HOW TO MANAGE A MASS CASUALTY SITUATION

Mihail Păduraru

BEING FAMILIAR WITH MEDICAL TRIAGE, THAT IS A SYSTEM USED TO CATEGORIZE INJURED IN ORDER TO OPTIMIZE EFFICIENCY, IS ESSENTIAL FOR DELIVERING OPTIMAL MEDICAL AID TO TRAUMA CASUALTIES AND WILL SAVE LIVES

TRIAGE : FRENCH TERM THAT MEANS TO SORT OR SELECT IS THE DYNAMIC PROCESS OF SORTING CASUALTIES TO PROVIDE THE GREATEST GOOD FOR THE GREATEST NUMBER OF CASUALTIES

“The best for the most with the available resources”

PRINCIPLES OF TRIAGE

 TREATMENT OF MULTIPLE CASUALTIES EXCEEDING THE AVAILABLE RESOURCES = LIMITED TO THE AMOUNT OF EQUIPMENT / PERSONNEL

 SORTING BY PRIORITY

 TREAT THE PREVENTABLE DEATHS BY PRIORITY (MARCH)

 ALSO GET THE WALKING WOUNDED BACK INTO ACTION

 GOAL TO DO THE MOST GOOD FOR THE MOST PEOPLE (SOME CASUALTIES WILL NOT RECEIVE NEEDED TREATMENT)

 THE LARGER NUMBER OF CASUALTIES OR THE FEWER RESOURCES TO RESPOND, THE MORE INCREASES THE IMPORTANCE OF ACCURATE TRIAGE

HISTORY – FIRST RECORD

FIRST APPLICATION ON NAPOLEON’S BATTLEFIELDS

BARON DOMINIQUE-JEAN LARREY (1766–1842), NAPOLEON’S SURGEON, ESTABLISHED AN AMBULANCE CORPS AND SYSTEM FOR PRIORITIZING WOUNDED FOR EVACUATION

WW I

CHEMICAL WARFARE AND MACHINE GUNS INCREASED THE NUMBER OF CASUALTIES and forced medics to use triage techniques to sort larger numbers of wounded

WW II

THE CONCEPT OF “BUDDY CARE” EMERGED

Every soldier was given a first aid kit & a tourniquet

KOREAN WAR

FIRST AERIAL EVACUATIONS

Mortality rates for soldiers sustaining wounds during combat decreased to less than 30%

VIETNAM WAR

Time from wounding to surgical care decreased from hours to minutes

PRESENT DAY

TRIAGE TOOK ON ITS MODERN FORM IN IRAQ AND AFGHANISTAN WARS

The troop mortality rate is less than 20%

TRIAGE NEEDS

 A DECISIVE PLAN

 SOMEONE TAKING CHARGE AND TASK ORGANIZING

 MEDICAL EQUIPMENT (initially you will never have enough)

 METHOD OF MARKING CASUALTIES

IT IS VERY IMPORTANT THAT CASUALTIES ARE PROPERLY MARKED

TRIAGE TOOLS

 ASSISTS GETTING A PROPER ACCOUNTABILITY OF CASUALTIES

 SHOWS CASUALTY WAS ALREADY CHECKED

 AVOIDS UNNECESSARY RECHECKING

TRIAGE DOCUMENTATION

 A PROPER DOCUMENTATION ON EACH CASUALTY

 A CASUALTY CARD PER CASUALTY

 MASTER TRACKER OF ALL THE CASUALTIES COVERING

 CASUALTY NUMBER

 WOUNDS SUSTAINED

 ASSIGNED TRIAGE GROUP

 EVACUATION PRIORITY

TRIAGE CATEGORIES

T1 – IMMEDIATE

THOSE CASUALTIES THAT NEED IMMEDIATE MEDICAL ATTENTION TO SAVE THEIR LIVES

 UNRESPONSIVE

 ALTERED MENTAL STATUS

 RESPIRATORY DISTRESS

 UNCONTROLLED HEMORRHAGE

 AMPUTATIONS PROXIMAL TO THE ELBOW OR KNEE

 SUCKING CHEST WOUNDS

 UNILATERAL ABSENT BREATH SOUNDS

 CYANOTIC PATIENT

 ABSENT OR VERY WEAK RADIAL PULSES

T2 – DELAYED

THOSE CASUALTIES WHO ARE IN NEED OF DEFINITIVE MEDICAL CARE, BUT SHOULD NOT DECOMPENSATE RAPIDLY IF CARE IS DELAYED INITIALLY

 DEEP LACERATIONS WITH BLEEDING CONTROLLED WITH GOOD DISTAL CIRCULATION

 OPEN FRACTURES

 ABDOMINAL INJURES WITH STABLE VITAL SIGNS

 AMPUTATED FINGERS

 STABLE HEAD INJURES WITH AIRWAY INTACT

T3 – MINIMAL

THOSE CASUALTIES WHO ARE WALKING WOUNDED

 VITAL SIGNS ARE STABLE

 REQUIRE MEDICAL ATTENTION BUT IT CAN BE DELAYED FOR DAYS, IF NECESSARY, WITHOUT ADVERSE EFFECT BECAUSE PATIENTS SUFFER FROM MINOR INJURIES TO INCLUDE:

 ABRASION

 CONTUSIONS

 MINOR LACERATIONS

 GET THEM BACK INTO ACTION!

T4 – EXPECTANT

THOSE CASUALTIES THAT HAVE LITTLE OR NO CHANCE FOR SURVIVAL DESPITE MAXIMUM THERAPY

 INITIALLY, RESOURCES SHOULD NOT BE DIRECTED TOWARDS THIS GROUP OTHER THAN COMFORT CARE

 AS THE TRIAGE EVENT PROGRESS AND RESOURCES BECOME AVAILABLE, EVERY EFFORT SHOULD BE FOCUSED ON SAVING THEM AS WELL

 DO NOT FORGET THEM!!!!!

DEAD

CASUALTIES THAT HAVE OBVIOUS FATAL WOUNDS AND NO SIGNS OF LIFE ARE TREATED AS T-4 AND EXPECTANT, UNTIL YOU CONFIRM THEY ARE DEAD DURING TRIAGE AND RE-TRIAGE

TREAT THESE CASUALTIES WITH THE UTMOST RESPECT!

TCCC IN RELATION TO TRIAGE

 TRIAGE ON THE BATTLEFIELD PRESENTS ITS OWN CHALLENGES THAT ARE DIFFERENT THAN IN A CIVILIAN ENVIRONMENT

 TRIAGE WILL VARY DEPENDING ON THE PRESENT PHASE OF TCCC

 CARE UNDER FIRE

 TACTICAL FIELD CARE

 COMBAT CASUALTY EVACUATION CARE

CARE UNDER FIRE

 FOCUS ON THE IMMEDIATE DANGER

 ELIMINATE THE THREAT

 IDENTIFY AND TREAT CASUALTIES WITH IMMEDIATE LIFE THREATENING INJURIES

 GET THE CASUALTY TO A MORE SECURE LOCATION

TACTICAL FIELD CARE

 ESTABLISH A SECURE PERIMETER

 EXPECT THE ENEMY TO COUNTER ATTACK WITHOUT WARNING

 CASUALTIES SHOULD BE PLACED INTO THE TRIAGE

CATEGORIES AND PRIORITIZED FOR EVACUATION

 PROVIDE CASUALTIES WITH HIGHER LEVEL OF CARE

 FOCUS ON T1 CASUALTIES FIRST

 REASSESS T2

 BUDDY CARE RENDERED TO THE TO GET THEM BACK IN THE FIGHT T3

COMBAT CASUALTY EVACUATION CARE

 CASUALTIES MUST BE RE-TRIAGED

 AS CASUALTIES ARE EVACUATED GREATER RESOURCES WILL BECOME AVAILABLE

 THE T4 GROUP SHOULD BE EVACUATED TO PROVIDE BETTER CARE

 IF EXCESS OF RESOURCES EXISTS, THEN RESUSCITATION SHOULD BE CONSIDERED

ASSESS THE SITUATION APPROACH

 ASSESS SITUATION “Is the scene safe?” From…

 ENEMY

 ENVIRONMENTAL ISSUES

 RETURN FIRE

 ESTABLISH SECURITY

 PRIORITIZE “How many casualties do I have?”

 ESTABLISH CCP – CASUALTY COLLECTION POINT

“Is the scene safe?”

CASUALTY COLLECTION POINT (CCP)

 THE ESTABLISHMENT OF A CCP IS VERY IMPORTANT TO SET UP PRIOR TO BEGINNING OF THE TRIAGE

 THE CCP SHOULD BE EASY TO DEFEND

 EVERYONE SHOULD KNOW WHERE IT IS

 ALSO EVERYONE SHOULD KNOW WHERE THE TRIAGE CATEGORIES ARE DESIGNATED IN THE CCP

 THE SENIOR MEDIC NEEDS TO SITUATE HIMSELF WHERE HE CAN OVERSEE EVERYTHING AND BE EASILY FOUND BY THE TRIAGE PARTY IF NEEDED

 THE JUNIOR AND SENIOR MEDIC NEED TO EASILY COMMUNICATE WITH EACH OTHER

 THE MEDEVAC HLZ SHOULD BE IN A CLOSE PROXIMITY OF THE CCP

 THE CCP LOCATION MAY CHANGE DEPENDING ON THE SITUATION

SALT3 TRIAGE PROCESS

 SORT

 ASSESS

 LIFE SAVING INTERVENTIONS

 TRIAGE: ASSIGN CATEGORY

 TREATMENT, FURTHER

 TRANSPORT

ANKARA EXPLOSION video

STEP 1 – SORT

GLOBAL SORTING

START BY GLOBALLY SORTING PATIENTS INTO GROUPS BASED ON VOICE COMMAND

 ASK: “IF YOU ARE INJURED AND CAN WALK PLEASE MOVE OVER TO ME”

 CASUALTIES WHO MOVED TO YOUR LOCATION HAVE THEM PROVIDE BUDDY AID TO THEMSELVES

THEN YOU SHOULD ASK:“IF YOU CAN, PLEASE WAVE YOUR HAND OR LEG, I WILL COME TO YOU”

 CASUALTIES THAT DO NOT RESPOND OR HAVE OBVIOUS LIFE THREATENING INJURIES SHOULD BE ASSESSED FIRST

 CASUALTIES THAT CAN WAVE AN ARM OR LEG SHOULD BE ASSESSED SECOND

 THEN REASSESS THE BUDDY AID CASUALTIES WHEN TIME PERMITS

 PRIORITY 1: STILL / OBVIOUS LIFE THREAT

 PRIORITY 2: WAVE / PURPOSEFUL MOVEMENT

 PRIORITY 3: WALKING

SYRIA EXPLOSION video

STEP 2 – ASSESS

INDIVIDUAL ASSESSMENT

SHOULD BE INITIATED ONCE CASUALTIES ARE SORTED ACCORDING TO STEP 1, THEN

 CASUALTIES ARE ASSESSED USING THE MARCHON ACRONYM

FOR:

 MASSIVE BLEEDING

 AIRWAY OBSTRUCTION

 RESPIRATORY IMPAIRMENT

 THESE PROCEDURES ARE TIME LIMITED, THE MEDIC SHOULD MOVE QUICKLY TO THE NEXT CASUALTY

 THIS STEP GOES HAND AND HAND WITH STEP 3

ASSESS IF THE CASUALTY

 HAS MAJOR UNCONTROLLED HEMORRHAGE

 OBVIOUS SEVERE BLEEDING

 NON-OBVIOUS: BLOOD SWEEPS

 HAS AIRWAY ISSUES

 OPEN AIRWAY

 LOOK / LISTEN / FEEL

 CONSIDER TWO BREATHS FOR NON-BREATHING

 IS IN RESPIRATORY DISTRESS

 EXPOSE AND INSPECT NECK AND CHEST LOOKING FOR PENETRATING / BLUNT TRAUMA

 OBEYS COMMANDS

 HAS RADIAL PULSE

MEDIC MUST ASSESS IF

 THE CASUALTY IS UNLIKELY TO SURVIVE GIVEN THE OBSERVED INJURIES AND AVAILABLE RESOURCES

 THE CASUALTY NEEDS LIFE SAVING INTERVENTION

 THE CASUALTY INJURIES APPEAR TO BE MINOR INJURIES FOR WHICH A DELAY IN CARE WILL NOT INCREASE MORTALITY

STEP 3 – LIFE SAVING INTERVENTION

STEP 3 GOES HAND IN HAND WITH STEP 2

IT IS LIMITED TO:

M: CONTROL MASSIVE BLEEDING

 TOURNIQUET

 PACK WITH GAUZE + APPLY PRESSURE BANDAGE

A: FREE AIRWAY

 OPEN BY POSITIONING THE HEAD AND OR BODY

(recovery position or sitting up)

 AIR WAY ADJUNCT – NPA, KING LT, CRIC

R: AVOID / TREAT TENSION PNEUMOTHORAX

 SEAL OPEN CHEST WOUNDS WITH OCCLUSIVE DRESSING

 NEEDLE DECOMPRESSION

STEP 4 – TRIAGE

T1 – IMMEDIATE

T2 – DELAYED

T3 – MINIMAL

T4 – EXPECTANT

DEATH

ASSIGN CATEGORY

 ASSIGN CASUALTIES TO 1 OF THE 5 CATEGORIES

 DO NOT CONFUSE TRIAGE CATEGORIES WITH MEDEVAC CATEGORIES, THEY ARE DIFFERENT

THIS PROCESS CAN BE POSTPONED UNTIL THE CASUALTIES ARE MOVED TO THE CASUALTY COLLECTION POINT

 PROPERLY MARK EACH CASUALTY WITH TRIAGE CATEGORY

 ASSIGN THE CCP TRIAGE SPECIFIC

 ASSIGN SOMEONE IN CHARGE OF EACH TRIAGE

SECTION

CASUALTIES WHO:

 DO NOT OBEY COMMANDS

 DO NOT HAVE A PERIPHERAL PULSE

 ARE IN RESPIRATORY DISTRESS

 HAVE UNCONTROLLED MAJOR BLEEDING

 HAVE AMPUTATION ABOVE THE KNEE OR ELBOW

» SHOULD BE TRIAGED AS T1- IMMEDIATE

CASUALTIES WHO:

 ARE STABLE

 NEED DEFINITIVE CARE

» SHOULD BE TRIAGED AS T2- DELAYED

CASUALTIES WHO HAVE:

 MINOR WOUNDS

 IF NOT TREATED CAN TOLERATE A DELAY IN CARE WITHOUT A INCREASE TO MORTALITY

» SHOULD BE TRIAGED AS T3- MINIMAL

THOSE CASUALTIES HAVING INJURIES THAT ARE LIKELY TO BE INCOMPATIBLE WITH LIFE GIVEN THE CURRENT AVAILABLE RESOURCES

» SHOULD BE TRIAGED AS T4- EXPECTANT

CASUALTIES THAT ARE NOT BREATHING EVEN AFTER LIFE SAVING INTERVENTIONS ARE ATTEMPTED

» SHOULD BE TRIAGED AS T4- EXPECTANT UNTIL YOU RE-TRIAGE AND CONFIRM THEY ARE DEAD

 THE DEAD SHOULD BE TREATED WITH THE UPMOST RESPECT

 THEY GAVE THE ULTIMATE SACRIFICE AND SHOULD BE TREATED WITH HONOR AND DIGNITY

STEP 5 – TREATMENT, FURTHER

MARCHON

IN A MASS CASUALTY SCENARIO IT IS ACCEPTABLE

 TREATMENT TO PATIENTS IS LIMITED TO WHAT YOU POSSESS

 CASUALTIES WILL PROBABLY NOT RECEIVE THE REQUIRED CARE THAT THEY NEED

 YOU HAVE A LOT GOING ON

 YOU ARE RESPONSIBLE FOR EVERYTHING THAT HAPPENS OR DOESN’T HAPPEN

 HAVE A PLAN, EXERCISE IT, BUT BE FLEXIBLE AND ADAPT TO CHANGES IN THE SCENARIO IN ORDER TO OVERCOME ANYTHING

 YOU HAVE TO HAVE PROPER ACCOUNTABILITY OF ALL YOUR CASUALTIES AND EQUIPMENT

 ENSURE THAT REASSESSMENT OF ALL PRIOR TREATMENTS IS CONDUCTED

 DON’T ALLOW UNNECESSARY TREATMENT TO TAKE PLACE, YOU ARE NOT CONDUCTING A PRIMARY SURVEY ON ONE INDIVIDUAL, MAKE SURE EVERYONE IS WORKING TOGETHER

 ENSURE THERE IS SOME ONE IN CHARGE OF EVERY TRIAGE SECTION

 USUALLY THE JUNIOR MEDIC IS OVERSEEING ALL CASUALTIES T1- IMMEDIATE

 ENSURE LSI’S HAVE BEEN PROPERLY CONDUCTED PRIOR TO MOVING ON TO FURTHER TREATMENTS

 JUNIOR MEDIC: YOU NEED TO SUPPORT THE SENIOR MEDIC AT ALL TIMES

 ASSIGN CASUALTIES TO PROPER EVACUATION PRIORITIES

 SEND MEDEVAC 9 – LINE IN A TIMELY MANNER

 SUPERVISE THAT EVERYTHING IS BEING DONE PROPERLY

 REMEMBER TO ENFORCE RE-TRIAGING AND PROPER TREATMENT OF CASUALTIES

STEP 6 – TRANSPORT

 THE IMPORTANCE ON PREPARING YOUR CASUALTIES FOR TRANSPORT CAN NOT BE OVERSTATED

 IT IS VERY CRITICAL THAT A PROPER 9 – LINE MEDEVAC REQUEST IS SENT IN A TIMELY MANNER

 SPECIAL EMPHASIS ON THE CORRECT NUMBER OF CASUALTIES BEING EVACUATED

 DO NOT FORGET ANYONE!!!

 TO INCLUDE THE DEAD

EVACUATION PRIORITIES

 DO NOT CONFUSES THE AIR EVACUATION PRIORITIES WITH THE SORTING PRIORITIES OF STEP 1

 SEND A PROPER ACCURATE 9-LINE AS SOON AS POSSIBLE

PATIENTS THAT NEED TO BE TRANSPORTED BY MEDEVAC SHOULD BE FURTHER SUBDIVIDED INTO EVACUATION PRIORITIES

 PRIORITY I: URGENT

 PRIORITY IA: URGENT – SURGICAL

 PRIORITY II: PRIORITY

 PRIORITY III: ROUTINE

 PRIORITY IV: CONVENIENCE

 PRIORITY I: URGENT

IS ASSIGNED TO PATIENTS THAT SHOULD BE EVACUATED AS SOON AS POSSIBLE, WITHIN MAXIMUM OF 2HRS IN ORDER TO SAVE LIFE, LIMB, OR EYE SIGHT, AND ALSO TO PREVENT COMPLICATIONS OF SERIOUS ILLNESS OR TO AVOID PERMANENT DISABILITY

 PRIORITY IA: URGENT – SURGICAL

IS ASSIGNED TO PATIENTS WHO MUST RECEIVE FAR FORWARD SURGICAL INTERVENTION TO SAVE LIFE AND STABILIZATION FOR FURTHER EVACUATION

PRIORITY II : PRIORITY

 IS ASSIGNED TO SICK AND WOUNDED PERSONNEL REQUIRING PROMPT MEDICAL CARE

 THIS PRECEDENCE IS USED WHEN THE INDIVIDUAL SHOULD BE EVACUATED WITHIN FOUR HOURS

 OR THEIR MEDICAL CONDITION COULD DETERIORATE TO SUCH A DEGREE THAT THE PATIENT BECOMES AN URGENT PRECEDENCE

 OR WHOSE REQUIREMENT FOR SPECIAL TREATMENT ARE NOT AVAILABLE LOCALLY OR WHO WILL SUFFER UNNECESSARY PAIN OR DISABILITY

PRIORITY III : ROUTINE

 IS ASSIGNED TO SICK AND WOUNDED PERSONNEL REQUIRING EVACUATION BUT WHOSE CONDITION IS NOT EXPECTED TO DETERIORATE SIGNIFICANTLY

 THESE CASUALTIES SHOULD BE EVACUATED WITHIN 24 HOURS

PRIORITY IV : CONVEINENCE

IS ASSIGNED TO PATIENTS FOR WHOM EVACUATION BY MEDICAL VEHICLE IS A MATTER OF MEDICAL CONVENIENCE RATHER NECESSITY

FURTHERMORE, EFFICIENT USE OF ASSETS MAY REQUIRE THE MIXING OF PATIENTS DESIGNATED WITH DIFFERENT PRIORITIES RATHER THAN TRANSPORTING THEM STRICTLY IN THEIR PRIORITY ORDER

Standard Evacuation Priorities

NATO / International Security Assistance Force (ISAF) Standard Operating Procedure

Governs operations in Afghanistan

Follows NATO doctrine

Specifies THREE CATEGORIES for casualty evacuation

A = urgent (2 hours)

B = Priority (4 hours)

C = Routine (24 hours)

WARNING

NEW PROCEDURE PROVIDES GUIDANCE TO AVOID THE OVERCALLING OF CAT “A”, OR URGENT, EVACUATIONS

Category A – Urgent (2 hours)

Critical, life-threatening injury such as…

 Significant injuries from a dismounted IED attack

 Gunshot wound or penetrating shrapnel to chest,abdomen or pelvis

 Any casualty with ongoing airway problem

 Any casualty with ongoing respiration difficulty

 Unconscious casualty

 Casualty with known or suspected spinal injury

 Casualty in shock

 Casualty with bleeding that is difficult to control

 Moderate / severe TBI

 Burns greater than 20%TBSA

Category B – Priority (4 hours)

Serious injury such as…

 Isolated, open extremity fracture with bleeding controlled

 Any casualty with a tourniquet in place

 Penetrating or other serious eye injury

 Significant soft tissue injury without major bleeding

 Extremity injury with absent distal pulse

 Burns 10-20% TBSA

Category C – Routine (24 hours)

Mild to moderate injury such as…

 Gunshot wound to extremity – bleeding controlled without

tourniquet

 Minor soft tissue shrapnel injury

 Closed fracture with intact distal pulse

 Burns <10%TBSA

REASSESSMENT / RE-TRIAGING

 ASSESSMENT & TRIAGE ARE DYNAMIC PROCESSES, WHEN A CYCLE IS COMPLETE VERIFY CONDITIONS TRATMENTS, CATEGORY & PRIORITY

 AS MORE RESOURCES BECOME AVAILABLE, MORE TRAINED MEDICAL PERSONNEL INCLUDED, ALL THE CASUALTIES SHOULD BE REASSESSED/ RE-TRIAGED

 REASSESSMENT AND RE-TRIAGING IS IMPORTANT SINCE PATIENTS CONDITIONS MAY CHANGE AND RAPID INITIAL EVALUATIONS MAY MISS IMPORTANT AND LIFE THREATENING INJURIES

START

Simple Triage And Rapid Treatment

SALT3 TRIAGE – IN CLOSING

 THE SALT3 TRIAGE IS RAPID METHOD WHERE A MINIMUM NUMBER OF RESOURCES & RESCUERS ARE INVOLVED

 INDIVIDUAL ASSESSMENT IS DEPENDENT ON THE PROVIDER’S SKILL LEVEL

 PRIORITIZATION FOR TREATMENT & TRANSPORT IS DYNAMIC AND MAY BE EFFECTED BY CHANGING PATIENT CONDITIONS, RESOURCES AND SCENE SECURITY

 UNFORTUNATELY IN A MASS CASUALTY SITUATION, YOU DON’T HAVE ENOUGH FOR EVERY CASUALTY AND THE GOAL HAS TO BE TO DO THE MOST GOOD FOR THE MOST PEOPLE

 THIS MAY MEAN THAT SOME INDIVIDUAL WILL NOT RECEIVE THE TREATMENT THAT THEY NEED IN THE TIME THAT THEY NEED IT

 ALSO, IF YOU DON’T HAVE A JOB, FIND A JOB!!!!

TRIAGE – WHAT NOT TO DO

 DO NOT CONSIDER TRIAGE COMPLETE AFTER INITIAL TRIAGE, RETRIAGE IS JUST AS IMPORTANT

 DO NOT IGNORE THE EXPECTANT CASUALTIES

 DO NOT PROVIDE COMPLEX MEDICAL CARE DURING THE TRIAGE PROCESS: DUE TO THE AMOUNT OF RESOURCES AND PERSONNEL AVAILABLE TREATMENTS WILL BE LIMITED

BOSTON ATACK INTERVENTION video

CONCLUSION

YOU SHOULD HAVE A GOOD GRASP OF

 PRINCIPLES OF TRIAGE

 THE DYNAMICS OF THE SALT3 TRIAGE

 A GOOD UNDERSTANDING ON HOW SALT3 IS EXECUTED AND MANAGING THE CONCEPT

 WHAT IS EXPECTED OF YOU AS A LEADER

Stay Safe My Brothers !

SEMPER FI

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