Boots on the Ground

Taking Imaging 3.0™ from the front lines of the battlefield to your practice.


January 2016

Imagine waking up to go to your practice on a Monday morning — it’s only a 10-minute walk away. The scent of mud and sewage hits your nose, and the air is filled with the sound of construction and other industrial noises. Sirens wail in the distance. You quickly sidestep the potholes that litter the ground as you enter your department, a series of beige walls meant for quick deconstruction should the need arise. Your patients often arrive by helicopter, and the minute you enter, work begins.

Welcome to being a combat radiologist. Welcome to Afghanistan.

Combat radiologists face a variety of difficult conditions on the front lines — fully staffed hospitals are in short supply, the patients often suffer from severe trauma, and the threat of attack overshadows every procedure. In this high-stakes environment, combat radiologists employ many strategies that align closely with Imaging 3.0™. As a result, these radiologists are some of the most valued members of their team.

Lieutenant Commander J. Carney, MD, head of the Orthopedic Surgery Unit in Kandahar, Afghanistan, often gives this advice to incoming physicians: “Make friends early with the radiologists. They are one of the most important assets. They have their finger on the pulse of everything in the trauma hospital.”

What’s it like to be a combat radiologist, and how can you cultivate these skillsets into your practice? Find out with these tips from radiologists who have (literally) been on the front lines.

Be Ready for Anything

In a combat environment, physicians have little time to treat patients — their goal is not necessarily to help soldiers recover to full health, but to get them well enough to disposition (meaning they are able to transfer to a hospital away from the front lines). Because of the need for quick turnaround, combat radiologists must be prepared and willing to perform tasks not normally included in the specialty, such as focused assessment with sonography for trauma (FAST) exams, which are used to determine if a patient has internal bleeding.

Uncommon tasks such as these are what Stephen L. Ferrara, MD, captain in the U.S. Navy and interventional radiologist at Walter Reed National Military Medical Center in Bethesda, Md., encountered when he first came to Kandahar, Afghanistan, during Operation Enduring Freedom in 2009. Although not a newcomer to the austere combat environment, Ferrara had to volunteer as a general medical officer rather than a radiologist, because the military had not yet determined that interventional radiologists were needed in combat.


When he arrived, Ferrara let the trauma team know his subspecialty, and they sent him to perform FAST exams. “In my head, I was thinking , ‘Radiologists don’t do those exams,’ but I told them I would. I could perform the procedure, and these exams would let me work directly with the patients,” says Ferrara.

Because of his willing attitude, Ferrara was quickly accepted as one of the primary members of the trauma team. “We all walked out of the trauma bay with blood on our gloves and sweat on our foreheads, and because of that, the other doctors viewed me as their equal. I was able to make important suggestions pertaining to patient care — once, I advised we do an angiogram, and we set to it, despite the procedure never having been done on the battlefield before,” explains Ferrara.

Ferrara’s work led to a paradigm shift in military medicine. Ferrara’s team went on to do many more interventional radiology procedures — and as a result, interventional radiology was permanently incorporated as a part of combat surgical hospitals.

John D. York, MD, captain in the U.S. Navy and interventional radiologist at the Naval Medical Center in Portsmouth, Va., encountered a similar situation a few months later, when he too was sent to Kandahar. “I’d never done a FAST exam before, but I read articles and determined the views the trauma team needed,” he says. York and the radiologists in Kandahar performed a variety of tasks, from using ultrasound to search for cardiac activity in patients undergoing CPR to mentoring physicians at local hospitals.

Be Visible

Combat radiologists are also highly visible members of the care team. Not only are they working directly with patients as they do tasks such as FAST exams, but Ferrara, York, and other combat radiologists also participate in clinical rounds and team discussions in which they (along with surgeons, internists, and other physicians) discuss how best to get each patient well enough to disposition. York says, “It was the ultimate integration of the health care team. The other physicians could ask me questions about findings and, in turn, if I had a question about what I was seeing, I could speak to them or even go physically examine the patient to help determine my findings.”

Ferrara notes his unit even had a workstation in the middle of the trauma bay. Every patient who received injuries from improvised explosive devices would receive imaging, and other physicians on the team would watch as the radiologists read the images. “It puts a lot of pressure on you, having everyone hover and listen to your every word, but it ensured we were integrated in the team. It was impossible to forget that we participated in the patients’ care because we were right there in the middle of everything.”

Note: Click on image below to enlarge

Ronald J. Boucher, MD, Stephen L. Ferrara, MD, and John D. York, MD, on duty in Kandahar, Afghanistan.

Put Words Into Practice

How do these actions translate to civilian life? Sometimes it means a willingness to participate on tumor boards or in the hospital’s leadership. Other times, it can be simply walking out of the reading room to determine if a referring physician has any questions about reports or sitting down with a patient to explain results. With health care still tied to fee-for-service, this can be difficult.

The key to overcoming the difficulty and incorporating valuable practices into your daily schedule is changing your mindset, says York. “We have to stop thinking of ourselves as just radiologists. It can be divisive. Instead, think of yourself as simply a doctor,” he adds.

Get into the Mindset

Ferrara agrees: “In the military, we look at things two ways: strategically and tactically. And that’s how you have to think about value-based care,” he explains. “First, you determine your strategy. You make a choice to be an active part of the health care team. And that means you don’t get to pick and choose what activities are and are not relevant to you. Then you have to look at your tactics: how can you find time to say yes to activities that may not otherwise be part of your schedule?”

Adds York, “A lot of times you simply have to decide you’re going to get out of your comfort zone, and be okay with that. Sometimes that means giving an actionable report. Instead of saying, ‘That’s not indicated,’ you can say, ‘That’s not indicated, but here is a study that might find the answer we’re looking for in this patient.’”

Set Yourself to the Task

Not that these are easy actions, notes Ferrara. He says, “Initially, actions such as these might have some tradeoffs with productivity. Maybe that means you make it up with longer hours or less vacation. But in the end, you reap dividends. That’s how investments work — there’s a short term cost, but by taking that cost on, we show our value and don’t become commoditized.”

By Meghan Edwards, copywriter for the ACR Bulletin

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