Radiology Afloat: The Impact of Diagnostic andInterventional Radiology during the 2005 TsunamiRelief Effort Aboard the USNS MercyStephen Ferrara, MD

J Vasc Interv Radiol 2009; 20:289–302

Abbreviations: CASREC ! casualty receiving bay, ICU ! intensive care unit, IVC ! inferior vena cava, OUA ! Operation Unified Assistance

AT approximately 9 a.m. local time onDecember 26, 2004, an earth-shatteringevent took place in the Indian Ocean;it was to become one of the worst nat-ural disasters the world had seen sincethe eruption of Mt. Krakatoa in 1883 inIndonesia. While thousands of Aceh-nese families made their ritual Sundaypilgrimage to the seaside to enjoy arelaxing family outing in the setting oftheir region’s immense natural beauty,a massive 9.2-magnitude earthquakeshook their island’s foundation, un-leashing a merciless tsunami thatwould claim an estimated 150,000lives from this single, humble prov-ince. Although Aceh’s capital city,Banda Aceh, was the world’s most se-verely affected location, the devasta-tion was felt vastly throughout Asiaand even as far away as Africa (Fig 1).Millions were affected in 14 nationsand as many as 300,000 were killed (1).Inhabitants of this part of the world,known as the Ring of Fire because of

its intense seismic and volcanic activ-ity, are no strangers to natural disas-ters. However, nothing could haveprepared them for this.

As Americans celebrated the holi-days, the media streamed home im-ages from the disaster, generating atremendous outpouring of sympathyfor the victims of this horrific tragedy.National governments and private ci-vilian aid organizations (identified asnongovernmental organizations, orNGOs) mobilized financial, materiel,and manpower aid in an effort to easethe suffering. The United States led inthis initiative, both as a governmentagency and through its citizenry. ByDecember 31, the US government hadpledged $350 million (eventually $950million was pledged by the Americangovernment and an additional $1 bil-lion was donated privately) (2), butperhaps more importantly, it mobi-lized one of its greatest assets to lendassistance: the US Navy. The USSAbraham Lincoln had been perform-ing its normal patrol work in the In-dian Ocean when the tsunami struck;within a matter of days, the ship ar-rived on station off the coast ofSumatra and began providing criti-cally needed food, potable water, andsanitation. The ship and its supportvessels shelved their original missionand stayed on station for more than 1month. During that time, thousands ofhelicopter sorties were flown to ensurethat the initial survivors of the tsu-nami had the best possible chance ofcontinued survival without falling vic-

tim to the harrowing threats of dehy-dration, disease, and starvation.

MISSION OF MERCY

With millions of US aid dollarscommitted and the Lincoln on stationproviding tons of food and thousandsof gallons of potable water, a finalpiece was yet missing: American med-ical expertise. On New Year’s Day2005, 6 days after the disaster hadstruck, one of the Navy’s two hospitalships, the USNS Mercy, was activatedand began making preparations toleave her home port in San Diego, Cal-ifornia.

The Mercy was constructed as awartime casualty receiving and treat-ment facility, and designed with thecare of trauma patients in mind. Theship is a floating tertiary care center,now tasked to take world-class Amer-ican medical know-how to the needi-est of third-world nations. It is an im-pressive medical platform. Convertedfrom the oil tanker S.S. Worth in 1985,Mercy is a 1,000-bed hospital complexcomplete with 12 operating rooms(including a converted angiographysuite), 80 intensive care unit (ICU) and20 postoperative beds, a full labora-tory and pharmacy, a blood bank, anda complete radiology department (Ta-ble 1). A helicopter pad is adjacent to amassive open casualty receiving bay(CASREC) via a bank of three eleva-tors. Patients can be triaged and resus-citated in CASREC, where portable x-ray units are used to obtain imagesthat are loaded onto the picture ar-

From the Department of Radiology, Naval MedicalCenter San Diego, Clinical Investigation Department(KCA), 34800 Bob Wilson Drive, Suite 5, San Diego,CA 92134-1005. Received February 15, 2008; finalrevision received April 16, 2008; accepted October20, 2008. Address correspondence to S.F.; E-mail:stephen.ferrara@med.navy.mil

The views expressed in this article are those of theauthors and do not necessarily reflect the officialpolicy or position of the Department of the Navy,Department of Defense, or the United States Gov-ernment. The author has identified no conflicts ofinterest.

© SIR, 2009

DOI: 10.1016/j.jvir.2008.10.026

Special Communications

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chiving and communication systemright in the treatment bay. Three com-pact, portable ultrasound (US) units(SonoSite, Bothell, Washington) canalso be employed by radiologists,emergency room physicians, and sur-geons to perform “fast scans” to lookfor free intraperitoneal fluid. For more

advanced imaging, patients can bebrought to the main radiology depart-ment directly adjacent to CASREC,where they can undergo imaging inany one of four radiography/fluoros-copy rooms or they can undergo acomputed tomography (CT) scan orformal US examination. From the ra-

diology unit, the patient can go di-rectly to the neighboring main operat-ing room complex, followed by aseamless transit to the postanesthesiacare unit or any one of the ship’s threeICUs or its isolation unit.

In addition to her substantial med-ical capabilities, Mercy can produce300,000 gallons of potable water perday, as well as medical-grade oxygen,and perform any number of biomedi-cal repairs or part fabrication. Al-though she had not deployed in thenearly 14 years since Operation DesertStorm, a rapidly assembled hospitalstaff and ship’s crew worked aroundthe clock to make ready for her first-of-a-kind mission. On January 5, 2005,Mercy sailed from San Diego boundfor Indonesia. “Operation Unified As-sistance” (OUA) had begun.

CALLING ALL HANDS

As capable of a medical platformas Mercy was, her greatest limitationwas glaringly apparent: manpower.Stretched increasingly thin since 9/11,the Navy medical department contin-ues to support fighting Sailors, Ma-rines, Soldiers, and Airmen around theworld—not only in Iraq and Afghani-stan, but in Africa and Europe as well.For Mercy to accomplish her missionof providing world-class support tothe tsunami victims, the Navy triedsomething completely novel: it calledon the American civilian medical com-munity for help. It responded in force.Partnering with American nongovern-mental organization Project HOPE, acall was put out for doctors and nursesto volunteer to spend terms of at least30 days aboard Mercy rendering aid tovictims of the tsunami. Volunteersflew to Singapore, where they wouldmeet the already–under way ship andthen complete the two- to three-daysail to Banda Aceh.

Because of the chaos of the situationon the ground, particularly in the ini-tial days after the disaster when re-sources were being mobilized rapidly,no guarantees could be made to vol-unteers regarding how they would beused within their specialties: needswere still undefined. Volunteers couldbe certain only that they would beworking extremely hard, in an unpre-dictable environment, helping peoplein desperate need. No assurances werenecessary, as an overwhelming flood

Figure 1. Epicenter of 9.2 magnitude earthquake off the western coast of Sumatra,Indonesia, December 26, 2004. Shaded areas depict countries most greatly affected byresultant tsunami.

Table 1Specifications of USNS Mercy

Specification Details

Commissioned November 8, 1986, San Diego, CaliforniaLength 894 ftBeam 106 ftDraft 33 ftDisplacement 69,360 tonsRange 13,420 nautical milesSpeed 17.5 knots (20.13 mph)Aircraft Helicopter platformBed capacity 1,000/80 ICU/20 PACUOperating rooms 12 (including angiography suite)Auxiliary services Radiology, laboratory/blood bank/histopathology, burn unit,

pharmacy, dental, physical therapy, optometry/lensfabrication, central sterile receiving, biomedical repair,engineering services medical gas production, laundryservices

Water production 300,000 gal/d

Note.—PACU ! postanesthesia care unit

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of volunteers eagerly and unhesitat-ingly came forward—a deluge that ex-ceeded the roughly 100-person volun-teer capacity the mission required andcould accommodate. Volunteers camefrom academic and private practices;some were newly trained and otherswere “semi-retired.” MassachusettsGeneral Hospital responded en blocwith nearly 40 doctors and nurses overtwo 30-day sessions. Some dedicatedvolunteers like pediatric intensivistDana Braner and nurse practitionerGabrielle Bergmann signed up for 4weeks but couldn’t bring themselvesto leave when their “tour of duty” wasover and eventually stayed on formany extra weeks.

The crew of Mercy was hailed as a“Team of Teams,” made up not only ofthe aforementioned Navy and civilianpersonnel, but Army and Air Forcepersonnel. The Public Health Servicealso loaned expertise from the Na-tional Institutes of Health, Centers forDisease Control, and the US CoastGuard. Once on station, Americansworked side by side with medicalteams from the International Commit-tee of the Red Cross and various inter-national militaries including units

from Germany, Australia, Singapore,and host nation Indonesia. Indepen-dently, many other international civilianorganizations also provided assistanceand sent medical teams (Table 2).

“ATTENTION IN THE MTF!”

After the 8,000 nautical mile jour-ney across the Pacific and IndianOceans and picking up her augmen-tees in Singapore, Mercy arrived onstation in Banda Aceh on January 31,2005, where she relieved the AbrahamLincoln and made final preparationsto receive her first patients (Fig. 2).The question remained, however, as tohow a behemoth such as the Mercy,built for treating combat casualties,could best be used in this humanitar-

ian assistance/disaster relief environ-ment. The international medical teamsthat had set up field hospitals ashorewere clamoring for Mercy’s diagnosticcapabilities. Each facility had dozensof patients whose treatment had beenstymied by an inability to make defin-itive diagnoses. In some instances theproblem was an inability to character-ize bacteria in the myriad infected pa-tients because of the lack of a microbi-ologic laboratory; in other cases no onecould determine what was reallywrong with many of these terribly illvictims. It became immediately clearthat proper medical imaging was anabsolute necessity if we were to providequality, “first-world” medical care.

But before any of this could be ad-dressed, the mission needed a clear

Figure 2. USNS Mercy relieves USS Abraham Lincoln off Aceh coast, Sumatra, Indone-sia, February 3, 2005.

Table 2The “Team of Teams”

Unit Personnel

Total military personnel 450*Medical officers (MDs) 12Medical Service Corps

(Allied Health Services/Administration)

18

Nurses 17Supply officers 2Warrant officers 2General duty corpsmen 70Specialty corpsmen 80Nonmedical personnel 247Project HOPE 180 (91/89)†Physicians 45 (22/23)DMD/OMFS 2 (0/2)RN/NP/CRNA 115DVM 2 (1/1)Optometry 2 (1/1)LCSW 3 (2/1)RD 2 (1/1)Administrative 9 (6/4)

* Numbers are approximate as actualnumbers of military and civilianpersonnel varied during the mission.† Civilians volunteered for either oftwo 30-day “tours of duty.”

Table 3Radiology Department Aboard USNS Mercy: OUA 2005

Personnel No. Equipment

Radiologist (IR trained) 1 1 GE LightSpeed 16-slice CT unitLead Technologist (Chief Petty

Officer)1 2 GE MPH digital radiography suites

Radiology Technologists 5 2 GE Digital Legacy radiography/fluoroscopysuites

Diagnostic radiology 2 1 GE Tilt-C angiography suiteAngiography 1 1 Acuson Sequoia US unitCT 1 3 SonoSite portable US unitsUS 1 3 GE OEC 9800 portable C-arm fluoroscopy

units5 GE AMX 4" portable x-ray unitsAGFA PACS

Note.—The Radiology Department was comprised of US Navy personnel only. IR !interventional radiology; PACS ! picture archiving and communication system.

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understanding of the patients. Themilitary mission the ship’s plannershad in mind assumed that the medicalcare would come from doctors treatingmilitary personnel of a substantivelyidentical culture. OUA was not thatkind of mission at all. Success requiredcreating and implementing solutionsto challenges that were not found in atraining manual; first and foremost,this meant gaining a sensitivity to theMuslim culture of the Acehnese peo-ple and to the immensely alien natureof an American hospital ship. TheMercy would call for a Muslim chap-lain, a culturally sensitive diet, andplacards translated into the native di-alect (one of the many services pro-vided by a small army of tireless Indo-nesian translators hired by the Navy).Part of that adaptation was allowingeach patient to bring a family memberto the ship to stay with them duringtheir entire hospital course. Althoughthis created a crowded and oftenstrangely aromatic atmosphere on thewards (astutely skeptical of hospital

fare, family members would often pre-pare local recipes right at the bedside),it was an essential part of gaining thetrust and confidence of a people whohad minimal, if any, firsthand knowl-edge of Americans—and who weremeeting us under the absolute worstof circumstances.

Advanced party liaisons who hadmet with medical and governmentalofficials on the ground in Banda Acehhad determined that Mercy would bemost helpful by serving in a dual ca-pacity: she would be the tertiary caremedical facility for the sickest patientswho exceeded the capabilities of thefield hospitals, and she would deployprimary care and preventive medicineteams to outlying villages to servethose unable to make the trek to BandaAceh. Three primary categories of pa-tients needed our assistance: (i) thosewith injuries and illnesses caused di-rectly by the tsunami; (ii) those withchronic medical illnesses who couldno longer receive medical care as aresult of the devastation of the local

infrastructure (including the destruc-tion of local hospitals and the death ofmany local physicians); and (iii) thosewho suffered acute trauma or had be-come ill after the tsunami had struckbut who had nowhere else to betreated.

What Mercy’s radiology depart-ment lacked in manpower, it made upfor in attitude (Table 3). The initialqueue of critically ill medical and sur-gical patients requiring CT scans wasnearly 50, and dozens of other ortho-pedic patients who had been bedrid-den for nearly a month required innu-merable plain radiographs, lower-extremity Doppler images, and C-armintraoperative fluoroscopy. Ultimately,many orthopedic patients went on toreceive inferior vena cava (IVC) filtersas well (n ! 12). Because of the highprevalence of tuberculosis, every pa-tient, as well as his or her family mem-ber escort, required a screening chestradiograph before they could be dis-positioned out of the CASREC. Thiswould have created a bottleneck in the

Figure 3. (a) Anteroposterior (AP) chest radiograph reveals bilateral patchy infiltrates in a 13-year-old male patient after near-drowning. The patient had clinical acute respiratory distress syndrome and was the first critically ill patient treated aboard the USNSMercy during OUA. (b) Shortly before discharge, the boy and his uncle take in the view from the Mercy’s flight deck.

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Figure 4. Images from a 15-year-old male patient with hemi-plegia, fever, cough, and shortness of breath. (a) AP chest ra-diograph reveals large left-sided pneumothorax as well as airspace and cavitary lesions following sea water aspiration. (b)Contrast-enhanced head CT with one of several cortical, ring-enhancing lesions and extensive surrounding white matteredema secondary to septic embolic phenomena. (c) AP chestradiograph in the same patient after left tube thoracostomyplacement with improvement in left-sided pneumothorax.

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flow of patients had it not been for theincredibly hard-working young x-raytechnologists who unselfishly pooledtogether for the common good regard-less of subspecialty expertise.

For the medical staff and crew thathad been with the ship since San Di-ego, a seemingly endless number ofplanning meetings and reviews of pos-sible scenarios had taken place. Forteammates who had joined us in Sin-gapore, the service they had pledgedweeks earlier was finally about to berealized. So many people clearlyneeded our help, and so much goodwas waiting to be done—our eager-ness and optimism were peaked. Andalthough no one was really sure whatto expect or just how well we wouldperform, when the first inbound pa-tient-laden helicopter was announcedover the 1-MC (a Navy ship’s publicaddress system), the anticipation waspalpable.

ORGANIZED CHAOS

Deluged with patients, every clini-cal service scrambled to triage individ-uals who represented (it seemed) ev-ery combination of age, sex, anddiagnosis. Yet despite this frenzied at-mosphere, each patient found a way to

make a personal impact on each of uswho participated in his or her care.One of the first and most memorablepatients was a 13-year-old boy namedIqbal who had lost both his parents inthe tsunami and had been found afterhaving clung to a piece of driftwoodfor days. On death’s doorstep, he suf-fered severe aspiration pneumonia,complicated by dehydration, malnu-trition, and chronic anemia (Fig 3a).Admitted to the ICU, he was intubatedfor nearly 1 week, but showed steadyimprovement until he eventually tran-sitioned to the ward and ultimately onto the normal activities of a 13-year-old (Fig 3b). Iqbal’s tragic family story,unfortunately, was more the rule thanthe exception. What made his case sounforgettable was that it was our firstunequivocal success with a critically illpatient, otherwise certain to die, wholived and could go on to thrive be-cause of the Mercy.

Not only was Iqbal a clinical suc-cess on an individual basis, his illnessrepresented the first of many pulmo-nary syndromes we would see so fre-quently in the ensuing weeks. Al-though the massive aspiration of seawater was lethal for so many, a num-ber of children and teenagers had thepulmonary reserve to survive the ini-

tial insult. The virulence of the marineorganisms, however, wreaked havocnot only in the lung but in the centralnervous system as well. Several pa-tients referred to the ship after Iqbalhad primary neurologic diagnosessuch as hemiplegia with associated fe-ver, cough, and shortness of breath.Most had already received shortbursts of a variety of available oral orintravenous antibiotic therapy withlimited success. Referred to Mercy pri-marily to undergo head CT examina-tions as part of their neurologyworkup, screening chest radiographsrevealed a more complicated and sin-ister process. Cavitary lesions, consol-idations, effusions, and even pneumo-thoraces were found in the setting ofmultifocal brain abscesses (Fig 4a,b).This process, initially referred to collo-quially as “tsunami lung,” was a con-dition in which a polymicrobial mix ofaggressive marine bacteria erodedthrough pulmonary parenchyma andsometimes pleura, ultimately gainingaccess to the left circulation and on tothe cerebrum (3). Fortunately, a clini-cal conundrum that had frustrated thephysicians ashore became readily elu-cidated with the assistance of modernimaging techniques—including con-trast-enhanced CT. Effective treat-

Figure 5. (a) AP chest radiograph reveals near-complete opacification of left hemithorax in a young adult male patient with severerespiratory distress. (b) AP chest radiograph (prone) after left chest tube placement shows marked improvement in left empyema.

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ments ensued: prolonged intravenousantibiotic therapy with imipenem ormeropenem, as well as percutaneouschest tube drainage in some cases (Fig4c), yielded uniform improvement

with significant progress in pulmo-nary status and neurologic function,often with a dramatic reversal of pa-ralysis within days of therapy. Thissustained antimicrobial regimen was

made possible by the importation of asimple interventional procedure takenfor granted daily in the United States,the lowly peripherally inserted centralcatheter.

Figure 6. Images from a 21-year-old man after a motor vehi-cle accident who experienced respiratory failure during airtransit to USNS Mercy. (a) Chest CT reveals dense dependentpulmonary consolidation secondary to aspiration pneumoniaand contusion. (b) Portable AP pelvic radiograph revealsproximal left femur fracture. (c) Fluoroscopic image afterplacement of Gunther Tulip retrievable IVC filter. The filterwas placed prophylactically as a result of the inability toprovide a conventional anticoagulation regimen in this poly-

trauma patient. (d) The patient was recovering well approximately 1 week after admission with ICU stay, left femoral openreduction and internal fixation, right femoral external fixation, and IVC filter placement.

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INTERVENTIONALRADIOLOGY:FUNDAMENTALLYESSENTIAL

Peripherally inserted central cathe-ter placement came to represent a fun-damental example of first-world med-icine. Because of the lack of facility,expertise, or equipment, this simpleprocedure was not available beforeMercy’s arrival, yet it became a main-stay of therapy and the turning pointfor numerous patients with polymi-crobial infections. Another interven-tional procedure that saved the lives ofseveral critically ill patients was thepercutaneous tube thoracostomy. Notsurprisingly, given the mechanism ofcatastrophe, a vast number of near-drowning patients who had survivedwere suffering from large empyemas.On several occasions, particularly inchildren, these patients experienceddecompensation into respiratory fail-ure on the helicopter flight inboundand underwent drainage percutane-ously in the CASREC, obviating intu-bation or prolonged ICU stay (Fig 5).Again, with appropriate medical ther-apy and adequate drainage, excellentclinical outcomes were routinely ob-tained.

All in all, approximately 300 inter-ventional procedures were performed;they ranged in complexity from ve-nous access to neuroembolization.Eighty cases were performed in theship’s angiography suite and gener-ally represent the higher-complexityvascular cases, whereas the remaining70% of cases were performed at thebedside or in the CT suite. More than2,700 additional radiology examina-tions were also performed, making ra-diology the “nerve center” of the med-ical treatment facility (MTF). Everypatient received a radiographic exam-ination, ranging from screening chestradiography to CT angiography to re-nal artery stent placement. One of themost remarkable features of this expe-rience was that it definitively provedthat imaging is what truly definesfirst-world medicine; and less intu-

itively, although interventional radiol-ogy services are casually perceived asa high-tech luxury in the delivery ofhealth care, they are actually integralto the most basic community standardwe have come to expect in every facetof American health care. This becameastonishingly apparent as specialistsand subspecialists from every facet ofclinical medicine clamored for mini-mally invasive, innovative solutions tothe unique and often incredibly diffi-cult clinical challenges this missionroutinely presented.

We were constantly faced with un-usual circumstances, such as the ne-cessity for extremely short hospitaliza-tions as a result of logistical reasons orhost nation limitations that precludedpatients from continuing their medicalregimen after the ship departed. Anexample of the latter involved severalcrush victims from Nias Island withmassive and complex orthopedictrauma. Many of these often youngpatients would require weeks of im-mobilization with a typical need forprophylactic anticoagulation. How-ever, given the circumstances, noenoxaparin would be available afterthey left the ship. Fearing the short-term orthopedic surgical successwould be complicated by the cata-strophic long-term complication ofpulmonary embolism, through a rigor-ous multidisciplinary approach weopted to place prophylactic IVC filtersin these patients (Fig 6). Although nodata could support such a practice,this mission frequently required “out-of-the-box” thinking: where a ship-board treatment, if unanticipated,could create a worse potential out-come than no treatment at all. Thischess game–like approach to medicalpractice, however, is one of the manythings that made this such a profes-sionally fulfilling experience.

Further examples of interventionalradiologic procedures that elevatedthe level and complexity of care in thisaustere environment to “Western stan-dards” are depicted in Figures 7–13.

Figure 7 shows one of many Mercy

patients who presented with ad-vanced head and neck carcinoma, inthis case papillary thyroid carcinoma,who were able to undergo successfulresection for at least palliation andperhaps increased survival (we didnot have the ability to give I-131 orother systemic antineoplastic thera-pies) because of the ability to performpreoperative embolization. In this na-tion in which the populace had mini-mal, if any, access to health care, thenumber of untreated benign and ma-lignant neoplasms we encounteredwas staggering.

Figure 8 depicts a young womanwith a massively protuberant abdo-men who was referred for imagingevaluation. Contrast-enhanced CT re-vealed a giant fibroid uterus, andupon seeing the engorged pelvic vas-cular channels, the surgeon was ini-tially reluctant to operate for fear oflife-threatening hemorrhage. Reas-sured by the ability to have the tumorpreoperatively devascularized, how-ever, the patient underwent an un-eventful hysterectomy after uterine ar-tery embolization.

In the treatment of another youngwoman with an abdominal mass, thistime a teenager (Fig 9), we found acongenital ureteropelvic junction ob-struction. At presentation, the pa-tient’s serum creatinine and potassiumlevels were markedly increased, butafter image-guided percutaneous ne-phrostomy tube placement, her chem-istry values normalized to the extentto which she could safely undergo aunilateral nephrectomy and contralat-eral pyeloplasty operation. Presum-ably because of the heavy mineral con-tent in the drinking water, exacerbatedby the baseline state of relative dehy-dration suffered by the general popu-lation in this equatorial climate, ob-structive urinary calculi was afrequently encountered condition. Aneven more remarkable example in-volved a middle-aged man who pre-sented with clinical evidence of ure-mia and a 1-week history of anuria(Fig 10). In addition to the obvious

4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™Figure 7. Images from a 58-year-old man with papillary thyroid carcinoma. (a) Photograph after US-guided needle biopsy of twodistinct areas within a large right-sided neck mass. (b,c) Axial images from contrast-enhanced neck CT depicts a large, heterogeneousmass in right neck with areas of necrosis as well as avid enhancement resulting from hypervascularity. Right external carotidarteriograms before embolization (d) and after embolization with 300–500-!m polyvinyl alcohol particles (e,f).

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Figure 8. Reproductive-aged woman referred for evaluation oflarge abdominal mass. (a) Coronal reformatting of contrast-en-hanced abdomen/pelvis CT shows a large mass arising fromthe pelvis consistent with large fibroid uterus. (b) Axial con-trast-enhanced CT shows engorged pelvic vasculature second-ary to mass effect. (c) Left uterine arteriogram before emboliza-tion shows significant hypervascularity and mass effect. (d) Af-ter preoperative particle embolization, marked reduction inuterine vascularity is seen.

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Figure 9. Images from a 15-year-old female patientwith abdominal mass and abnormal serum creatinineand potassium levels. (a) Axial contrast-enhanced CTreveals marked bilateral hydronephrosis, right greaterthan left. (b) Coronal reformat suggestive of bilateralcongenital ureteropelvic junction obstruction. (c) Latephase of intravenous pyelogram reveals markedly di-lated left collecting system with no apparent right-sidedrenal function. (d) Left nephrostogram (prone) afterpercutaneous nephrostomy tube placement.

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Figure 10. Images from a 58-year-old man with 1week of anuria and a serum creatinine level of 31mg/dL. (a) Kidney/ureter/bladder radiographyreveals extensive urolithiasis with several stonesforming apparent “casts” of the ureteropelvic junc-tion. (b,c) Longitudinal sonographic images dem-onstrate massive bilateral hydropyonephrosis, leftgreater than right, and nephrolithiasis. (d) Spotfluoroscopic image after bilateral nephrostomytube placement. (e) Right-sided (prone) antegradenephrostogram after left nephrectomy and rightpyeloplasty. Residual stones were removed percu-taneously.

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radiographic findings, his serum cre-atinine level was greater than 31 mg/dL. A trial of bilateral percutaneousdrainage was performed, which re-sulted in marked improvement in se-rum creatinine level, decreasing to 1.5mg/dL after 3 days. The cause of theanuria was an obstructive urethralstone that was successfully removedsurgically in conjunction with openstone removal with right-sided ne-phrectomy and left-sided pyeloplasty.

ROUTINELYEXTRAORDINARY

The remarkable nature of this expe-rience cannot be summed up by sim-ply recounting the scores of medical

successes. In reality, the medical victo-ries serve merely as a symbol of thegreater success—the experiment thatproved that a vastly diverse group ofprofessionals could be thrust togetherhalfway around the world, united bynothing more than their passion tohelp others, and accomplish amazingfeats. Additionally, the Mercy missionfurther confirmed that advanced diag-nostic imaging is what defines first-world medicine while the ability toperform image-guided, minimally in-vasive procedures defines what wehave come to expect from routineAmerican medicine. Simply put, theaddition of a well-rounded interven-tional radiologist elevates the stan-

dard of care like no other single phy-sician can.

I had never experienced such asense of camaraderie among physi-cians in my career. Maybe it’s becausethis mission of mercy had subselectedfor a certain type of personality, atleast among the civilian volunteers(Navy personnel were not volunteers),or maybe the living environment—which was like a large fraternal camp,living in squad bays, sharing meals,and weathering rough seas together—brought a sense of unity. Maybe it wasthe fact that we were practicing med-icine for desperately needy people thatmade us all feel so dedicated to themission and each other. Or perhapswe were having the professional timeof our lives because we were liberatedfrom the economic and administrativeburdens that can distract us from oureveryday practices, and this allowedus to focus on our real passion—doingsometimes straightforward, some-times complex, but always amazingprocedures for people who desper-ately needed our help. It was medicinedistilled down to the most basic, pure,and beautiful concept: that of provid-ing excellent care, unencumbered byexternal influences so readily apparentin the practice of modern medicine to-day.

The beauty of “medical diplomacy”is the mutual regard it engenders. It iseven capable of lifting the political ba-rometer. According to Pew Global Re-search Associates (4), America’s ap-

Figure 11. Portable US units were heavily used to provide pri-mary and obstetric care ashore.

Figure 12. A patient discovered to have transverse myelitis was brought aboard theMercy in Dili, East Timor. Logistical challenges including limited helicopter availabilitysometimes required ship-to-shore transport of patients by small boat operations.

Figure 13. The Mercy’s pathologist, LCDR Mike Favata, preparesa slide during a CT-guided spine biopsy.

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proval rating in Indonesia, the world’smost populous Muslim nation, wasonly 15% before the tsunami, it morethan doubled to 38% after Mercy’s2005 visit. Although America is farfrom being popular there, this kind ofpositive movement is quite hard toachieve with the use of traditional dip-lomatic methods, and the US govern-ment has clearly taken notice. DuringMercy’s return home from BandaAceh, the previously distant Indone-sian government requested Mercy’shelp after another massive earth-quake, this time afflicting Nias Islandoff the Sumatran coast. Mercy imme-diately steamed to assist, and nosooner had OUA ended when OUA IIbegun. Since that time, the Mercy andher identical east-coast counterpart,USNS Comfort, have made subse-quent humanitarian missions to Asia(in 2006) and South America (in 2007).

As subsequent missions occur, wecontinue to strive to improve and re-fine our methods of providing themost effective humanitarian assistancepossible. The mission of humanitarianassistance varies greatly from disaster

relief, however, and each journey pre-sents its own unique challenges. Sim-ply defining the goals of the missioncan be a daunting task, requiring mod-ulation of a host of variables includingindividual skill sets, equipment, andtime on station—not to mention tryingto meet the goals of those we havebeen charged to help. It is important toremember that the 2005 mission in In-donesia marked the first time thisform of civilian/military collaborationhad occurred, placing this sort of ini-tiative in its very infancy. The goodnews, nonetheless, is that the USgovernment (through the Navy) hasmade a commitment to this effort,and through continued collaborationwith the civilian community, theprocess will undoubtedly matureand improve. For further informa-tion on how to volunteer for yourown “experience of a lifetime” med-ical humanitarian assistance mission,visit www.projecthope.org.

There is no sign that this strategy toreveal the “gentler side of America” isgoing to disappear anytime soon. Mer-cy’s 2008 trek is already planned, and

whatever its geopolitical payoff, themedical benefits for some needy peo-ples in these far-off lands will be tre-mendous.

References1. US Geological Survey. Most destructive

known earthquakes on record in theworld. Available at http://earthquake.usgs.gov/regional/world/most_destructive.php. Accessed January 12, 2008.

2. United States Agency for InternationalDevelopment. USAID Earthquake andTsunami Reconstruction. Available athttp://www.usaid.gov/locations/asia_near_east/tsunami/ngolist.html. Ac-cessed January 12, 2008.

3. Kao AY, Munandar R, Ferrara SL, et al.Case records of the Massachusetts Gen-eral Hospital. Case 19-2005: a 17-year-old girl with respiratory distress andhemiparesis after surviving a tsunami.N Engl J Med 2005; 352:2628–2636.

4. Kohut A. America’s Image in theWorld: Findings from the Pew GlobalAttitudes Project. Presented to U.S.House Committee on Foreign Affairs;Subcommittee on International Organi-zations, Human Rights, and Oversight.Available at http://pewglobal.org/commentary/display.php?AnalysisID!1019. Accessed December 27, 2007.

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