Imaging under fire: Inside the combat radiology tent
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 332nd 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, Folio and his two radiology colleagues read more than 15,000 complex trauma cases.  With tens of thousands of images to read each day, Folio explained, “You just could not get to every image you needed to. In private practice interpretation averages something like one second; this was less.”

At times, the ER would be so busy that Folio would storm into the waiting room and ask every patient to stand up. “Anyone who could stand up was drafted to help us help the people that were dying. For the people who couldn’t stand up, say someone bowled over with appendicitis, maybe I would help him after I took care of some more life threatening things.”

And yet, on average, patients shot and helicoptered into the base (up to four med-evac helicopters, each lifting six soldiers, could land simultaneously), were in the OR in an average of 20 minutes. For those with more fortunate injuries, like fractured ankles, once they were released from assisting Folio in the ER, a day or two would pass before a lull in trauma allowed the radiologists to read the fracture.

The hospital treated life, limb and eyesight—military and Iraqi. “This presented some of the more challenging cases,” Folio said, referring to Iraqi children. “It’s hard to see a kid sitting there in the ER who might be booby trapped with a bomb.” Military procedure mandated that the least experienced techs, nurses and physicians had to take out bombs and operate under potentially even more threatening scenarios, protecting the military’s higher-ups in the chain of command.

Painting the picture
While the group performed some minor interventional procedures, radiology’s role was critical to guiding flight surgeons. Blast and ballistic injuries were most common, usually from improvised explosive devices (IEDs), with patients brought in at least hourly.

In one of the most severe and unusual cases, Folio described a soldier who was shot in the knee while on patrol in a chopper. By the time the GI made it to x-ray, the bullet embolus had migrated through his vascular system and into the soldier’s lung. “When one of your physicians says ‘Wow, my God,’ you know it’s a big deal.” The patient was rushed from x-ray to the OR and put under the knife within 20 minutes of arrival at Balad.

Imaging helped the radiologists piece together a story, to get a feel for where blast fragments were, to find entrance and exit wounds and to get an overall vision of the damage. Determining bullet trajectory gave the Radiology Flight the best idea of the affected organs, which they were able to determine in approximately 60 percent of cases. Folio helped develop a standardized coordinate system for CT, Cartesian Positioning System (CPS), which applied a mathematical model to help physicians determine bullet trajectories and pinpoint injuries.

Apart from volume and seriousness of injuries, “The most unexpected part of the deployment was to see how long and hard people could work. Even though they were exhausted, they showed heroic ingenuity working on the difficult cases,” Folio concluded.