Battlefield lessons learned: How to add value to radiology, part 2

Battlefield lessons learned: How to add value to radiology, part 2

By Lena Kauffman

Ron Boucher, MD, chief of radiology at the VA Medical Center in Seattle, Wash., and clinical professor of Oregon Health & Science University, spent 9 months practicing radiology in a battlefield tent hospital only a mile from the front in Kandahar, Afghanistan.

In Part II of a two-part interview, the former chair of radiology at the Naval Medical Center in San Diego and 23-year military veteran provides the readers of with hard-earned advice on how to add value in the civilian setting. 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 What tools do you have ready access to in the field? Has that limited access contributed to innovation and the development of new techniques?

The most important tools we had were ultrasound and CT. The other tool that I would say was probably even more important was the ability and openness of the environment to allow radiology to participate in the decision-making, the triage and the willingness of the entire medical team to recognize the value of what we could bring.

Were we limited? Yes, we were limited in a lot of things. We didn’t have the right supplies. We didn’t have all the equipment we wanted. You don’t have a supply system where you just call up one of your vendors and say “Hey, can you send me over this catheter to do this study.” You can’t do that, so you actually have to make do with what you have and think outside the box.

You had to think about how to do things differently. For instance, we had a metal OR table. Think about that when you are trying to introduce interventional radiology. You can’t image through a metal OR table. So we had to get innovative. We actually took the patients halfway off the table. Somebody was holding them. Our C-arm didn’t fit inside the shipping containers that had been converted into ORs and the ORs were too short for the C-arm to actually even extend all the way. So there were a lot of challenges like that, but you actually had to sit there and ask, what can we do with what we have?

What was nice about [the experience] was that we took what we needed and at the same time as I was there, we were building a brick-and-mortar hospital that was built to withstand the rocket attacks we were getting. Part of our job was taking care of the coalition casualties and part of our job was to build this brick-and-mortar hospital. It opened the day I left, so I never got to work in the brick-and-mortar hospital. Presumably, advances in combat radiology would be most readily transferrable to trauma radiology. Has combat radiology enriched civilian radiology in any way?

Boucher: We can definitely learn several lessons from combat radiology. If you can remove the blanket of healthcare politics—by which I mean the predatory practices, the turf wars, the financially driven care, the excessive paperwork, the Joint Commission—and you remove all those stressors and focus on the patient with the most important intent being to save this life and limb, everything changes. The entire medical team worked together almost seamlessly [in the combat situation]. You had your country differences and language barriers sometimes, but I will tell you that without those other pressures, everybody worked collaboratively, and I was very inspired by this. Now if we could transfer that to our current civilian practices, it would be good, but I don’t think that is possible in our current healthcare environment.

One thing that would be great is if we could put radiology on the front line [in civilian healthcare]. I probably will not be popular for saying this, but you want radiology to become invaluable, and I saw that first hand. We made radiology invaluable. The way you do that is that you incorporate yourself into the healthcare of that patient from the beginning to the end, and then other people rely on your valuable real-time feedback to make actionable items right there on the spot.

You have to be point-of-care radiologists from the beginning. That changes things from being behind a desk, and I’m not a big advocate for teleradiology because it removes you from the actual care of the patient or the interaction with providers. There is a role for teleradiology, because we actually did use it. But radiologists can learn a lot from this, and if they actually take that point and bring radiology to the front line and become invaluable, that would be the most important lesson to learn.

The other thing was putting interventional radiology in the trauma bay because it changed everything about the way we cared for the acutely injured patient. If we did that in the civilian practice—put the interventional suite either right next to the OR or in the trauma bay—they could use them a lot more efficiently and better. In working with a multinational team in Afghanistan, have you learned anything you would like to share from radiologists from other countries? 

Boucher: Before we got there, the Canadians owned the healthcare environment, so they were in charge of the multinational medical unit.  The Canadian forces only had two or three radiologists in the entire Canadian forces and they didn’t send any [to Afghanistan]. They would telerad everything.

When the Americans came, what changed everything was that we brought assets. There were two radiologists right there on the front line, and we brought equipment. So we brought technology and people. There were two other multinational medical units that were supplemented, and one of them was run by the British. They did have a radiologist there. But we also sent the American radiologist as well.

The Americans probably had a greater number of assets and more people, so we were able to support it a bit better just because of that. I suspect that the other countries, if they’d had the other people, would have sent them, but the lesson we’ve learned is twofold. One, radiologists become invaluable at the battlefront and two, interventional radiology is critical in a trauma situation and it is a requirement to be placed in theaters [of war]. What lessons from your own experience would you wish to pass on to civilian radiologists, technologists and others working in diagnostic imaging?

Boucher: In Afghanistan, not only are we there for the trauma, but we are there for the entire inpatient population. And not only are we doing that, we had to take care of the entire surrounding forward-operating base.

In my talk, I show people that the orthopedic surgeon understood us really fast. He said, “Oh, my gosh, if I want to know anything that is happening, I’m going to call Ron because he knows everything that is happening in inpatient, everything that is happening on the trauma side and everything that is happening out in the environment,”—because we saw everybody that came through.

That became important. From that point on, the radiologists became the medical center directors for those trauma hospitals because people realized that they were the ones that saw the entire environment. That is actually true in the civilian sector, but people don’t realize it: When we are reading studies, we actually see the trends and all the populations. We see the whole picture.

The most important message to take away from this was really understanding how to create value for the radiologists in the involvement of the healthcare of an individual (from the time they show up to the time they leave); how to provide real-time feedback to providers who can take action [based on that information] immediately; and to be available for consultation immediately.

The problem I see is that this impinges a lot on peoples’ lifestyles. I think we are our own biggest enemy because a lot of us don’t see that as the need for us to survive. We don’t see that as most important. The ACR and its Imaging 3.0 effort are now focusing on how to create value in a radiologist. What I’ve learned in real time is that the ACR is supporting us to move in that direction—where we actually are integrated into the healthcare of a patient rather than being remotely attached to it.

Editor's Note: Part I in this series recounts Dr. Boucher's experience practicing battlefield radiology in Afghanistan.

Lena Kauffman is a contributing writer for