Imaging under fire: Inside the combat radiology tent

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Forty-two miles north of the Iraqi capital of Baghdad in the notorious Sunni Triangle lies the largest U.S. military hospital in Iraq, the 332 nd Expeditionary Medical Group in Balad. This level III facility is the epicenter of the military’s highest-ever survival rate—for soldiers wounded on the Iraqi battlefield, 98 times out of 100, if they make it to Balad, physicians will save their lives.

One of the physicians responsible for this record survival rate is Les R. Folio, DO, MPH, former chief of radiology at Balad’s Radiology Flight group and at the time a full bird Air Force Colonel. In 2007, Folio, a radiologist at Walter Reed Army Medical Center in Washington, D.C., and associate professor of radiology, military and emergency medicine at the Uniformed Services University in Bethesda, Md., departed on his eighth overseas deployment, to the Air Force Theater Hospital at Balad, Iraq. Other deployments included a year overall in the Middle East, South America and Antarctica.

Folio describes a whole different order of radiology in Iraq, detailed in his book Combat Radiology. Over what would be his last deployment, Folio interpreted thousands of trauma neuroradiology cases, moved the radiology department (while under attack) to a permanent facility and introduced CT wound path trajectory analysis, not only to treat patients—but also to track snipers.

Folio and the Radiology Flight introduced novel technologies and streamlined hospital processes, launching a slew of programs that would transform combat radiology; and then he retired in 2009.

This story is the first of a series of stories chronicling the work of Folio and the Radiology Flight at Balad, including the deluge of combat trauma cases; the development of health IT advancements such as universal trauma windows and air traffic controller triaging; and the continuing research into wound path identification and trajectory analysis. In addition to treating casualties, Folio’s team faced their own, exposed to daily attacks at both their tent facility and later their hardened hospital. The shelling killed at least one nurse and one physician, and wounded a neurosurgeon—this over a period in which Iraq is seen as becoming a significantly less bloody venue.

Not your normal residency
Through 2009, combat radiologists received little training, mostly consisting of the offer to take vacation time to participate in a handful of days experiencing trauma care at R Adams Cowley Shock Trauma Center at the University of Maryland in Baltimore. With a gunshot wound frequency of one or two a day, this optional training seemed a bit specious given that this daily total might not have even matched the hourly trauma seen in Balad, offered Folio.

Folio lamented the lack of training, in particular for technologists, who were not required to undergo specialized training in CT, limiting their ability to perform advanced procedures in the high-intensity Balad facility. This circumstance is changing, though, with the establishment of a three-week course taught by military and civilian radiologists and flight surgeons at Baltimore Shock Trauma. Folio’s textbook is used as course material to help prepare radiologists, who no longer have to use vacation time to receive training.

Life, limb and eyesight
In Balad, the Radiology Flight group consisted of three radiologists working round the clock in eight- to 12-hour shifts, forgoing a day off for more than a month at a time. Folio had visited the neurosurgical facility in 2005 to advise military management on systems and supplies the hospital would need. On his return, the list of essential technology included:

  • Two 16-slice multidetector CT scanners;
  • One diagnostic x-ray unit;
  • Two portable x-ray systems; and
  • An ultrasound device.

“CT has without a doubt been the most helpful modality in Iraq,” Folio reflected, finding some of the post-processing applications like volume rendering and multiplanar reformation especially critical. Scoffing at the overutilization craze at public hospitals, Folio said, “We had a saying, instead of the CPR ‘ABC’ mantra ‘Airway, Breathing, Circulation’ to save lives, we would go with ‘Airway, Breathing, CT.”

The normal shift typically consisted of showing up, hearing about an explosion, a firefight or a Humvee (High Mobility Multipurpose Wheeled Vehicle) accident, and getting to work. “It was more or less like receiving a bus accident every two hours,” Folio elaborates.

In just four months,