it cannot be a rule.

Remain flexible, with the skills to due what is appriopriate at the time given the situation.


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## JANES (27 Apr 2005)

"We can not trade one set of rigid guidelines for another"
- Capt (N) Frank Butler


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## Dale Turner (27 Apr 2005)

Just my two cents...
 One of the first things we are taught whether you're Reg or Res is scene safety. That being said "scene safety" is becoming a relative concept. In a combat sit. we as medics are just as responsible to make the scene safe as our infantry collegues are. You cant effectively treat a casualty when you're still under effective fire. So I agree with the statement that sometimes the best treatment is to return fire. 

Also that being said I think it's imperative that our training scenarios reflect a combat flavour to them.  Now some will say that we'll need to involve infantry units to facilitate this type of training. However we've all seen CSS convoys coming under attack from insurgents in Iraq.  Some of these CSS convoys did'nt have any infantry to provide security.  So isn't it reasonable to train as Fd Ambs in convoys that come under attack from the unconventional enemy and throw in the TCCC sops as well?

Again just my two cents. :soldier:


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## TCBF (27 Apr 2005)

Not to digress from the original thread, but, yes Battle Task Standards covers that:

B-GL-383-002/PT-023 Battle Task Standards - Medical: pg. iii, para 5. 

  "These Field Amb BTS emphasize aspects unique to the provision of medical support.  Combat Service Support BTS 1001, " ..."4101" (Defend)  ...  "4316"  (Conduct Road Movement)...."...are of great relevance to Fd Amb operations and should be consulted where a more detailed breakdown of certain tasksis required."

BTS L4316 D/F Conduct Road Movement:  " 6.  i: The packet reacts to air attack or ambush IAW BTS 5004, Defend Against Air Attack or BTS 5006, React to Ambush."


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## Armymedic (28 Apr 2005)

TCBF said:
			
		

> "Any casualty management plan should be considered advisory rather than directive in nature"



You know, if there actually was a plan, an honest workable plan that every soldier knew and practiced each and every exercise, predeployment training, and deployment continuous training, we wouldn't be having this discussion...


And these...


			
				TCBF said:
			
		

> Not to digress from the original thread, but, yes Battle Task Standards covers that:
> 
> B-GL-383-002/PT-023 Battle Task Standards - Medical: pg. iii, para 5.
> 
> ...



Do not cover it. They are paper guidelines to the unit for training, not workable solutions for the soldiers to practice actual skills. 

So are you saying...

What we have and do right now in the CF in regards to when and how we take care of our casualties is sufficient for all situations?


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## JANES (29 Apr 2005)

We need a flexible guideline, not an SOP, not a drill.  We need to practice TCCC CUF principals, and develope and practice TT&P's WRT casualty recue, so we know how to do them effectively if required.


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## Armymedic (29 Apr 2005)

Well, I am sure we can keep this arguement going for a while...but I am looking for improvements.

Here is the area of your concern...



> Care Under Fire
> 
> 1. React to fire
> a. seek cover
> ...



I understand your point of view, but it is not workable, because in point 2, attention is are already being directed towards the casualty vs having all thier attention at the enemy threat.
Possibly adjusting the wording in point 1 would be more realistic, because once the threat is neutalized, then you can carry on to the next stage of care, and the remander of the points are nulified.



> 1. React to fire
> a. seek cover
> b. return fire as trained
> c. attempt to neutralize threat.


possibly...
d. if contact becomes prolonged then leader to assess need to account for casualties....

or wording to that effect, where it becomes the leaders perogative to take care of casualties sooner then our current doctrine allows.



			
				JANES said:
			
		

> We need a flexible guideline, not an SOP, not a drill.   We need to practice TCCC CUF principals, and develope and practice TT&P's WRT casualty recue, so we know how to do them effectively if required.



possibly DRILL and SOP are the wrong terms. But JANES is correct, we need a standardized principle that we all know and train with, all the time.


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## TCBF (29 Apr 2005)

" They are paper guidelines to the unit for training, not workable solutions for the soldiers to practice actual skills."

What?  

The Battle Task Standards are just that - Standards.  They were provided by me in this case because of Snr Med A's concern in his post that:

 "  So isn't it reasonable to train as Fd Ambs in convoys that come under attack from the unconventional enemy and throw in the TCCC sops as well?"

So I provided those BTS above in particular to illustrate that Fd Ambs DO have BTS that cover convoys under attack.

As far as "Workable solutions for soldiers to to practice actual skills" goes - BTS are  check lists detailing whether an element has accomplished a series of mandated battle tasks to the standard which the Army demands.  For example, the BTS 6003 B/C/D Treat and Evacuate Casualties is a checklist included in the Infantry BTS.  

If you want to develop a checklist for rapid treatment of cas - whether it becomes an SOP or not - it cannot reduce  element commanders' flexibility to use all of their combat power to fight the engagement as they see fit.  The decision to employ combat power to treat cas must remain a command one, not a medical one.  Here at CMTC, any Medical O/C who attempts to interfere in an assessed combat BTS by attempting to force an element  to deal with cas before possible - from a tactical point of view - would get summed up by the Tactical O/C without much ado.

By all means, develop an SOP, for all of the good reasons listed above, but do not lose site of the mission - state CLEARLY that the decision to employ combat power to treat casualties is the element commander's call, not the SOP's call.


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## Armymedic (29 Apr 2005)

The argument is pulling away from what I am trying to achieve, but the talk of the BTS did bring me to realize I should look at them myself to ensure that this protocol will fit into them. As it is the BTS which we go back to in training, (regardless of their relevancy in the ever changing world) hence any new standard of training must fit with them. 

Possibly it is BTS 6003 B/C/D Treat and Evacuate Casualties, the one of which you speak, that needs to be looked at.  



> Here at CMTC, any Medical O/C who attempts to interfere in an assessed combat BTS by attempting to force an element  to deal with cas before possible - from a tactical point of view - would get summed up by the Tactical O/C without much ado.



ah, CMTC...where we still practice fighting the tank battles from the cold war.....

You are absolutely right on that point, and to do that would be a mistake by the Med OC. I think we are talking on different levels, you at Bn, Company and Cbt team, me at section and fire team. 

So, if what I have works as a procedure at the lower level, then guidance is needed at the higher level on how best to use it, ensuring that 





> the decision to employ combat power to treat casualties is the element commander's call


 within the parameters of his mission.


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## JANES (29 Apr 2005)

I think you're trying to re-invent the wheel.  The longer and more complicated the "guideline" becomes the less it is open to flexibility.  The original TCCC CUF guidelines that Butler produced are sufficiently brief yet guiding.  It simply states "Protect the casualty" which covers practically all scenarios.  It does not state perform a rescue, but implies that you "can" or if you can't then the best way to protect him is to continue the fight.  If the fight is just so intense that you cant rescue him, and the medic if fighting for his life, can't get to the casualty - then his firepower is the best medicine, if the casualty exsanguinates before help can arrive, then he is just a casualty of war.  Cést la vie.  Ultimately it is the commander decision, and sometimes it may be a tough decision to make.  Sometimes not rescuing a casualty from a zerod zone will prevent additional casualties - we've all seen Full Metal Jacket!  Should you send a medic to do a rescue?  Do you expose the asset to that increased threat?  Simplicity is best and Butler hit it on the head.  Thats why his guidelines are recognized by the National Association of EMTs (US) and American College of Physicians and Surgeons.


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## TCBF (29 Apr 2005)

"ah, CMTC...where we still practice fighting the tank battles from the cold war....."

Full Spectrum of Operations (all three blocks at once).  But, that's another thread.

"I think you're trying to re-invent the wheel.  The longer and more complicated the "guideline" becomes the less it is open to flexibility.  The original TCCC CUF guidelines that Butler produced are sufficiently brief yet guiding."

Please show us these here.

However this turns out, kudos to all for discussing it.


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## Fraser.g (29 Apr 2005)

Here is the Orrigional TCCC evaluation sheet from the US Rangers with changes in wording for Canadian Military Consumers.   

GF


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## JANES (29 Apr 2005)

Good thing you Canadianized it, I don't speak American.  The Ranger document is an evaluation form for their Ranger First responder course, similiar to combat life saver, or our TCCC pilot.  Here is Capt Butlers TCCC CUF guidelines (you can also find in PHTLS 2003) included here are the official revisions, and are current to date.
1.  Casualty stays engaged as a combatant if appropriate.
2.  Return fire as directed or required.
3.  Try to keep yourself from getting shot.
4.  Try to keep the casualty from sustaining additional wounds.
5.  Airway management is generally best deferred until the Tactical Field Care phase 
6.  Stop any life-threatening external hemorrhage:
	- Use a tourniquet for extremity hemorrhage
	- For non-extremity wounds, apply pressure and/or a HemCon dressing
7. Reassure the casualty


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## Fraser.g (29 Apr 2005)

Sarcasm noted,

I changed any ref to the Ranger First Responder, also the "GO" "NO GO" as well as changed any Trade names of Medications to the Canadian Equivalent. I am sure that you are conversant with the subtle changes but many reading this thread may not be as conversant as you.

I also note that there is the "Official Ref" to hemcon dressings. I am unaware if they are authorized for use by the CF. 

Here is the ref for where the original doc can be found.

GF

http://www.drum.army.mil/sites/tenants/division/CMDGRP/SURGEON/91W%20slide.htm


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## JANES (1 May 2005)

And because I know how much you hate Quickclot:

"The anticipated guidelines will call for HemCon to be used first in situations where hemostatic agents are appropriate and QuikClot to be used as the second option if HemCon is not effective."
 - Interview with Captain Frank K. Butler, M.D.
Command Surgeon United States Special Operations Command


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## Armymedic (1 May 2005)

The document you attached is very similar to the protocols I described at the top of the thread. 

Once major difference is that the interventions allowed by the CF are far fewer then described in that document. In fact, at this time, Med Tech are not allowed to do IV meds of any type in the field, so it is highly unlikely anyone will be allowing the "uneducated masses" of cbt arms to do those skills. Heck, we are not allowed to teach them how to start IVs.

That doc would be an excellent assessment tool for Med Techs.

Also the document is for TCCC trained Cbt first responders from 10 Mtn Div...

I personally think that program is much better then the commericaly avail PHTLS for our needs, perhaps that could be looked at as well, but that is a discussion for another thread.


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## JANES (5 Jun 2005)

"Also the document is for TCCC trained Cbt first responders from 10 Mtn Div..."

So tell me then why it states "RFR" as in Ranger First Responder throughout the document.  For only the standard Rangers in the 10 Mtn Div?  What about the other first responders in 10 Mtn Div?  Aren't they allowed?


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## Bruce Monkhouse (5 Jun 2005)

Janes,
You are starting to piss me off, these two[ this one and the Tactical Combat Casualty Care Course] medical threads are extremely informative and very reassuring for the personall on the pointy end to know that our medics are as professional as the system allows them to be, and all you can do is sit back with your empty profile and crap on everyone. Well I happen to know a couple of the main posters here and they are nothing but professional.
You, on the other hand, appear to be a whiny internet trashbag, so do us a favour and either state your qualifications and affiliations or hit the road.
This is your warning.
Bruce


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## old medic (6 Jun 2005)

JANES said:
			
		

> So tell me then why it states "RFR" as in Ranger First Responder throughout the document.  For only the standard Rangers in the 10 Mtn Div?  What about the other first responders in 10 Mtn Div?  Aren't they allowed?



Irrelevant.
We are not here to split hairs about word meaning in another military's documents.

Further to Bruce's comments above, this medical forum is visited by numerous medical trades
and professionals of CFMG. They are here for professional discussion or to assist in answering
questions. They do not come here for the sarcasm or goofy comments.


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