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role was different from most of the medical scenarios I had developed a plan of action that ultimately got him diag-
encountered before this moment—I was used to being told by nosed and treated.
Command what to do, not the inverse. 3. When you are trying to manage a situation at the lowest
level, do your research. Look up materials that can help
It was one of the scariest moments of my career, as I was un- guide your judgments. If answers are not readily available,
sure if I had waited too long to recommend medical evalua- you’re likely dealing with something outside your scope.
tion or missed something simple that could have prevented 4. Trust what you learned at the schoolhouse or during train-
John’s symptom progression. I was at a mental crossroads. Ul- ing events but also break away from the trainee mindset.
timately, I chose to seek the help of other professionals, with Use the lessons learned from those experiences to help
the support of my team leader and Battalion surgeon, who guide your clinical decisions. Remember to always advance
recommended evacuation as well. the case and advocate for the patient.
5. To younger 18Ds and SOF medics just graduating: don’t
be complacent just because you are deploying to a country
Medical Evacuation
where the work is easy. Unlike others, your job starts with
After we requested medical evacuation, we received phone every medical mishap. Medical emergencies can happen
calls from every rank across various branches. They were all anywhere. If your team is going outside the wire, irrespec-
concerned about John’s status. Some questioned my decision tive of threat levels, you should treat it as if you are going
to medically evacuate him given his reassuring vital signs, no to receive patients.
apparent traumatic wounds, and absence of focal neurologic
deficits (the anisocoria resolved during John’s transport) with Conclusion
only an imaging report from the Lebanese neurology team.
Based on his signs and symptoms, John was not considered Reflecting on this experience, I navigated uncharted medical
to be an urgent or priority evacuation patient by the higher territory in terms of the scope of practice of an SOF medic for
command. This caused me and my team to experience many several days too long. I did not fully grasp the situation because
administrative challenges, and I faced criticism due to John’s I had never taken care of a patient like this before. There was no
perceived clinical stability. algorithm, and despite trying to manage his symptoms on site,
researching his symptoms and consulting my Battalion surgeon
In hindsight, I learned a critical lesson regarding patient evacu- back home, I was unsure how to optimally manage this patient.
ation: as the team medic, I should have taken ownership of the In a way, I fell back on my training. Ultimately, I prioritized
entire evacuation process. I provided John with the CD copy John’s well-being amid potential backlash for using limited re-
of his MRI scan, but I should have instead found a way to send sources to evacuate a patient whose symptoms could have been
the images to the U.S. neurology team prior to John’s arrival. attributed to posttraumatic stress, sleep deprivation, and phys-
ical exhaustion. This incident underscored the importance of
trusting clinical instincts and knowing when to seek help.
Final Diagnosis and Follow-Up with John
When John returned home, his evacuation proved crucial as Acknowledgments
his stateside examination revealed that he was battling second- The authors thank the Special Operations Forces to School of
ary empty sella syndrome and hypopituitarism. The etiology Medicine (SOFtoSOM) Editorial Board for their support of
remained uncertain, but clinicians considered the possibility this work.
that chronic exposure to mild traumatic brain injuries during
6–8
training may have played a role. Empty sella syndrome pres- Author Contributions
ents with variable constellations of symptoms, which may in- ZL and MAB conceptualized the paper with the help and
clude cognitive alterations, chronic headaches, sleep disorders, guidance of IRM, BLE, MS, FA, RB, and RMD. BLE, RMD,
high blood pressure, swelling of the optic disc, or visual acuity MS, RED, and IRM provided subject matter expert guidance
9
abnormalities. The cause of the anisocoria was never deter- on traumatic brain injury and neurocognitive function. MS,
mined, as this neurologic deficit has not been previously re- FA, and RB provided data analysis and insight based on pa-
ported in individuals with empty sella syndrome. We speculate tient symptoms in an acute emergency setting with limited re-
that the anisocoria was potentially due to exposure to chem- sources. RMD is the project lead for the “SOF/GWOT Lessons
icals during the blast or on site at the compound. John has Learned” series with the JSOM. ZL and MAB drafted the
since been medically retired from service and has responded manuscript. Critical revisions and editing were performed by
positively to treatment. IRM, BLE, MS, FA, RB, and RMD. All authors read and ap-
proved the final manuscript.
Lessons Learned
Disclosures
The following lessons emerged from this experience: The authors declare no conflicts of interest.

1. Not every wound is readily visible nor do they always pres- Disclaimer
ent themselves classically. Remain vigilant over your team- The views expressed in this manuscript are entirely those of
mates. You know their mannerisms; if something doesn’t the authors and do not necessarily reflect the views, policy, or
seem right, follow that instinct. position of the United States Government, Department of De-
2. Your Battalion surgeon and team leadership are there to fense, or United States Special Operations Command.
help you when you need it most on missions or deploy-
ments. When John first presented with anisocoria, it shook Funding
me. With their support, I worked through the problem and No funding was received for this work.

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