# OEMS, some tips...



## HNcorpsman (Jul 30, 2009)

hey so, while in the navy i have had the opportunity to go to OEMS (operational emergency medical skills) this course has been by far the BEST course i have ever attended in my entire life!!! im not exaggerating... the BEST... the class was taught by a retired army COL. his name is Dr. Hagmann. the class is also staffed with ALL Special forces medics... Navy seals, 18Delta, and SAS...  anyways i cant really go into details to much about the class but there was alot of learned tips and i would like to share some of them... some of you guys probably already know all this stuff but hey, if i can get to some of the other guys i have done something right? here it is...

*this is specifically for combat medics, and corpsman*

PT assessment
M-massive bleeding
A- airway
R- respiratory
C- circulation
H- head inj/hypothermia
O- open wound/infection
N- no pain/anesthesia 

tension pneumo thorax in a combat setting is VERY common, be aware that a classic sign is grunting upon exhalation... also the absence of bilateral chest rise and fall... JVD and tracheal deviation can happen up to two hours after the tension, so dont rely on it. you dont have to do needle decompression on the PTs chest.. you can also do it on the PTs axillary area... about  a palms width from the armpit... (better if PT is wearing a flak jacket.) dont ventilate a PT with tension Pneumo either, it will make it worse.

chest tubes must be done CLEAN!!! speed is NOT important... if you cant keep it clean, or dont have time. DONT DO IT!!

IVs- only give an IV if you can no longer feel the PTs radial pulse.... this is when the PTs blood pressure is so low that they MUST have IV fluids... this method is called hypotensive resuscitation. the idea is that giving fluids to a trauma PT with loss of blood will only make things worse... it will raise their blood pressure causing them to bleed more, and it will dilute their blood with water... either NS or LR... they are essentially the same thing. once they regain that radial pulse discontinue the IV. dont use 14g either... 16 or 18 is fine. use the fast 1 if you have it... it dosnt hurt THAT bad, i have had it done to me... in the sternum...

evisceration, if evac is longer than 2 hours put guts back in... if less than 2 taco.

these are just SOME of the things we learned... there is much more, much more... we also got to do IVs in the jugular using back pressure. IVs in the femoral using back pressure, FAST 1 IO (fun), we got to use lidocaine extensively while doing IVs and numbing the area in prep for a chest tube.


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## Afflixion (Jul 30, 2009)

HNcorpsman said:


> hey so, while in the navy i have had the opportunity to go to OEMS (operational emergency medical skills) this course has been by far the BEST course i have ever attended in my entire life!!! im not exaggerating... the BEST... the class was taught by a retired army COL. his name is Dr. Hagmann. the class is also staffed with ALL Special forces medics... Navy seals, 18Delta, and SAS...  anyways i cant really go into details to much about the class but there was alot of learned tips and i would like to share some of them... some of you guys probably already know all this stuff but hey, if i can get to some of the other guys i have done something right? here it is...
> 
> *this is specifically for combat medics, and corpsman*
> 
> ...



Don't mean to nitpick but you want to start a line 16ga or larger if you can get it as soon as you can. Waiting to start a line until they are in hypovolemic shock is a bad waste of time and you most likely guarenteed that mans death. One other thing, If you have time to use lidocaine on a chest tube chances are it could wait until the casualty is in definitive medical care. I'm three deployments down the road and have yet to do a chest tube in the field, done a few moonlighting in the CASH, but that's it.


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## HNcorpsman (Jul 30, 2009)

i hear yah... yeah definitely get the IV started but dont actually give the PT fluids until you loose the radial pulse... make sense? 

yeah the Dr. that taught us basically told us that you shouldn't do a chest tube in the field... there are just some cases where you might consider it... for example extremely long evac times, over 24 hrs. also the use of lidocaine is important because of the massive amounts of pain associated with pushing a giant plastic tube in someone pleural space... that much pain could cause that PT to crash. but yeah, if you dont have time to use lidocaine that you dont have time to do a chest tube. 

are you in the army? i know when i went to OEMS they sent a army medic, i think he was SF though...


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## mycrofft (Jul 31, 2009)

*Median time from call to dustoff to second echelon care makes the difference.*

Ech2 (Echelon 1 was [is?] self-aid/buddy care) is closer to battle area now and better commo and transport make a different ball game, where TK's are cool, and delaying some forms of rescusitation is good.
It's good that "lessons learned" aren't thrown away as they were after Nam, but flexibility is still needed to medically meet today's challenge instead of yesterday's.
Soldiers in Nam were initially given technology and practice basically from WWII, the difference between WWII, Korea then Nam being primarily the reduction in time from injury to definitive if "meatball" care (and widespread use of antibiotics) and much fatter suppply line with disposible plastic items.


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## Afflixion (Aug 2, 2009)

Roger, you are definitely going to hold off on fluid resuscitation until the Pt takes a turn for the worse. In regards to busting clots I believe the magic number for that is 93/P bp if I remember correctly. Yes, I'm in the Army and I have been through W1 ASI school.

In regards to Mycrofft, are you wondering the time for dustoff? In good conditions and depending on how far away you are from the base it's about 20-30m from the time you first spout out that 9-line on the net. Some placesd are quicker some are slower... Some damn medevac's feel the need to not monitor the net either... Also the Army has decided to make an entire center for "Army Lessons Learned" Took them long enough to realize that learnin from past mistakes is necessary


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## HNcorpsman (Aug 2, 2009)

20-30 mins!!! wow thats good!!

one of my buddies just got back from a embedded training team deployment in afghanistan and he said some medevacs were several hours, and thats the best they could do!


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## Afflixion (Aug 2, 2009)

Yeah, in Iraq medevac is well set every sheriff has at least 3 crews with ione on call 24/7. This has changed drastically since my first deployment in 05 out in Tikrit  at FOB Danger it would take hours... The problem is these modern day pilots don't fly if theres a cloud in the sky...


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## HNcorpsman (Aug 2, 2009)

yeah i hear that...


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## kecpercussion (Aug 2, 2009)

True true...most won't even leave ground cause of a little fog...but damn, still a really cool job


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## Afflixion (Aug 2, 2009)

military flight medics = Glorified Taxi drivers.... Us bullet sponges treat and stabilize...flight medics just fly them to the nearest MTF. Just one non-POG's experience and opinion though.


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## arsenicbassist (Sep 16, 2009)

*FYI on IV*



Afflixion said:


> Don't mean to nitpick but you want to start a line 16ga or larger if you can get it as soon as you can. Waiting to start a line until they are in hypovolemic shock is a bad waste of time and you most likely guarenteed that mans death. One other thing, If you have time to use lidocaine on a chest tube chances are it could wait until the casualty is in definitive medical care. I'm three deployments down the road and have yet to do a chest tube in the field, done a few moonlighting in the CASH, but that's it.



Fluid resuscitation in the field is about worthless unless you're going to sit on it for a lengthy period. Studies show that around 63% of GSW pts survived after recieving IV fluids in the field....while around 70% survived with no fluids. Point being, don't waste time unless you are certain. And if you're going to, at least go with Hetastarch...500cc to start, but no more than 1000cc total.

Cheers


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## arsenicbassist (Sep 16, 2009)

*NS and LR...the same?*



HNcorpsman said:


> hey so, while in the navy i have had the opportunity to go to OEMS (operational emergency medical skills) this course has been by far the BEST course i have ever attended in my entire life!!! im not exaggerating... the BEST... the class was taught by a retired army COL. his name is Dr. Hagmann. the class is also staffed with ALL Special forces medics... Navy seals, 18Delta, and SAS...  anyways i cant really go into details to much about the class but there was alot of learned tips and i would like to share some of them... some of you guys probably already know all this stuff but hey, if i can get to some of the other guys i have done something right? here it is...
> 
> *this is specifically for combat medics, and corpsman*
> 
> ...



Be mindful...NS and LR are not the same thing. Essentially, LR is converted to Bicarb in the liver and is a good choice for combating systemic acidity. Probably wouldn't be a big deal in the short scheme of things, but if you're gonna sit on someone for a while, it's probably a good thing to know.

Cheers


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## mycrofft (Sep 17, 2009)

*In WII they used the original colloid...plasma.*

But evac to care beyond a dressing station could take days.


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## arsenicbassist (Sep 17, 2009)

very true....use caution always.


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## Afflixion (Sep 17, 2009)

arsenicbassist said:


> Fluid resuscitation in the field is about worthless unless you're going to sit on it for a lengthy period. Studies show that around 63% of GSW pts survived after recieving IV fluids in the field....while around 70% survived with no fluids. Point being, don't waste time unless you are certain. And if you're going to, at least go with Hetastarch...500cc to start, but no more than 1000cc total.
> 
> Cheers



The reasoning behind not to give more than 1L of hetastartch is rationing of supplies. You must ensure that you wait for ten to fifteen minutes prior to starting the second bag of hetastartch as it takes some time for it to work. The reason why I stated to start a line is because though in fancy civilian hospitals they change out the line when they get to the hospital in a CSH they keep that line until they get evac, and I don't know about others but I can start a line in a few seconds, there isn't much time wasted there. One should always remember BLS before ALS though. Your going to have some time to wait for that bird even if medevac conditions are all green it will still take fifteen minutes minimum for that bird to get to you provided your reasonably close to a FOB with medevac. also IO with the FAST1 is acctually quite fast just palpate the angle of louis use the introducer and hook up your line and your good to go.


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## Akulahawk (Sep 17, 2009)

arsenicbassist said:


> Fluid resuscitation in the field is about worthless unless you're going to sit on it for a lengthy period. Studies show that around 63% of GSW pts survived after recieving IV fluids in the field....while around 70% survived with no fluids. Point being, don't waste time unless you are certain. And if you're going to, at least go with Hetastarch...500cc to start, but no more than 1000cc total.
> 
> Cheers


A problem with administering Hetastarch while it does work, you must be careful that you don't over administer it. You could end up with enough fluid in the vascular system that you raise the BP to the point where you pop the clot and your patient begins bleeding again... Permissive hypotension allows for the clot to stabilize and you provide only enough fluid to keep things going... so to speak.

One of the good outcomes from combat operations is that a LOT is learned about field trauma care...


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## arsenicbassist (Sep 17, 2009)

Akulahawk said:


> A problem with administering Hetastarch while it does work, you must be careful that you don't over administer it. You could end up with enough fluid in the vascular system that you raise the BP to the point where you pop the clot and your patient begins bleeding again... Permissive hypotension allows for the clot to stabilize and you provide only enough fluid to keep things going... so to speak.
> 
> One of the good outcomes from combat operations is that a LOT is learned about field trauma care...



Excellent point. That, in my opinion, is the true reason for not administering over 1L. While it is an excellent volume expander, it brings with it a whole new chain of complications.


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## Akulahawk (Sep 17, 2009)

From memory: Hetastarch, when used as a volume expander, will ultimately draw about 3x the amount of what's infused into the bloodstream. So... your 500 mL infusion results in about a 1500 mL expansion of fluid drawn into the intravascular space at about 1 hour post administration. Conversely, of 1000 mL of NS or LR infused into the intravascular space, results in about 300 mL retained fluid in that intravascular space. IMHO, you can maintain better control of blood volume with regular crystalloid fluids than you can with colloidal fluids. Of course, the colloidal fluids do take less space in the pack than crystalloids do, for a given end result.

I'd probably prefer to use 250 mL or 500 mL hespan bags due to weight/size considerations and just be judicious in administering that fluid, under combat conditions. Remember that most persons in combat will be younger... and better hydrated. If the patient is already dehydrated... there won't be as readily available reservoir of fluids to draw into the intravascular space from the other fluid compartments.


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## arsenicbassist (Sep 17, 2009)

Akulahawk said:


> From memory: Hetastarch, when used as a volume expander, will ultimately draw about 3x the amount of what's infused into the bloodstream. So... your 500 mL infusion results in about a 1500 mL expansion of fluid drawn into the intravascular space at about 1 hour post administration. Conversely, of 1000 mL of NS or LR infused into the intravascular space, results in about 300 mL retained fluid in that intravascular space. IMHO, you can maintain better control of blood volume with regular crystalloid fluids than you can with colloidal fluids. Of course, the colloidal fluids do take less space in the pack than crystalloids do, for a given end result.
> 
> I'd probably prefer to use 250 mL or 500 mL hespan bags due to weight/size considerations and just be judicious in administering that fluid, under combat conditions. Remember that most persons in combat will be younger... and better hydrated. If the patient is already dehydrated... there won't be as readily available reservoir of fluids to draw into the intravascular space from the other fluid compartments.



3x may be a stretch, but don't quote me...i think it's more along 1.5-2x. Still a fairly large amount in the long run.... In combat, when you have a guy who's lost 3 liters, do you really have enough crystalloids to replace that? or even give him a reasonable chance or survival? Which takes us back to the length of time for some MEDEVACS to arrive...1 hour might not be the time you're getting, it may be a lengthy time. I suppose this may be more of a situation dependent type of choice. If they're your guys, you should already be making sure they are well-hydrated warriors. All good points that are brought up though. I just don't think any medic is carrying around 9 bags of NS or LR to replace large quantities of fluid over long periods of time. I tend to roll with 1L LR, 1.5L NS, and 1L Hetastarch... sometimes with some Dex, depending on how I feel about things, all by personal choice, with my operators each carrying their own 500mL Hetastarch. Keep the faith though guys...I like hearing people discuss things like this...we're only making military medicine better.


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## arsenicbassist (Sep 17, 2009)

or if you're really feeling saucy....try something like 6% NS in Dextran.... it's about 7 times more effective than 0.9%, with less of a chance of normal anion gap metabolic acidosis. extreme hypertonics are an amazing thing if you can get your hands on them.


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## Akulahawk (Sep 17, 2009)

arsenicbassist said:


> 3x may be a stretch, but don't quote me...i think it's more along 1.5-2x. Still a fairly large amount in the long run.... In combat, when you have a guy who's lost 3 liters, do you really have enough crystalloids to replace that? or even give him a reasonable chance or survival? Which takes us back to the length of time for some MEDEVACS to arrive...1 hour might not be the time you're getting, it may be a lengthy time. I suppose this may be more of a situation dependent type of choice. If they're your guys, you should already be making sure they are well-hydrated warriors. All good points that are brought up though. I just don't think any medic is carrying around 9 bags of NS or LR to replace large quantities of fluid over long periods of time. I tend to roll with 1L LR, 1.5L NS, and 1L Hetastarch... sometimes with some Dex, depending on how I feel about things, all by personal choice, with my operators each carrying their own 500mL Hetastarch. Keep the faith though guys...I like hearing people discuss things like this...we're only making military medicine better.


 Here's exactly why Military Combat Medicine is taking the lead in trauma care. When you're dealing with an extended evac time, the normal rules just don't apply... and you have to seriously begin to worry about perfusion to end-organs while not popping the clot. The Trauma Docs are learning TONS about this and training the field medics and corpsmen what has been learned. I just hope that some of what has been learned can be readily translated back into the civilian world for better trauma care.


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## arsenicbassist (Sep 17, 2009)

It's comin', it's comin'...I've seen a few places implementing some "new" methods. I must admit that I learn a great deal from all of the people in this forum. Not because we're all insane medical genuises...but because we've all had different experiences and we're not too stubborn to learn from our brethren.


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## HNcorpsman (Sep 18, 2009)

it will probably be a good 10 years before some of these new methods are used... In all honesty i don't see a big difference between the uses of NS and LR... If I have a Pt who is bleeding internally i will NOT give them IV fluids!! now if they have a extremity amputation, but i stop the bleeding i might consider giving them 500 mL... but no more... Like what has been said before you really don't want to risk popping that clot, the bodies BP goes down for a reason when someone looses blood... the lower the blood pressure the easier it is too clot... like i have said before if they have that radial pulse then there pressure is high enough to maintain life... once you loose it give the fluids until you regain the pulse... simple as that!


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## Summit (Sep 18, 2009)

What is hetastarch exactly?

And this thread is a very interesting read from the wilderness point of view.



arsenicbassist said:


> Fluid resuscitation in the field is about worthless unless you're going to sit on it for a lengthy period. Studies show that around 63% of GSW pts survived after recieving IV fluids in the field....while around 70% survived with no fluids. Point being, don't waste time unless you are certain.



That's rather uninformative statistic. What percentage of the 70% would have indicated IV resus and for the 63% did they receive adequate and are these numbers controlled for confounding variables?


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## arsenicbassist (Sep 18, 2009)

Summit said:


> What is hetastarch exactly?
> 
> And this thread is a very interesting read from the wilderness point of view.
> 
> ...



I think the same thing myself. I'm sure there are certain variables that push one way or the other. Regardless, we've all thrown in some interesting things and have probably learned a thing or two...or at least questioned a thing or two. My guess would be a lot of the mistakes occur from blowing the clot or treating too aggressively. And from wilderness type SAR, check out hypertonics such as 6% NS in Dextran, makes for a good read if you're sitting for patients over a long period. 

Remote EMT-P


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## arsenicbassist (Sep 18, 2009)

Hetastarch is a colloidal VE with a half-life of about 30 hours. Last a good long while. We basically use it because it causes a significant increase in circulating volume. Great for unit tactics. There are some good reads on it, and occassionally you can find a non-military physician who can tell you a little more about it. I'd write more, but I'm having dinner. I'll get back later on it though.


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## HNcorpsman (Sep 18, 2009)

but he is absolutely right... in the field, in combat having IV access is not important, unless the evac will be longer than 2 hours... when i go out on patrols... i will take my M9 med bag (very small) but all i have in it is, mainly tourniquets , cinch tights, quick clot, NPAs, King Lt, surgical kit i maid, bowline chest seal, 14g extra long needle cath for tension pneumo, you know just the quick stuff... and then in the convoy vic's i will have my big med bag with usually 4 IVs, morphine, other what nots. then back at the FOB/COP i will have my set up... kind of like little echelons in the first echelon on care...


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## Akulahawk (Sep 18, 2009)

arsenicbassist said:


> I think the same thing myself. I'm sure there are certain variables that push one way or the other. Regardless, we've all thrown in some interesting things and have probably learned a thing or two...or at least questioned a thing or two. My guess would be a lot of the mistakes occur from blowing the clot or treating too aggressively. And from wilderness type SAR, check out hypertonics such as 6% NS in Dextran, makes for a good read if you're sitting for patients over a long period.
> 
> Remote EMT-P


HSD is an interesting idea... and has been studied somewhat. It's been a while since I've seen any studies...


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## arsenicbassist (Sep 18, 2009)

I've only come across a few of them, but if I come upon some I'll post the links on here.


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## Luno (Sep 19, 2009)

*Summit*



Summit said:


> What is hetastarch exactly?
> 
> And this thread is a very interesting read from the wilderness point of view.
> 
> ...



Actually it's a very informative statistic, however there are pieces missing, I'll try to locate the study again, but it's Vietnam era stuff, and if I remember correctly the study was concerning penetrating torso trauma, rather than extremity GSW.


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## newguy (Oct 6, 2009)

*i loved OEMS, buttttt..........*

Man I loved OEMS, just loved it. And for me not being an EMT or a Military Medic it was an EYE opener and I LEARNED SO MUCH!!! I did the course on Wheeler Army Airfield, HI next to Schofield. I was on a waiting list for 2 years, and YES it was worth the wait. 

i loved OEMS but this chick (Army medic) complained about the "training aids" that was used for the class, and it went on the news and the course is no longer offered to 25ID.


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## HNcorpsman (Oct 7, 2009)

did you go through the longer course (week long lecture and pig lab) or just the pig lab? was Dr. Hagmann there? yes, i agree, OEMS was definitally the best class/course i have every taken in my entire life, lectures where very pertinent, and usefull, and the lab was invaluable... thankfully the military paid for me to fly from japan to NC, and payed for the class as well... haha i had a good time, now im saving lives in Afghanistan with the techniques Dr. hasgmann taught and gave me, i am a better corpsman and a better EMT just by taking that course...


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## newguy (Oct 7, 2009)

HNcorpsman said:


> did you go through the longer course (week long lecture and pig lab) or just the pig lab? was Dr. Hagmann there? yes, i agree, OEMS was definitally the best class/course i have every taken in my entire life, lectures where very pertinent, and usefull, and the lab was invaluable... thankfully the military paid for me to fly from japan to NC, and payed for the class as well... haha i had a good time, now im saving lives in Afghanistan with the techniques Dr. hasgmann taught and gave me, i am a better corpsman and a better EMT just by taking that course...



hey doc whats up? hey i took the standard 2 week course. yes Doc Hagmann was there so were some Army SF Medic and i think there was a couple of PMC Medic. I did the pig lab too, can't talk much about it..you know how it is..but you're right, definately the best class I've ever been to.

hopefully after i get my NREMT-P I can get a job as a PMC Medic. Keep doing good things in A'Stan, Iraq is pretty quiet right now...


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## HNcorpsman (Oct 8, 2009)

cool, cool, when i went there were 4 FMF corpsman including us, 3 PJs and a couple of SEAL corpsman... righto, im ready to slay the taliban from here to pakistan...


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## newguy (Oct 14, 2009)

hahaha i don't want to slay...but if i have to i'd rather do it in the private sector were they have better weapons and gear and a better pay check. we all fight for the same thing, i just want to get paid more. cause honestly...i don't think (we) military personnel are getting paid enough while we're out in front lines...


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## HNcorpsman (Oct 14, 2009)

i just get mad when someone in kuwait gets the same entiltlements as i do... im here on the FRONT lines of afghanistan, going on convoys and patrols getting shot at almost every other day, while at the same time some guy in kuwait gets the same hostile fire pay, and harzadous duty pay as i do yet, has never shot his weapon or been fired upon... WTF?? im not mad at the person just the people who decide the pay entitlements.


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## newguy (Oct 14, 2009)

HNcorpsman said:


> i just get mad when someone in kuwait gets the same entiltlements as i do... im here on the FRONT lines of afghanistan, going on convoys and patrols getting shot at almost every other day, while at the same time some guy in kuwait gets the same hostile fire pay, and harzadous duty pay as i do yet, has never shot his weapon or been fired upon... WTF?? im not mad at the person just the people who decide the pay entitlements.



dude, i'm on the same page as you are. there should be different pays, front line pays and then support personnel pay. but then again when i see paw prints, triple canopy, aegis and other contractors...i get a little jealous...better weapons, gear and pay. its like private school (PMCs) vs. private school (military). rather than paying PMCs, they should focus the money on military personnel.


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