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

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 this information once the patient is transferred from one battlefield station to another as they go through the medical transit system. We basically and fundamentally brought first-world equipment into a third-world country and transformed the entire medical system to deliver first-class care. How was the reality of serving in combat areas and treating soldiers and civilians different than you had imagined?

Boucher: The first shock that came to me was that we were actually in a battlefield, so that changes everything. It was like the T.V. show M.A.S.H. with tent hospitals, and people were shooting at us and bombing us while we were treating patients. It was not uncommon to have incoming bombing and rocket attacks in the middle of treating a patient that is about to die.

This battlefield environment changes how you see things, because, one, you never sleep and two, the trauma is unpredictable. Not only the level of trauma, but also the number of patients you see is unpredictable. It becomes a mass casualty event every time. We had as many as 15 people show up at one time, and we only had four trauma teams. And so you start thinking about that. It becomes very unpredictable.

The acuity and level of injury were probably the biggest things [that surprised me], and then being shot at and bombed with the lack of sleep complicated the situation. The multinational environment also created a very interesting environment: Not everyone knew what a radiologist even did. Most of these injuries were life-and-limb situations, which characterized battlefield care.

I initially had thought we’d be remote from the battlefield and did not realize we would be in the proximity. We actually were in the middle of the battlefield and literally got patients within minutes of being killed or injured. It was like M.A.S.H. I didn’t know what to expect, but upon arrival, it was, “Oh my God, we are getting bombed and there are casualtues coming in. This is it. This is a real war.”

The shock for me was that within a few hours of arriving in theater, we were not only getting bombed, we were getting our first casualties, and they were missing entire legs and arms, or the face had been blown off, or he had been eviscerated. We looked around and realized, we are here, and we have to take care of these people.

The other thing [about battlefield radiology] is that most of these folks are young. I think the average age of all of these war fighters we saw was probably low- to mid-20s. Then you also had an environment where you had multiple different nations, so you aren’t just taking care of Americans.

What I always tell people is that a battleground is the most challenging and humbling but also the most taxing environment for learning and pushing limits, because there is no better place to be where you are most needed as a physician. You have accomplished much in your service, including helping to create a permanent interventional radiology position in Kandahar. What are you most proud of?

Boucher: I was so proud of the young men and women who fought this war. Despite the horrific injuries they had sustained, they still had this determination and this optimism and tenacity to survive. Having them trust us to participate in their health care inspired me. They made a difference. They were true heroes, and taking care of them inspired me to consider the way we treat people. I was really blessed to be part of that process.

Editor’s Note: This is the first installment of a two-part interview. Check back for Part II: Battlefield lessons learned: How to add value to radiology, part 2.

Lena Kauffman is a contributing writer for