Les R. Folio

Frostbite in a mountain climber treated with hyperbaric oxygen: case report.

We describe a case of frostbite to all fingers of a mountain climber, treated with hyperbaric oxygen (HBO). All fingers eventually healed to full function, with only some cosmetic deformity to the tip of the most severely affected finger. Because few cases of frostbite treated with HBO have been reported, we hope that such case reports will stimulate future research in this area. It is hoped that multiple anecdotal cases may help guide future research in this area. Sequential digital photographs were taken at various stages of healing during HBO treatments. We raise the possibility of photographic techniques and standards that may facilitate planning of therapy for frostbite with improved treatment comparisons, resulting in more consistency in the future. For example, a graphical software application is described that allows morphing of sequential images to demonstrate healing progress in a concise movie format. The morphing allows concise demonstration of healing to the referring provider and patient and helps in teaching and research on frostbite treatment outcomes.

Mass Casualty Tracking with Air Traffic Control Methodologies

BACKGROUND An intrahospital casualty throughput system modeled after air traffic control (ATC) tracking procedures was tested in mass casualty exercises. ATC uses a simple tactile process involving informational progress strips representing each aircraft, which are held in bays representing each stage of flight to prioritize and manage aircraft. These strips can be reordered within the bays to indicate a change in priority of aircraft sequence. In this study, a similar system was designed for patient tracking. STUDY DESIGN We compared the ATC model and traditional casualty tracking methods of paper and clipboard in 18 four-hour casualty scenarios, each with 5 to 30 mock casualties. The experimental and control groups were alternated to maximize exposure and minimize training effects. Results were analyzed with Mann-Whitney statistical analysis with p value < 0.05 (two-sided). RESULTS The ATC method had significantly (p = 0.017) fewer errors in critical patient data (eg, name, social security number, diagnosis). Specifically, the ATC method better tracked the mechanism of injury, working diagnosis, and disposition of patients. The ATC method also performed considerably better with patient accountability during mass casualty scenarios. Data strips were comparable with the control method in terms of ease of use. In addition, participants preferred the ATC method to the control (p = 0.003) and preferred using the ATC method (p = 0.003) to traditional methods in the future. CONCLUSIONS The ATC model more effectively tracked patient data with fewer errors when compared with the clipboard method. Application of these principles can enhance trauma management and can have application in civilian and military trauma centers and emergency rooms.

Medical Applications of Digital Image Morphing

The authors present a unique medical technical application for illustrating the success and/or failure of the physiological healing process as a dynamically morphed video. Two examples used in this report include the healing of a severely fractured humerus from an explosion in Iraq and the other of dramatic tissue destruction from a poisonous spider bite. For the humerus, several sequential x-rays obtained throughout orthopedic surgical procedures and the healing process were morphed together representing a time-lapsed video of the healing process. The end result is a video that demonstrates the healing process in an animation that radiologists envision and report to other clinicians. For the brown recluse spider bite, a seemingly benign skin lesion transforms into a wide gaping necrotic wound with dramatic appearance within days. This novel technique is not presented for readily apparent clinical advantage, rather, it may have more immediate application in providing treatment options to referring providers and/or patients, as well as educational value of healing or disease progression over time. Image morphing is one of those innovations that is just starting to come into its own. Morphing is an image processing technology that transforms one image into another by generating a series of intermediate synthetic images. It is the same process that Hollywood uses to turn people into animals in movies, for example. The ability to perform morphing, once restricted to high-end graphics workstations, is now widely available for desktop computers. The authors describe how a series of radiographic images were morphed into a short movie clip using readily available software and an average laptop. The resultant video showed the healing process of an open comminuted humerus fracture that helped demonstrate how amazingly the human body heals in a case presentation in a time-lapse fashion.

Echelons of Combat Casualty Care and Associated Imaging Resources

This chapter provides an overview of the various levels and capabilities of hospitals in deployed military bases in combat zones. This includes the equipment and staffing resources, capabilities, and roles in the flow of combat casualty care. The major role of radiologists in the combat setting is at Level 3 facilities. The equipment at our Level 3 facility in Balad, Iraq, will serve as an example of resources available at most other Level 3 facilities in Iraq and Afghanistan.

Loose Body in Elbow of a Baseball Player: Arthroscopic/ Radiologic Correlation

We present the case of a 21 year old male college varsity baseball player who presented with sudden non-traumatic right elbow pain and limited range of motion. Plain radiographs suggested a calcified intra-articular body. Magnetic Resonance (MR) was performed to better characterize the location, consistency and mobility of this body. Multiple intra-articular bodies were found at subsequent arthroscopy. This case emphasizes the close correlation among the clinical, radiographic, MR and arthroscopic findings.

Skeletal Trauma in Iraq

There are unique challenges to imaging extremities in a combat hospital environment and providing the information necessary to the orthopedic surgeons for surgical planning. Tremendous results have been witnessed in recent years with the judicious use of external fixators in the field [1]. In addition, wound vacuum-assisted closure along with aggressive forward field surgical approach, premier air-evacuation, and appropriate antibiotic therapy have helped limb salvage on the battlefield and in the higher echelons [2]. These temporizing stabilization and treatment modalities have saved the limbs of countless wounded warriors who would have otherwise lost their extremities or ended up with more severe disabilities such as those from prior conflicts. Example cases will be shown that have not been demonstrated in previous chapters, and only those unique to military combat setting. Again, even though military-specific from one perspective, any civilian setting can have combat-like conditions in a mass casualty disaster.

Abdomen and Pelvis Imaging in Iraq

The majority of the injuries during the time I was in Iraq were blast and ballistic injuries; this was especially true for the abdomen and pelvis due to lack of body armor in these regions. Like any other trauma center, the pelvis AP X-ray was second only to the CXR. The plain X-rays of the abdomen and pelvis were often used as a survey of retained blast fragments and major fractures.

The Combat Environment: Preparation for Deployment

The environment of a deployed combat hospital brings many challenges such as artillery fire, heat, sand, dust, cold, and frequent power outages. This chapter will provide an overview of deployment preparation and battlefield challenges the military radiologist needs to know. In addition, the concepts and cases presented here should provide baseline knowledge for mass casualty/disaster preparation for any radiologist where there is an emergency room.

Chest Imaging in a Battlefield Hospital

The chest X-ray is the bread and butter of diagnostic imaging and among the most common radiologic studies throughout the world, and the combat hospital is no exception. Chest CT is also common in the battlefield hospitals, and not just for initial trauma, but for follow-up trauma (anywhere in the body), the ICU patients, wards, etc., as well. The chest is one of the major indicators of clinical status, and portable CXRs are done almost daily on every ICU patient. Checking the status of tubes and lines, aeration, atelectasis, effusions, contusions, other fluid collections on morning CXR’s is a daily activity in combat hospitals, not unlike many civilian hospital ICUs stateside and internationally.

Blast and Ballistics: Types, Background, Terminology

Many combat casualties are victims of explosives, resulting in catastrophic polytrauma with multiple types of injuries. Terrorists attack in an attempt to drain resources, injuring many, with grueling psychological effects to help get their message across. Blast injuries are not as unique to battle as we would hope, however, as they are unfortunately becoming more common worldwide outside the battlefield environment. Familiarity with imaging manifestations of blast injuries, for example, is paramount no matter the setting, country, or location. Disasters, explosions, and shootings can happen in all types of settings and can occur anywhere. Some example cases of blast and ballistic injury are highlighted to illustrate our experiences in imaging findings and surgical follow-up in combat casualties.