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  • Soldiers' Strength Inspires Radiologists Serving in Afghanistan

    December 01, 2010

    Last Christmas day in war-torn Afghanistan is one that Cmdr. Ronald Boucher, M.D., will never forget.

    It was cool in the desert, with no snow—an unusually nice day in the city of Kandahar. Dr. Boucher spent most of the day treating the sick and wounded while trying to enjoy the holiday as best he could. The 20-year military veteran and chair of radiology at the Naval Medical Center in San Diego had been deployed in August as an active duty U.S. Navy physician in a multinational medical unit comprised of Americans, Canadians, British, Danish, Dutch and Australians.

    That Christmas day, Dr. Boucher and his fellow medics were bonding as they celebrated, smiling, laughing, sharing stories, gifts and cookies sent from home.

    "The Christmas spirit was upon us," Dr. Boucher recalled. "We were all thinking about our kids and families at home, missing them dearly, wanting that one hug and kiss good night."

    The festivities were abruptly halted, however, when a young coalition soldier struck by an improvised explosive device (IED) was brought into the battlefield hospital, a M.A.S.H.-like unit at Kandahar Airfield. The soldier's considerable injuries included bilateral traumatic above-the-knee amputations, extensive soft tissue loss of the buttock and perineum and a shattered pelvis.

    Once in the hospital, radiologists performed a focused assessment with sonography in trauma (FAST) scan that revealed extensive internal bleeding, while field medics skillfully placed high tight bilateral lower extremity tourniquets to maintain critical central blood volume.

    Suddenly, the young soldier lost consciousness. He was taken immediately to the operating room, where surgeons from different nations worked to stabilize lower his extremity bleeding from the amputations, simultaneously performing an emergent open laparotomy and thoracotomy while anesthesiologists managed his airway and blood pressure. The soldier's wounds were so extensive, however, that it was impossible to stop the bleeding. He died after four hours of intense effort, forever changing Dr. Boucher and fellow medics.

    "This young gentleman had the best possible chance of survival, anywhere in this theater or arguably even in our homeland," Dr. Boucher said. "I was part of and witnessed an amazing feat—a pool of highly talented individuals all focused on a unified front, 31 people of different nations and specialties in the operating room."

    Radiologists Fill Medical, Humanitarian Roles

    Dr. Boucher's experience with the young soldier was the most memorable of what would be his first and only wartime deployment. Considering the challenges he faced, Dr. Boucher felt fortunate to share the experience with another radiologist assigned to the hospital—Cmdr. John York, M.D., an interventional radiologist in the U.S. Navy. Cmdr. Steven Ferrara, M.D., an interventional radiologists also stationed at the Naval Medical Center in San Diego, was deployed as a General Medical Officer (GMO), arriving a few months before the U.S. took control of the NATO Multinational Medical Unit.

    The three radiologists were deployed by the Navy as individual augmentees, commonly referred to as "IA's," to support the Army. The augmentees are Navy personnel "on loan" to Army units, where they fulfill jobs in fields such as medicine, information technology and intelligence.

    As a diagnostic radiologist, Dr. Boucher's primary duty was providing radiology services for coalition force casualties, yet he also filled a secondary humanitarian role, caring for local nationals, many of whom were children.

    "The Americans brought 'first world' equipment and medical care to a 'third world' country," said Dr. Boucher, who trained six weeks to prepare for living and working in a wartime environment.

    Most patients suffered either life- or limb-threatening injuries and illnesses, Dr. Boucher said. He saw children who picked up munitions left from previous wars—items that exploded in their faces or hands—and local Afghans burned from a fuel truck intentionally detonated by an insurgent.

    Other duties included providing women's health and prenatal care and mentoring Afghan physicians in radiology—a specialty that does not exist in the country's healthcare system, Dr. Boucher said. By teaching local physicians to use ultrasound for diagnosis, Dr. Boucher developed the first radiology-physician mentor program in Kandahar.

    "I felt a greater sense of community through this experience," he said. "Much of this effort served as an opportunity to win the hearts and minds of the local people and Afghan leaders."

    Despite what he describes as "trauma as horrific as you can ever imagine," with soldiers suffering single, double and triple amputations and extensive musculoskeletal and neurological injuries, Dr. Boucher was able to draw inspiration from the experience.

    "The determination and optimism of these young soldiers and sailors gave me strength though this deployment," Dr. Boucher said. "The coordinated care and collaboration we shared with our NATO forces is admirable. It was inspiring to see so many countries combine strength and knowledge for a common cause."

    Radiologist Doubles as General Medic

    Although he was first deployed as a GMO working with one physician's assistant and nine medics, caring for approximately 2,200 soldiers, Dr. Ferrara also ended up providing radiology services once he saw the opportunity to use his special skills on the battlefield.

    "Our primary mission was to provide medical support to these soldiers on combat missions 'outside the wire' as we pushed the fight to the Taliban," Dr. Ferrara said. "We also were responsible for the routine health of these soldiers, caring for both their acute illnesses as well as preventive medicine and ongoing health maintenance, resulting in about 30 patient encounters a day."

    Although the battlefield hospital where Dr. Ferrara volunteered consisted of three operating rooms, a small ward and intensive care unit, he soon learned that there was only one general radiologist covering a service that included around-the-clock CT, plain-film and ultrasound. From then on, Dr. Ferrara offered radiology assistance anytime he could break away from his other duties. Theater commanders quickly understood the importance of interventional radiology to casualties on the front lines.

    As a result, the first dedicated interventional radiology position in the Afghanistan theater was born, fostering the creation of a dedicated equipment and supply chain allowing that brought full-service capabilities including angiography, IVC filters, embolization and stent-graft placement.

    Over the next several months, the interventional radiology team performed dozens of life- and limb-saving angiograms and interventional procedures, and even served as a referral center for wounded casualties across southern Afghanistan. That led to the creation of the permanent interventional radiology position in Kandahar, Dr. Ferrara said.

    Attacks Spur Equipment Improvements

    "It was not unusual to undergo incoming fire while in the midst of treating patients," Dr. Ferrara said. "While standard procedure during rocket attacks is to don body armor and take cover in concrete shelters, that was not always possible. Patient care always comes first and it is one of a doctor's duties to first protect their patient from that same incoming threat."

    Dr. Ferrara took on another, somewhat unexpected role as an inventor of sorts. While reading trauma films, he began to notice a predictable pattern of injury: blast-related spine injuries in soldiers whose tactical vehicle had driven over and detonated an IED. The explosion would lift the vehicle straight up from the ground, Dr. Ferrara noted, resulting in multiple vertebral compression factors. Working with a civilian friend, the pair designed a modification to the underside of the seats that would redirect the explosive forces away from the solders in the vehicle.

    This invention is an example of how the battlefield "gives me the opportunity to do what every doctor wants to do—make a substantial difference in the lives of their patients," especially those who "selflessly risk their lives for their country," Dr. Ferrara said.

    "Being able to care for Americans injured on the battlefield is the realization of my purpose for joining the military at the onset of the first Gulf War in 1991," said Ferrara. "It is also the culmination of my reason to be a physician, which is to care for the sick and injured for the sheer purpose of helping others, putting your skills to meaningful use, exclusive of the business and bureaucracy of medicine which can pervade a traditional practice."

    Perhaps most importantly, Dr. Ferrara's experience in Afghanistan has helped to prioritize his life and improve his perspective. "The simple things gain greater meaning and make it easier much to find patience with the trivial frustrations of daily life."

    Part of a multinational medical unit assigned to a battlefield hospital at Kandahar Airfield in , (from left) Navy Cmdrs. Ronald Boucher, M.D., and Stephen Ferrara, M.D., provided life- and limb saving radiology procedures to coalition force casulaties as well as local nationals. Photo courtesy of Cmdr. Stephen Ferrara, M.D.
    Radiologists serving in Afghanistan observed "trauma as horrific as you can imagine," according to Cmdr. Ronald Boucher, M.D., top, manning the multinational hospital in southern . "It was not unusual to undergo incoming fire while in the midst of treating patients," said Cmdr. Stephen Ferrara, M.D., far right, treating patients with, from left, Dr. Boucher and Cmdr. John York, M.D. Photos courtesy of Cmdr. Stephen Ferrara, M.D.
    The multinational team of medics provide coordinated care to wounded patients. "It was inspiring to see so many countries combine strength and knowledge for a common cause," said Cmdr. Ronald Boucher, M.D. Photo courtesy of Cmdr. Stephen Ferrara, M.D.
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