From the frying pan into the fire: Battlefield radiology, part 1

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 - Ron Boucher, MD

Ron Boucher, MD, chief of radiology at the VA Medical Center in Portland, Ore., and clinical professor of Oregon Health & Science University, spent nine months practicing radiology in a battlefield tent hospital only a mile from the front in Kandahar, Afghanistan.

In Part I of a two-part interview, the former chair of radiology at the Naval Medical Center in San Diego and 23-year military veteran provides with a visceral account of his service in Afghanistan. Boucher also will share what he learned from this in his presentation Extreme Radiology and the Interventions in Modern Warfare at 1 p.m. PST on Oct. 19, 2014, at the Radiology Business Management Association’s Fall Educational Conference at the Westin, Seattle. If you cannot make it in person, tune in for a free live-stream of the presentation sponsored by Imagine.  Live-stream registration is online only at   How has combat radiology changed in the 23 years you've been in active duty?

Boucher: I think the most important thing that has changed in the wars in Iraq and Afghanistan is that most of the injuries we see are related to IEDs, which are improvised explosive devices. We do not see a lot of BBs and bullets. It is mostly blast injuries, and when you have blast injuries, what you have is something I characterize in my talks as the most horrific injuries in any previous war because you really are blowing up the body into the pieces.

The injuries are worse than ever, and for the treatment of those injuries, you are really going into rapid resuscitation and triage, which means that you are trying to figure out immediately what you can do to save life and limb. So for combat radiology, what has changed, most fundamentally, is that we put radiologists right in the battlefield. That has never happened before.We also introduced interventional radiology as a critical element in trauma evaluation.

Before the U.S. took over the NATO hospital healthcare, the tent hospital was administered by other countries [from the multinational force], most of the radiology was done by teleradiology, which became relatively useless: Time is of the essence back in a battlefield environment. When they would telerad studies out, they never got the reports back in time for clinical decisionmaking, and there was no interaction with the radiologist.

What the Americans did was bring radiology right to the battlefront, right to the trauma bay: Then radiologists went from obscurity to being one of the most valuable players in the battlefield hospital. What happened was that as soon as a patient arrived, the radiologist would be one of the initial assessors on ABC (airway, breathing, circulation) [as well as] evaluating the extent of internal hemorrhage by doing a fast focused ultrasound exam of the trauma.

The radiologist in essence became the triage officer because you answered one of two questions: One, did the patient have extensive internal injuries where they had to go to the OR immediately? If there were internal injuries, the casualty went to the OR. If there wasn’t internal bleeding, then the next thing you did was go to CT. Radiology became one of the most important players in the initial care of the veteran or the war-care fighter.

[If the patient went to CT], the radiologist accompanied the patient to the CT and they completed the CT and an immediate review, real time, with the trauma team, providing immediate, total bidy trauma assessment where time-sensitive decisionmaking was imperative.

If the patient went to the OR, we performed catheter-directed intravascular evaluation with angiography while the surgeons worked to stabilize the internal bleeding. We would work collaboratively, at the same time taking care of the patient in real time. This teamwork became a very important factor that changed everything about how health care was delivered and contributed substantially to saving limb and lives.

Another battlefield improvement was the introduction of advanced medical imaging equipment. In previous wars, we really never had a CT in the battlefield. In this war in Iraq and Afghanistan, we brought ultrasound, CT and the unprecedented introduction of interventional radiology.

The other important thing that improved the healthcare delivered is that now we have PACS and teleradiology (as a supplement, not the primary source of reads), so we are able to communicate