Page 86 - JSOM Winter 2022

of the attack specifically indicates that medical stabilization casualty was found to be in severe shock, with four units of
and evacuation of injured personnel often relied on the con- blood (unspecified type) administered prior to transport. He
tingency plan crafted by nonmedical personnel who were was intubated by the host national medical facility and was
delegated the responsibility or by Special Operations medics continued on ventilator support throughout the duration of
during an initial in-country assessment. Assumption of risk the transport. During transport, he was given seven more units
also involved acceptance of the absence of in-country quick of packed red blood cells. His documented injuries included
reaction forces, the requirement to self-sustain while in or to fragments of shrapnel to the forehead and right eye, including
extract oneself from conflict, and the need to provide some the globe; a compound tibia and fibula fracture with an exter-
degree of prolonged field care where no “golden-hour” pol- nal fixator in place; and a left ulnar fracture with an external
icy mandate existed. 2,5,6 At the time of the Benghazi attack, fixator in place. His primary evacuation diagnosis was trau-
the only dedicated military medical personnel was a single matic shock.
Special Forces medic attached to an Operational Detachment
Alpha team tasked with a security detail and assisting with Case 2
developing a nascent Libyan counterterrorism task force. On Case 2 was an adult male injured by an undocumented mech-
September 11, 2012, they remained in Tripoli. There were no anism. The patient was documented to have no medical or
additional dedicated medical personnel available to provide surgical history. He had documented smoke inhalation injury
critical care to the wounded from the Benghazi attack; medical and was coughing up black sputum. He had documented sta-
care centered on the collective knowledge and experience of ble vital signs (exact numbers not available), was ambulatory,
the Operators, diplomats, and staff there at the time. and had an oxygen saturation level of 95% on room air. His
primary evacuation diagnosis was vapor upper respiratory
Goal of This Investigation inflammation.
We sought to describe cases involving the use of military med-
ical assets for evacuation in support of the diplomatic mission Case 3
in Libya. Case 3 was an adult male injured by an undocumented mecha-
nism. The patient was documented to have no medical or sur-
gical history. His documented injuries included a compound
Methods
radial fracture with external fixator in place and compartment
Ethics syndrome with an unspecified treatment documented. He had
The US Air Force 59th Medical Wing regulatory office re- a neck injury with a Jackson-Pratt drain in place. He was in-
viewed protocol FWH20180147E and determined it to be ex- tubated prior to transport; however, he was documented to
empt from institutional review board oversight. We obtained be alert and oriented to person, place, and time prior to this
only deidentified data. Cases were identified through a second- intervention. His only vital sign documented was an oxygen
ary review of previously described datasets. 4,7 saturation level of 96% on room air. His primary evacuation
diagnosis was an open radial shaft fracture.
Database Description
The US Department of Defense (DoD), through TRANSCOM, Discussion
oversees medical evacuation patient movements throughout
military areas of operation as part of the military missions. All three patients had unknown mechanisms of injury, as
TRANSCOM TRAC ES provides the electronic platform of showcased, because of limited patient data via TRAC ES. As
2
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medical coordination for all DoD patients. As an automated such, the mission preparation was likely quite broad. Based on
2
information system, TRAC ES assembles, assesses, and prior- the description, all three patients would have required, at the
itizes patient movement requirements, assigns resources, and minimum, need for care at a Role 2 tactical surgical hospital or
distributes data to relevant parties. Data entry into TRAC ES a Forward Resuscitative Surgical Detachment for stabilization
2
includes an initial patient summary with demographics, pri- and transfer to a Role 3 or 4 for further management. Case 1
mary diagnosis, evacuation priority level, origin, and desti- could arguably be considered the most critical patient because
nation. Additionally, medical personnel can provide free text of the multiple injuries requiring what would have resulted in
background information to make available details of the per- activation of a massive transfusion protocol. In such austere
13
tinent history and describe the initial clinical course. Other de- environments, the use of fresh whole blood may have been
tails of the database have been described previously. 4,8-12 implemented for more rapid resuscitation. Case 2 represents
a burn inhalation injury subject who likely needed urgent in-
tervention to avoid an airway-related death. The third patient
Results
in this case series suffered complicated orthopaedic injuries
2
We identified three cases of evacuations within TRAC ES as- requiring management for compartment syndrome, a time-
sociated with the Benghazi consulate attack on September 11, sensitive diagnosis. All three of these patients required the re-
2012. The patients described and their corresponding infor- sources of a major trauma system, such as a Role 3 or Role 4.
mation in the database are inputs of the flight surgeon. All
cases were evacuated from host nation hospitals to LRMC. Comparing results from the Benghazi consulate with larger
Transportation methods from the host nation medical facility AFRICOM theater-based injuries and medical evacuations,
to the transport team were not available. All were transported Benghazi highlights similarities and notable differences, in-
to LRMC by military aircraft under urgent status. cluding that the Benghazi attack represents a singular 24-hour
period only. A retrospective review of all TRAC ES medical
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Case 1 records for medical evacuations from the AFRICOM the-
Case 1 was an adult male injured by an undocumented mecha- ater found that between January 1, 2008, and December 31,
4
nism. Medical and surgical history were not documented. The 2018, 936 cases were recorded in the TRAC ES system. The
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84 | JSOM Volume 22, Edition 4 / Winter 2022