Radiology and the Evolution of Battlefield Medicine

Imaging has been integral to wartime medicine since the early days of radiology. How is the specialty adapting to support the changing needs of patients on the battlefield?image battlefied

When you picture the development of military medicine, how prominently does imaging factor in? The evolution of radiology has been intertwined with modern-day warfare for the past 120 years.

Radiology was born at a time when Western military powers were transitioning from line and column warfare (in which highly ordered and organized soldiers fired muskets at each other) to battles involving rifled muskets, breech loaders firing high-velocity steel-jacketed bullets, and more advanced Gatling guns.

As warfare changed, the required types of battlefield medical care also shifted. Radiology became an extremely valuable adjunct to wartime care, especially behind-the-lines surgery. It was first used by the Italian army in a hospital in Naples after the Abyssinian campaign in 1896, just months after Roentgen’s discovery of x-rays. Imaging was invaluable in locating and localizing bullets lodged in soft tissues.

Radiology continued to be sporadically used throughout wars in the late nineteenth century; however, it was World War I that legitimized the role of radiology as an established combat medical specialty and an integral part of battlefield medicine. The new generation of warfare, invented by the French, revolved around massive firepower through indirect artillery fire, as observed in the trench warfare so integral to World War I. Radiology became a necessity, as mobile x-ray vehicles emerged right behind the frontlines, and fixed x-ray units set up shop farther back. Radiology allowed medical personnel to localize and evaluate fractures and bullets much more efficiently than previous methods.

As warfare evolved, so did combat radiology. Radiology units in field surgical hospitals moved with the maneuver units in World War II, providing invaluable imaging support and guidance to the surgeons. This change was prompted by warfare trends that involved surprise, speed, agility, and the ability to maneuver.

Warfare has continued to change in modern times. Over the past 20 years, we’ve seen the emergence of asymmetric warfare — as faced by the United States and coalition troops in Afghanistan and Iraq. Instead of nation-states fighting nation-states, this warfare involves nation-states fighting a long, protracted, low- to medium-intensity, burn-out war against non-state actors (some examples would be the British Army fighting against the Irish Republican Army in the 1970s, Afghan resistance against the Soviet Union in the 1980s, Israel fighting Hezbollah, and Pakistan fighting Taliban).

The signature weapon of asymmetric warfare is the improvised explosive device (IED). These devices are not restricted to battlefields in Iraq and Afghanistan, where IEDs were responsible for almost half to two-thirds of U.S. and coalition casualties from 2001 to 2013. By 2012, about 6,572 U.S. troops had died in Iraq and Afghanistan, and 2,483 of those deaths were IED related1 IEDs have been used frequently in recent decades, including in the United Kingdom by the IRA in 1970s and in Indonesia, Pakistan, France, Belgium, Nigeria, Spain, Turkey, and, of course, in the United States, even before 2001 and as recently as 2016. IEDs are especially dangerous because they are easy to make, easy to place, and easy to detonate, yet the high amount of shrapnel inside wreaks havoc on its victims.2

On the battlefields of Iraq and Afghanistan, military radiology played a vital role in the higher-than-90-percent survival rate of IED-related and other battlefield casualties.3 Through imaging, radiologists were able to give surgeons the exact location of shrapnel in the victims’ bodies and identify other problems that may have been externally invisible, such as damaged organs or eardrums. With radiologist, surgeons were granted an explicit roadmap to a person’s injuries, whereas, before they could only do exploratory surgery to identify a problem.

Advances in technology have allowed radiology to optimize its contribution to wartime medicine without being located at the frontlines. The forward deployment of 64-MDCT scanners in theaters of war and the development of high-speed Very Small Aperture Satellite (VSAT) teleradiology networks allowed U.S. military radiologists stationed in places like Germany or Alaska to read and interpret imaging studies performed in Iraq and Afghanistan. Radiologists were able to diagnose accurately primary, secondary, tertiary, and quaternary effects of blast-related trauma in real time from across the world. The deployment of MRI scanners in the combat zones of Afghanistan for immediate post-event baseline imaging of traumatic brain injuries revolutionized the specialty of battlefield imaging.

Recent decades have shown that acts of war are not always limited to the literal battlefield. In 2015, there were 11,774 terror attacks, resulting in 28,328 deaths worldwide.4 In this volatile climate, the importance of the civilian radiology community in preparation for threats cannot be overstated. Radiology has to be at the forefront of prevention, mitigation, preparation, response, and consequence-management of catastrophes such as a stolen, industrial, unshielded radiation source hidden in a heavily visited mall; a homemade IED developed by homegrown actors with specific political motivations or religious ideology; or an improvised nuclear device by a transnational non-state actor. One of the prime examples of radiology’s role in protecting civilians against terrorist threats was the anthrax mail letters of 2001. Radiologists in Fairfax, Va., were among the first to suspect and diagnose anthrax using chest radiographs and CT scans of anthrax victims.5

What is in the future for military radiology? A new era of warfare — cyber attacks and cyber warfare — is upon us. Whether it is a radiologist’s PACS being hacked or personal and financial information being stolen, radiologists must continue to be watchful. Today’s military radiologist, a 21st century medical warfighter, is at the forefront of an asymmetric battlefield, ready to answer the call of duty, whether in austere settings in remote corners of the world or right in our backyard, preparing around the clock to respond to crises at home or abroad at a moment’s notice.

By Mohammad Naeem, MD, Colonel, United States Army, Staff Radiologist, Fort Belvoir Community Hospital, Va

The views expressed in this article are those of the author and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government.


1.Levesque WR. IEDs continue to kill and maim U.S. troops despite multibillion dollar effort. Tampa Bay Times.Setpember 27, 2012
2.Zorova G. How the IED changed the U.S. military. USA Today. December 18, 2013.
3.Goldberg MS. Updated Death and Injury Rates of U.S. Military Personnel During the Conflicts in Iraq and Afghanistan. Working Paper Series Congressional Budget Office Washington, DC, December 20
4.CNS News. June 3, 2016
5.Batchelor JS. CT is the gold standard for inhalation anthrax imaging. November 29, 2001.

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