Latest wars catalyze change in way military uses imaging technologies

April 30, 2003

Handheld ultrasound shines as tool for early evaluationExpensive high-tech weaponry made the military victories possible in Iraq and Afghanistan. But imaging technology provided the means to save lives.CT, computed radiography, and

Handheld ultrasound shines as tool for early evaluation

Expensive high-tech weaponry made the military victories possible in Iraq and Afghanistan. But imaging technology provided the means to save lives.

CT, computed radiography, and portable ultrasound carried the brunt of the load. In many cases, ultrasound provided a first look at casualties, while digital radiographs rendered greater detail. CT aided in the assessment of complications and the planning of complex surgery in mobile hospitals and in brick-and-mortar facilities thousands of miles away from the battlefield.

SonoSite has sold about 300 of its 180 Plus handheld scanners to the military. About half are in the hands of physicians assigned to mobile surgical teams or combat support hospitals either in Iraq or Afghanistan. The SonoSite units were purchased because ultrasound can help determine the severity of an injury, recording abdominal or chest bleeding or other vascular damage, as well as the presence and location of foreign bodies, according to Ron Dickson, chief business development officer, U.S. government division for the Bothell, WA, company.

"Many times when a grenade or land mine goes off, there is more than just gross injury," he said. "You get all kinds of materials-rocks, glass, metal, Kevlar, leather-anything that might be on the soldier's body is going to be embedded in that wound."

Other SonoSite products are being evaluated for use on the battlefield. Several physicians assigned to classified missions are evaluating the use of the company's superlightweight iLook units in forward combat units, Dickson said.

"These are being tested to see if ultrasound has some clinical or significant patient benefit for a medic in a forward situation," he said.

To get a more detailed look at injuries, the U.S. Army, Air Force, and Marines use CR. A complete unit, consisting of x-ray generator and tube, patient table, and Kodak's ACR 2000 CR system, is packed into two custom-made barrels weighing less than 500 pounds each. These can be packed in the back of a HumVee or moved from place to place in a surgical hospital using a cart. Special operations soldiers have done one better, cutting their CR equipment to the bare minimum and packing it into hardened suitcases.

Mid-Atlantic Telerad, a systems integrator in Oak Hill, VA, came up with these portable solutions. Doing so took more than three years, said Darin Briggs, product manager. The spur came from the U.S. Marines.

"They were using film and needed HazMat teams to get rid of the chemicals," he said. "They heard about the digital capabilities of x-ray, and that got the ball rolling."

CR systems are augmented at mobile surgical hospitals by rectangular enclosures, called ISO shelters, so named because they meet international standards for size and shape. The shelters house radiographic suites, radiography/fluoroscopy systems, and CT scanners. They look like small boxcars without the wheels but are small enough to fit into C-130 transport aircraft.

Philips Medical Systems received orders last fall to integrate their Mx8000 Dual scanners into ISO shelters for military deployment in Afghanistan, Iraq, and elsewhere. Practicality dictated the choice of the two-slice systems over their more powerful kin.

"The dual-slice systems are air-cooled-the others are water-cooled," said Paul O'Brien, vice president of government business at Philips. "Getting water to the desert is a big problem."

The first of these Philips scanners are scheduled to ship May 1, 2003. They will replace older Picker PQ 5000 and PQ 2000 single-slice scanners, which have been workhorses for the military in Afghanistan and Iraq.

Philips is also outfitting military shelters with its own brand of digital R/F systems. They feature 16-inch image intensifiers for fluoroscopy along with table and wall buckys for flat images. Philips CR plates and readers take the place of film and film processors. They will replace R/F tables currently in the field, which were manufactured by the defunct Continental X-Ray. Earlier this year, Philips added CR to 12 ISO shelters containing Picker-made radiography systems.

"This was a rush job for an order we received at the end of December," O'Brien said.

In the months leading up to the invasions of Afghanistan and Iraq, quick turnaround by vendors was a must. Another challenge for Philips has been meeting the unique siting requirements of the military. R/F and CT scanners must be fitted into ISO shelters that partially fold up before being shipped to the site. They may sit for days or weeks in scorching heat or freezing cold, and must then operate effectively in rooms about half the size for which they were designed. None can be a "special order." Still smarting from media coverage in the 1980s of custom-made wrenches and toilet seats that cost thousands of dollars each, the U.S. military buys only off-the-shelf.

"They want to buy commercial products, so we sell them commercial products," O'Brien said. "What makes these systems special is what we do with them in the ISO shelters and how we mount them in there."

In the Persian Gulf, less than 60 miles from Kuwait, is the USNS Comfort, an 894-foot supertanker that's been converted into a floating trauma center staffed mostly by physicians from the National Naval Medical Center in Bethesda, MD. The ship's crew of 750 navy and civilian medical personnel staffs 12 operating rooms and has beds for 1000 casualties. Today only 50 to 100 patients are onboard, according to Tim Artz, director of Agfa's global government program.

"They're treating Iraqis as well as coalition combat troops," he said.

Patients are flown to the ship from the mainland by helicopter, where they are brought below deck to a huge emergency room, called casualty receiving. Agfa CR readers have replaced wet film processors, freeing up space that can be used for other purposes, such as the servers that route and archive computed radiographs and digital images from other modalities using the Agfa's Impax PACS.

"Part of our project was removing darkrooms," Artz said.

The journey home for many wounded U.S. soldiers includes a flight to Ramstein Air Force Base in Germany and a trip across town to Landstuhl Regional Medical Center. There the complexities and complications of combat injuries are examined using a Toshiba quadslice Aquilion, the only CT at the medical center.

The Aquilion was installed only about six weeks ago as part of an emergency requisition to replace a single-slice scanner. Army brass, working with the government accounts department at Toshiba America Medical Systems, issued the purchase order March 2. The Aquilion landed in Frankfurt three days later. It was up and running within 60 hours.

Toshiba staff worked with physicians and technologists at Landstuhl for three weeks, training them on the system. Before they could finish, casualties began arriving, according to Mike Marker, TAMS manager of government accounts.

"They really didn't have much time to gear up on the system," he said.

Two key factors in selecting the Aquilion were the image quality resulting from 0.5-mm slice thickness and the postprocessing capabilities of the Vitrea workstation, which is supplied by Vital Images. Reliability was the third, according to Marker.

"We were able to demonstrate minimal downtime on our existing installed scanners," he said.

Specialty care or consultation is available throughout the Landstuhl medical center and from staff at any of the surrounding affiliated clinics utilizing the hub-and-spoke Sienet PACS network installed by Siemens Medical Solutions. Data can be transferred to distant sites over the Web, according to Wade Davis, Siemens product manager for government national accounts.

Among these sites is Walter Reed Army Hospital, a sprawling medical complex in Washington, DC. It is the last stop for many U.S. soldiers in a system that has redefined military care at least partly through the use of 21st century imaging technology. The most advanced imaging equipment available supports their care.