Bonus Chapters Flashcards

Question

Define INDIRECT (OFF LINE) medical oversight

Answer 1

Off-line processes such as: - protocol development - quality improvement - personnel education - prospective + retrospective patient care review

Answer 2

BLS - provision of emergency care without the use of advanced therapeutic interventions ALS - Provider skills include advanced airway interventions, intravenous line placement, medication administration, cardiac monitoring and 12-lead electrocardiographic (ECG) interpretation, and certain invasive procedures.

Answer 3

designed to prevent or reduce the need for EMS calls and decrease ED utilization for targeted patients or frequent users

Answer 4

Responsible for ascertaining the primary medical condition and severity

Answer 5

= physician with specialized interest and knowledge of patient care activities unique to the prehospital environment - administrative authority to implement patient care protocols - interact with all aspects of the system - remove a provider from practice if medical care or behaviour is substandard

Answer 6

Complete certification (risks & benefits) of transfer Informed consent obtained from patient or family Appropriate transportation (equipment & personnel) arranged Treatment & stabilization performed Acceptance from receiving facility ensured Appropriate patient care data sent (faxed or with patient)

Answer 7

Boyle's Law = volume of a unit of gas is inversely proportional to its pressure - hypoxia at altitude due to fewer molecules of oxygen present per volume of inhaled gas. Dalton's Law = total barometric pressure at any given altitude equals the sum of the partial pressures of gases in the mixture - A decrease in arterial oxygen tension with increasing altitude, resulting in hypoxia.

Answer 8

Temperature fluctuations - changes metabolic rate and O2 consumption Dehydration - monitor fluids, get humidified air Noise - hearing protection Vibration

Answer 9

ADVANTAGE: Transport time <75% ground time Larger service area Avoid common traffic delays and ground obstacles Access usually inaccessible rural & remote locations DISADVANTAGE: Helicopter landing zone requirement more difficult than ground Noise & Vibration Weather limits availability Confined space for transporting pts and equipment, and performing procedures

Answer 10

ADVANTAGES: Increased range & speed Greater patient, crew, and equipment capacity Decreased cabin noise & turbulence Pressurized cabin DISADVANTAGES: Limited to areas w/ airports & runways, & refuelling stations Pts require multiple vehicles for each length of trip to hospital

Answer 11

Vehicles & personnel should >100ft (30m) from landing zone Spectators should be kept >200ft (61m) from landing zone No smoking or running <50ft (15m) of helicopter All items (IV lines, poles) should be kept below shoulder height Only flight crew opens & closes aircraft doors Only flight crew directs & supervises loading & unloading of patient & equipment Ground personnel should use eye & ear protection. Approach helicopter only when signalled to by pilot or onboard crew member Approach & depart helicopter only forward of rear cabin door & in crouched position with head down Never approach or depart from rear of helicopter Stay clear of tail rotor If aircraft is parked on slope, approach & depart on downhill side (greatest clearance under blades) Keep landing zone clear of (or hold on to) all loose articles (hats, scarves, sheets, pillows) Protect patient from dust and debris. Follow flight crew’s instructions at all times In disaster situations and mass casualty incidents, victims, witnesses, and spectators may become hysterical or exhibit signs of an acute situational reaction. These individuals must be kept clear of the landing zone and helicopter at all times. Injured victims who exhibit this behaviour should not be triaged for helicopter transport, or they should be transported only with adequate physical or chemical restraints in use. If you do not know if an action is safe, ask before you act.

Answer 12

LANDING AREA: Landing zone should be as close as possible to the scene or hospital entrance but not so close that it may interfere with ground operations or patient care. Landing zone should be at least 100 × 100 ft (30 × 30 meters) in area. Landing zone should be as flat and level as possible. Landing zone must be clear of debris. HAZARDS & OBSTRUCTIONS: Identify all potential hazards that may be on the ground or near the approach/departure path of the landing zone. Landing zone should be clear of wires, poles, trees, buildings, vehicles, and spectators. Road cones, ropes, tape, and barricades are not recommended for use near landing zone. Perimeter of landing zone should be at least 50 ft away from potential obstructions and hazards. Landing zone should be located upwind from any hazardous material incident. APPROACH & DEPARTURE PATHS: Path should point into the wind and be free of obstruction to an altitude of 500 ft (152 meters) above the surface. Path should not pass over command posts, treatment areas, or operationally congested areas on the ground. DAY OPERATIONS: Use radio communications and hand signals. Stand with your back to the wind. NIGHT OPERATIONS: Use radio communications and lighting to designate landing zone. Spotlights should be directed at the top of possible hazards, not toward the approaching or departing aircraft. Position a portable light, vehicle headlights, emergency vehicle flashing lights, flare, or chemical stick at each corner, with a fifth light upwind. Nonessential lights should be turned off. LIGHT SOURCES: Lights must be clear of landing zone. If portable, lights must be well secured. Never point lights toward an approaching or departing helicopter. WIND INDICATOR: Indicator may be a windsock, flag, flare, or smoke. Indicator must be clear of landing zone. If portable, indicator must be well secured.

Answer 13

Distance to closest appropriate facility is too great for safe & timely transport by ground Patient’s clinical condition requires that time spent in transport be as short as possible Patient’s condition is time critical, requiring specific or timely treatment not available at referring hospital Potential for transport delay associated w/ ground transport is likely to worsen patient’s clinical condition. Patient requires critical care life support during transport that was not available from local ground ambulance service Patient is located in area inaccessible to regular ground traffic Local ground units are not available for long-distance transport. Use of local ground transport services would leave local area without adequate EMS coverage. For interfacility medical transport, requesting physician determines need for AMT. For scene medical transport, the requesting authorized out-of-hospital provider determines need for AMT

Answer 14

GCS <14 RR <10 or >29 SBP <90 Unstable chest wall fractures Suspected HTX or PTX Paralysis Multisystem trauma (>2 body regions injured)

Answer 15

1) Mitigation 2) Preparedness 3) Response 4) Recovery

Answer 16

When demand exceeds available resources

Answer 17

Staff - hospital personnel Stuff - supplies & pharmaceuticals Structure - physical location & management infrastructure

Answer 18

Severe supply and demand mismatch where the need for resources exceeds the supply

Answer 19

RPM = Respirations Perfusion Mental status

Answer 20

1) those who will most likely die despite available care 2) those who will survive without care 3) those who will benefit from austere field interventions

Answer 21

= Secondary Assessment of Victim Endpoint Used to identify patients who are most likely to benefit from care available under austere field conditions or in a resource-poor environment. For use by: 1) for those working within disaster zone that begin caring for patients immediately but may not be able to transport patients to a definitive care facility for days 2) for those caring for patients within hospitals where demand for resources exceeds supply

Answer 22

Elderly Young children Nursing home residents Deaf people People w/ physical disabilities Non-English speaking Homeless Mentally ill Racial & Ethnic minorities

Answer 23

1. Incident command - Responsible for overall management of incident - Not a physician - Can appoint command staff to manage public information, safety, and interagency coordination 2. Operations section - Manages incident tactical activities - Manages the resources assigned to staging areas - Medical care and triage fall within this section 3. Planning section - Collects, evaluates, and disseminates information about incident operations and the status of resources - Develops incident action plans - Conducts planning meetings 4. Logistics section - Provides facilities, services, and material in support of the incident - Procures equipment and supplies - Provides food and medical support - Arranges for transportation needs 5. Finance section - Maintains records on personnel and equipment - Provides payments to vendors for supplies and use of equipment - Determines the cost of various alternatives for strategic planning

Answer 24

- Closer to ground because shorter - Higher respiration rate compared to adults - Greater surface area to volume ratio - Thinner skin - Smaller fluid reserves - Higher metabolic rates

Answer 25

CHEMICAL Nerve agents - Sarin - Soman - Tabun - VX - Mustard agent - Novichok agent BIOLOGIC - Anthrax - Plague - Smallpox - Botulism - Viral hemorrhagic fever - Tularemia RADIOLOGIC - Simple device - Dispersal device

Answer 26

Fear of unknown or unfamiliar Lack of training for hospital personnel Lack of equipment, PPE and diagnostic aids Potential for mass casualties Psychological casualties Crime scene requiring evidence collection and interaction with law enforcement Potential for ongoing morbidity and mortality (dynamic situation)

Answer 27

- damage at DNA level - occurs quickly, symptoms in hrs-days - cutaneous (burns) - hematologic (bone marrow failure) - gastrointestinal (vomiting and GIB) - @extreme doses, neurologic (seizure, coma, death)

Answer 28

1) Irradiation - like getting CXR - not radioactive, no risk to others 2) Internal contamination - Radioactive material in body (lungs, GI tract) - Isolation room, collect all secretions & body fluids - can take meds to limit uptake or facilitate removal of certain radioactive elements 3) External contamination - Radioactive material on skin & clothing - Need to remove clothes and wash w/ warm water + soap

Answer 29

Dosimeters - which measure the amount of radiation received by the wearer

Answer 30

- can increase KI to full adult dose in peds close to 70kg - Monitor TSH + T4 in neonates - Nonpregnant adults >40yrs also unlikely to benefit from tx, so can withhold unless doses over 5Gy (500cGy) are received

Answer 31

SYNDROMES: - Pulmonary symptoms - PNA - Rashes - Sepsis syndrome - ILI symptoms EPIDEMIOLOGY: - Multiple, simultaneous events - Dead animals - Large numbers of patients w/ high toxicity and death rate

Answer 32

Isolate pt in single room w/ adjoining anteroom Have handwashing facilities & PPE available in anteroom Use negative air pressure if possible Use strict barrier precautions: PPE, gowns, gloves, HEPA filter respirators, shoe covers, protective eyewear, N95 masks, or powered air purifying respirator (PAPR) Alert hospital departments that generate aerosols: Laboratory (centrifuges), pathology (autopsies) For some agents (Ebola) all skin surfaces must be covered by PPE

Answer 33

ANTHRAX - Cutaneous = Contact precautions - Pulmonary & GI = Standard precautions BOTULISM - Standard precautions PLAGUE - Standard & Droplet precautions SMALLPOX - Standard, Contact, & Airborne precautions TULAREMIA - Standard precautions VIRAL HEMORRHAGICS - Standard, Contact, & Airborne precautions

Answer 34

Anthrax - Bacillus anthracis Botulism - Clostridium botulinum toxin Plague - Yersinia pestis Smallpox - Variola major Tularemia - Francisella tularensis Viral Hemorrhagic Fevers - Filoviruses (Ebola, Marburg - Arenaviruses (Lassa, Machupo)

Answer 35

Spores germinate inside macrophages Bacteria multiple in Tracheobronchial LNs D2-10 have ILI, malaise, fever, cough Can develop to: - Sepsis - Shock - Hemorrhagic mediastinitis - Dyspnea - Stridor CXR can have wide medastinum & hilar LNA - Bloody pleural effusions - Consolidation Hemorrhagic MENINGITIS in 50% Death by D3 common

Answer 36

Papule > Large vesicle Severe edema around lesion & Regional lymphadenitis Lesion ruptures @ D7, forms Black Eschar Either eschar sloughes off & illness resolves or disseminates & pt dies

Answer 37

Sore throat Neck swelling Cervical & Submandibular lymphadenitis Fever Dysphagia Respiratory distress N/V Fever Mesenteric lymphadenitis Severe abdo pain Hematemesis Ascites Bloody diarrhea

Answer 38

ALL DOSES x7-10d ADULTS - Ciprofloxacin 500mg PO BID or - Doxycycline 100mg PO BID or - Amoxicillin 500mg PO TID PEDS - Cipro 20-30 mg/kg/d PO divided BID (max 1g) or - Doxy 4.4mg/kg/d PO divided BID (max 200mg) or - Amox 20-40mg/kg/d PO divided TID (max 1500mg)

Answer 39

TREAT x60d or until 3x Vaccine doses ADULTS - Ciprofloxacin 400mg IV q12h or - Doxycycline 100mg IV q12h or - Penicillin G 4mill units IV q4h PEDS - Cipro 20mg/kg/d IV divided q12h (max 800g) or - Doxy 4.4mg/kg/d IV divided q12h (max 200mg) or - Penicillin G 250-400 units/kg/d IV divided q4h (max 24mill units) ------------------ Choose 1 above, then add 2nd drug Linezolid or Clindamycin for protein synthesis inhibition If YES Meningitis, then add 3rd drug Meropenem, for CNS penetration ALL MEDS GIVEN IV UNTIL TOXICITY RESOLVES, then switch to ORAL

Answer 40

TREAT x60d or until 3x Vaccine doses ADULTS - Ciprofloxacin 500mg PO BID or - Doxycycline 100mg PO BID or - Amoxicillin 500mg PO TID PEDS - Cipro 20-30 mg/kg/d PO divided BID (max 1g) or - Doxy 4.4mg/kg/d PO divided BID (max 200mg) or - Amox 20-40mg/kg/d PO divided TID (max 1500mg)

Answer 41

3x doses on D0, 14, 28 Complete course reqs 18mos

Answer 42

1) Pneumonic 2) Bubonic 3) Septicemic

Answer 43

Sudden onset Fever, Chills, ILI Fulminant PNA - classically lobar - can be ARDS Progresses to Hemoptysis, Systemic toxicity, Respiratory failure, Circulatory collapse, and Death Coagulopathy, DIC Acral gangrene = Black Death

Answer 44

Bacilli multiply in regional LNs Result in large tender Buboes Fever/Chills Weakness Can disseminate in 50%, get septicemic plague or secondary pneumonic plague and die if they are untreated

Answer 45

Endotoxemia Shock DIC Coma

Answer 46

First 48hrs - but up to 4d for Respiratory

Answer 47

ALL DRUGS x10d at least IV TX: ADULTS - Streptomycin 1g IM q12h - Gentamicin 5mg/kg IM/IV q24h - Doxycycline 100mg IV q12h - Ciprofloxacin 400mg IV q12h - Chloramphenicol 25mg/kg IV q6h PEDS - Streptomycin 15mg/kg IM q12h (max 2g/day) - Gentamicin 2.5mg/kg IM/IV q8h - Doxycycline 2.2mg/kg IV q12h (max 200 mg/day) - Ciprofloxacin 15mg/kg IV q12h (max 800mg/day) - Chloramphenicol 25mg/kg IV q6h --------------------------- PO TX: ADULTS - Doxycycline 100mg PO BID - Ciprofloxacin 500mg PO BID - Chloramphenicol 25mg/kg PO QID PEDS - Doxycycline 2.2mg/kg PO BID - Ciprofloxacin 20mg/kg PO BID - Chloramphenicol 25mg/kg PO QID --------------- Pregnant Women can have all above except Streptomycin & Chloramphenicol

Answer 48

From onset of rash until scabs fall off = 1-2wks

Answer 49

4 Types = Variola Major & Minor, Hemorrhagic & Malignant (flat) Inhale virus, goes to LNs Asymptomatically spreads to spleen, bone marrow, lymphoid tissue, liver 8-12d later get Fever, prostration, HA Maculopapular rash > Vesicles > Pustular - leaves pitted scars

Answer 50

Chickenpox spreads trunk > extremities & face - different stages of healing vesicles Smallpox spreads face & arms > trunk & legs - all lesions at same stage

Answer 51

MAJOR: 1) Febrile prodrome: - ≥38.3 - 1–4d prior to rash onset w/ at least prostration, HA, backache, chills, vomiting or severe abdo pain 2) Classic smallpox lesions: - Deep-seated, firm/hard, round well-circumscribed vesicles or pustules - may umbilicate or become confluent 3) Lesions in same stage of development: - On any one part of body all lesions in same stage MINOR: 1) Centrifugal distribution of lesions 2) First lesions on oral mucosal palate, face, or forearms 3) Patient appears toxic or moribund 4) Slow evolution of lesions from macule>papule>vesicle (1–2d each stage) 5) Lesions on palms & soles -------------------- LOW RISK: - NO febrile prodrome or - Febrile prodrome + <4 Minor MODERATE RISK: - Febrile prodrome + 1 other Major or - Febrile prodrome + =/>4 Minor HIGH RISK: - ALL 3 Major

Answer 52

Vaccination of susceptible population - Vax immunocompetent pt w/in 3d of exposure, can prevent dz - Vax w/in 7d may prevent death Pts w/ dz should also isolate at home if well (enough), as dz untreatable

Answer 53

Pregnant women People w/ eczema HIV+ Malignant disease Chronic steroid use Hereditary immunodeficiencies

Answer 54

If risk of exposure: - Give vaccine + VIg 0.3mL/kg IM If complications from vaccine: - Gvie VIg 0.6mL/kg IM divided over 24-36hr

Answer 55

Progressive vaccinia Ocular autoinoculation Eczema vaccinatum

Answer 56

Community-based hospital coalition planning Personnel trained in recognition, mass casualty triage, & treatment Decontamination facility w/ protocols (runoff water, warm water, patient privacy) PPE readily accessible & compliant w/ regulations Rapid access to antidotes, cyanide antidote kits, & anticonvulsants Hospital incident management system in place Knowledge of how to access experts quickly

Answer 57

Nerve Agents Vesicants Cyanides Pulmonary Intoxicants

Answer 58

= Organophosphates Inhibit acetylcholinesterase enzyme Block degradation of ACh at postsynaptic membrane Accumulation results in overstim. of Muscarinic + Nicotinic resceptors

Answer 59

Muscarinic: - Miosis - Salivation - Rhinorrhea - Lacrimation - Bronchorrhea - Bronchospasm - Vomiting - Defecation Nicotinic: - Muscle fasciculations - Flaccid paralysis - Tachycardia - HTN Usually no bradycardia or urination, like other organophosphates AND: Seizure Coma Apnea Psychological changes x4wks

Answer 60

Clothing + Shower Decontamination - Reactive skin decontamination lotion (RSDL) Pre-Tx w/ Pyridostigmine to prevent nerve agent binding Atropine for muscarinic effects - improves ventilation, dries secretions - approx 20mg Pralidoxime (2PAM) for nicotinic effects - reverses paralysis +/- Phentolamine 5mg IV for HTN side effect Midazolam or Diazepam for seizures ------------------------- VAPOUR Exposure: Mild: Obs 1hr, then d/c, no tx needed LIQUID Exposure: Mild: Atropine 2mg IV + 2-PAM 1g IV over 30min VAPOUR & LIQUID: Moderate: Atropine 2-4mg IV, repeat q5-10min prn 2-PAM 1g IV over 30min, repeat q1h prn Severe: Atropine 6mg IV, 2mg IV, repeat q5-10min prn 2-PAM 1g IV over 30min, repeat q1h for total 3g Midaz/Diaz 5mg IV or Midaz 10mg IM, repeat prn

Answer 61

Vapour Exposure (Sarin) Mild: Rhinorrhea + Miosis Moderate: Mild PLUS increased secretions, wheezing or dyspnea, muscle weakness or fasciculations, or GI effects Severe: Apnea, seizures, LoC, flaccid paralysis, or major involvement of 2 organ systems Liquid Exposure (VX) Mild: Localized sweating & fasciculations where a drop touches skin; NO miosis; may be delayed for 18hr Moderate: GI effects; miosis uncommon; may be delayed for 18 hr Severe: Apnea, seizures, LoC, flaccid paralysis, or major involvement of 2 organ systems; occurs <30mins at or above median lethal dose (LD50)

Answer 62

Decontaminate w/ clothing removal, wash w/ H2O + RSDL soap or dilute bleach Skin = resembles 2nd-degree burns, vesicles, bullae - standard burn care - LESS IVF needed Eyes = conjunctivitis, corneal ulcer, blepharospasm - mydriatics, topical antibiotics, oral analgesics, and petroleum jelly Airway = Irritation, hemorrhagic necrosis of bronchioles - Humidified air, PPV, bronchodilate Systemic = bone marrow suppression - try G-CSF

Answer 63

1) Primary - Unique to high-order explosives - Results from impact of over-pressurization wave w/ body surfaces 2) Secondary - Results from flying debris & bomb fragments 3) Tertiary - Results from individuals being thrown by blast wind 4) Quaternary - All explosion-related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms - Includes exacerbations or complications of existing conditions PLUS 5) Fifth - Hyperinflammatory state due to toxic materials absorbed by body

Answer 64

Primary = Barotrauma - Auditory, Pulmonary, GI bowels - TM rupture, middle ear damage, hearing loss - Abdominal hemorrhage, organ perforation - TBI, concussion - Pulmonary contusions = BLAST LUNG = SUPPORTIVE CARE Secondary = Most common cause of morbidity & mortality following a blast event - Any traumatic injury from flying debris - Tx w/ ABX, Tetanus booster, HBV ppx (infected suicide bomber shrapnel) Tertiary = Head injuries & fractures - tx w/ associated mgmt Quaternary - Tx the worsened co-morbidities

Answer 65

Medical record should accurately document objective findings associated with a patient’s wounds. Emergency clinicians should not speculate about their mechanism or cause.

Answer 66

Bullets in myocardium Missiles w/ potential to embolize Missiles in contact w/ synovial fluid Missiles in contact w/in intervertebral disks Limiting joint motion Impinging on nerves Bullets in vessel lumens Resulting in lead poisoning Bullets in subcutaneous locations (especially hands & feet)

Answer 67

Slap marks with digits delineated Looped or flat contusions from belts or cords Circular contusions from fingertip pressure Parallel contusions with central clearing from linear objects Contusions from shoe heels and soles Semicircular contusions and abrasions from bite marks

Answer 68

Laceration = tear in the skin produced by blunt trauma Incised wound = when a sharp-edged implement is drawn across skin, is longer than it is deep Stab wound = puncture wound that is deeper than it is wide

Answer 69

Multiple superficial incisions located on the anterior trunk, arms, and face Multiple superficial stab wounds located on the anterior trunk, arms, and face Parallel incisions, in close proximity to each other, on the nondominant side of the body Sparing of sensitive body areas Linear or curved incisions toward the hand inflicting the wound Intact clothing covering the wound Evidence of prior wounds in repeat offenders

Answer 70

1) care under fire (CUF) 2) tactical field care (TFC) 3) combat casualty evacuation care (CASEVAC)

Answer 71

1) direct threat 2) indirect threat 3) evacuation care

Answer 72

Search Rescue Technical Medical

Answer 73

Type of disaster and predicted numbers and types of potential victims Capabilities of team to deal with medical aspects of the situation, including dealing with injured team members Local emergency departments’ level of functioning; trauma center status and location Local EMS resources Location of planned triage staging area Communications with local resources (e.g., EMS, police, emergency departments, fire and rescue) Weather, environment, or hazardous materials issues Availability of other resources

Answer 74

Crush injuries Compartment syndrome Particulate inhalation Hazardous Material exposures Blast Injuries

Answer 75

Hypovolemia 2/2 third spacing of fluid Dysrhythmias 2/2 severe metabolic acidosis & hyperK

Answer 76

Renal failure ARDS Sepsis Ischemic organ injury DIC Electrolyte disturbances

Answer 77

Cardiac monitoring IVF HyperK tx U/O monitoring

Answer 78

INTRINSIC Limitations of human cognition High levels of uncertainty High decision density High cognitive load Narrow windows of opportunity Multiple interruptions or distractions Low signal-to-noise radio Surge phenomena Novel or Infrequently occurring conditions Patient factors (Acuity, Language, Delirium) EXTRINSIC High communication load Poor teamwork Overcrowding Production pressures High ambient noise levels Information gaps Report delays Inadequate staffing Poor feedback Inexperience Inadequate supervision Sleep deprivation or Sleep debt Fatigue Multiple transitions of care Poorly designed procedures ED layout

Answer 79

Longer reaction time Lapses in attention or concentration Lost information Errors of omission Poor short-term memory Poor mood (increased confusion, stress, irritability) Reduced motivation Distractibility Sleepiness Poor psychomotor performance - At circadian low points - When sedentary - On long, difficult, or externally paced tasks w/ no feedback - In unchanging surroundings, particularly w/ reduced light or sound, or w/ low motivation, interest, or novelty

Answer 80

Optimize circadian-friendly schedules Forward rotating (clockwise w/ circadian rhythms) Rapid changes Minimize consecutive nights (1 or 2) 24-48 hrs off after nights Allow social time, including some weekends 8hr shifts (absolute max 12hrs) Institute regular, predictable template Practice proper sleep hygiene Use a sleep-friendly room: room-darkening blinds, “white noise” (electric fan) or earplugs, no phones, family aware Maintain a regular sleep routine Try anchor sleep Avoid caffeine, alcohol, drugs Prophylactic naps Modulate circadian rhythms Exercise Consider bright light Eat healthy Eat a balanced diet Avoid junk food Keep regular mealtimes Promote a healthy lifestyle and work style Promote a personal healthy lifestyle Educate friends & family about shift work issues Educate colleagues about shift work issues Advocate for department improvements in working conditions Advocate for shift worker–friendly community services Avoid pharmaceuticals Use caffeine in moderation prn Do not use sedatives or stimulants Avoid alcohol before sleep

Answer 81

Chemical Biologics Radiologic Nuclear Explosives

Bonus Chapters Flashcards

(107 cards)