1. Radiology Afloat: The Impact of Diagnostic and
Interventional Radiology during the 2005 Tsunami
Relief Effort Aboard the USNS Mercy
Stephen Ferrara, MD
J Vasc Interv Radiol 2009; 20:289–302
Abbreviations: CASREC ϭ casualty receiving bay, ICU ϭ intensive care unit, IVC ϭ inferior vena cava, OUA ϭ Operation Unified Assistance
AT approximately 9 a.m. local time on
December 26, 2004, an earth-shattering
event took place in the Indian Ocean;
it was to become one of the worst nat-
ural disasters the world had seen since
the eruption of Mt. Krakatoa in 1883 in
Indonesia. While thousands of Aceh-
nese families made their ritual Sunday
pilgrimage to the seaside to enjoy a
relaxing family outing in the setting of
their region’s immense natural beauty,
a massive 9.2-magnitude earthquake
shook their island’s foundation, un-
leashing a merciless tsunami that
would claim an estimated 150,000
lives 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 Asia
and even as far away as Africa (Fig 1).
Millions were affected in 14 nations
and 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 have
prepared them for this.
As Americans celebrated the holi-
days, the media streamed home im-
ages from the disaster, generating a
tremendous outpouring of sympathy
for the victims of this horrific tragedy.
National governments and private ci-
vilian aid organizations (identified as
nongovernmental organizations, or
NGOs) mobilized financial, materiel,
and manpower aid in an effort to ease
the suffering. The United States led in
this initiative, both as a government
agency and through its citizenry. By
December 31, the US government had
pledged $350 million (eventually $950
million was pledged by the American
government and an additional $1 bil-
lion was donated privately) (2), but
perhaps more importantly, it mobi-
lized one of its greatest assets to lend
assistance: the US Navy. The USS
Abraham 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 of
Sumatra and began providing criti-
cally needed food, potable water, and
sanitation. The ship and its support
vessels shelved their original mission
and stayed on station for more than 1
month. During that time, thousands of
helicopter sorties were flown to ensure
that the initial survivors of the tsu-
nami had the best possible chance of
continued survival without falling vic-
tim to the harrowing threats of dehy-
dration, disease, and starvation.
MISSION OF MERCY
With millions of US aid dollars
committed and the Lincoln on station
providing tons of food and thousands
of gallons of potable water, a final
piece was yet missing: American med-
ical expertise. On New Year’s Day
2005, 6 days after the disaster had
struck, one of the Navy’s two hospital
ships, the USNS Mercy, was activated
and began making preparations to
leave her home port in San Diego, Cal-
ifornia.
The Mercy was constructed as a
wartime casualty receiving and treat-
ment facility, and designed with the
care of trauma patients in mind. The
ship 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. Converted
from the oil tanker S.S. Worth in 1985,
Mercy is a 1,000-bed hospital complex
complete with 12 operating rooms
(including a converted angiography
suite), 80 intensive care unit (ICU) and
20 postoperative beds, a full labora-
tory and pharmacy, a blood bank, and
a complete radiology department (Ta-
ble 1). A helicopter pad is adjacent to a
massive 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 images
that are loaded onto the picture ar-
From the Department of Radiology, Naval Medical
Center San Diego, Clinical Investigation Department
(KCA), 34800 Bob Wilson Drive, Suite 5, San Diego,
CA 92134-1005. Received February 15, 2008; final
revision received April 16, 2008; accepted October
20, 2008. Address correspondence to S.F.; E-mail:
stephen.ferrara@med.navy.mil
The views expressed in this article are those of the
authors and do not necessarily reflect the official
policy or position of the Department of the Navy,
Department of Defense, or the United States Gov-
ernment. The author has identified no conflicts of
interest.
© SIR, 2009
DOI: 10.1016/j.jvir.2008.10.026
Special Communications
289

2. chiving and communication system
right in the treatment bay. Three com-
pact, portable ultrasound (US) units
(SonoSite, Bothell, Washington) can
also be employed by radiologists,
emergency room physicians, and sur-
geons to perform “fast scans” to look
for free intraperitoneal fluid. For more
advanced imaging, patients can be
brought to the main radiology depart-
ment directly adjacent to CASREC,
where they can undergo imaging in
any one of four radiography/fluoros-
copy rooms or they can undergo a
computed tomography (CT) scan or
formal US examination. From the ra-
diology unit, the patient can go di-
rectly to the neighboring main operat-
ing room complex, followed by a
seamless transit to the postanesthesia
care unit or any one of the ship’s three
ICUs or its isolation unit.
In addition to her substantial med-
ical capabilities, Mercy can produce
300,000 gallons of potable water per
day, as well as medical-grade oxygen,
and perform any number of biomedi-
cal repairs or part fabrication. Al-
though she had not deployed in the
nearly 14 years since Operation Desert
Storm, a rapidly assembled hospital
staff and ship’s crew worked around
the clock to make ready for her first-
of-a-kind mission. On January 5, 2005,
Mercy sailed from San Diego bound
for Indonesia. “Operation Unified As-
sistance” (OUA) had begun.
CALLING ALL HANDS
As capable of a medical platform
as Mercy was, her greatest limitation
was 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 the
world—not only in Iraq and Afghani-
stan, but in Africa and Europe as well.
For Mercy to accomplish her mission
of providing world-class support to
the tsunami victims, the Navy tried
something completely novel: it called
on the American civilian medical com-
munity for help. It responded in force.
Partnering with American nongovern-
mental organization Project HOPE, a
call was put out for doctors and nurses
to volunteer to spend terms of at least
30 days aboard Mercy rendering aid to
victims of the tsunami. Volunteers
flew to Singapore, where they would
meet the already–under way ship and
then complete the two- to three-day
sail to Banda Aceh.
Because of the chaos of the situation
on 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 be
used within their specialties: needs
were still undefined. Volunteers could
be certain only that they would be
working extremely hard, in an unpre-
dictable environment, helping people
in desperate need. No assurances were
necessary, 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 by
resultant tsunami.
Table 1
Specifications of USNS Mercy
Specification Details
Commissioned November 8, 1986, San Diego, California
Length 894 ft
Beam 106 ft
Draft 33 ft
Displacement 69,360 tons
Range 13,420 nautical miles
Speed 17.5 knots (20.13 mph)
Aircraft Helicopter platform
Bed capacity 1,000/80 ICU/20 PACU
Operating rooms 12 (including angiography suite)
Auxiliary services Radiology, laboratory/blood bank/histopathology, burn unit,
pharmacy, dental, physical therapy, optometry/lens
fabrication, central sterile receiving, biomedical repair,
engineering services medical gas production, laundry
services
Water production 300,000 gal/d
Note.—PACU ϭ postanesthesia care unit
290 • Diagnostic and Interventional Radiology in 2005 Tsunami Relief March 2009 JVIR

3. of volunteers eagerly and unhesitat-
ingly came forward—a deluge that ex-
ceeded the roughly 100-person volun-
teer capacity the mission required and
could accommodate. Volunteers came
from academic and private practices;
some were newly trained and others
were “semi-retired.” Massachusetts
General Hospital responded en bloc
with nearly 40 doctors and nurses over
two 30-day sessions. Some dedicated
volunteers like pediatric intensivist
Dana Braner and nurse practitioner
Gabrielle Bergmann signed up for 4
weeks but couldn’t bring themselves
to leave when their “tour of duty” was
over and eventually stayed on for
many extra weeks.
The crew of Mercy was hailed as a
“Team of Teams,” made up not only of
the aforementioned Navy and civilian
personnel, but Army and Air Force
personnel. The Public Health Service
also loaned expertise from the Na-
tional Institutes of Health, Centers for
Disease Control, and the US Coast
Guard. Once on station, Americans
worked side by side with medical
teams 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 civilian
organizations also provided assistance
and sent medical teams (Table 2).
“ATTENTION IN THE MTF!”
After the 8,000 nautical mile jour-
ney across the Pacific and Indian
Oceans and picking up her augmen-
tees in Singapore, Mercy arrived on
station in Banda Aceh on January 31,
2005, where she relieved the Abraham
Lincoln and made final preparations
to receive her first patients (Fig. 2).
The question remained, however, as to
how 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 teams
that had set up field hospitals ashore
were clamoring for Mercy’s diagnostic
capabilities. Each facility had dozens
of patients whose treatment had been
stymied by an inability to make defin-
itive diagnoses. In some instances the
problem 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 one
could determine what was really
wrong with many of these terribly ill
victims. It became immediately clear
that proper medical imaging was an
absolute necessity if we were to provide
quality, “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 2
The “Team of Teams”
Unit Personnel
Total military personnel 450*
Medical officers (MDs) 12
Medical Service Corps
(Allied Health Services/
Administration)
18
Nurses 17
Supply officers 2
Warrant officers 2
General duty corpsmen 70
Specialty corpsmen 80
Nonmedical personnel 247
Project HOPE 180 (91/89)†
Physicians 45 (22/23)
DMD/OMFS 2 (0/2)
RN/NP/CRNA 115
DVM 2 (1/1)
Optometry 2 (1/1)
LCSW 3 (2/1)
RD 2 (1/1)
Administrative 9 (6/4)
* Numbers are approximate as actual
numbers of military and civilian
personnel varied during the mission.
† Civilians volunteered for either of
two 30-day “tours of duty.”
Table 3
Radiology Department Aboard USNS Mercy: OUA 2005
Personnel No. Equipment
Radiologist (IR trained) 1 1 GE LightSpeed 16-slice CT unit
Lead Technologist (Chief Petty
Officer)
1 2 GE MPH digital radiography suites
Radiology Technologists 5 2 GE Digital Legacy radiography/fluoroscopy
suites
Diagnostic radiology 2 1 GE Tilt-C angiography suite
Angiography 1 1 Acuson Sequoia US unit
CT 1 3 SonoSite portable US units
US 1 3 GE OEC 9800 portable C-arm fluoroscopy
units
5 GE AMX 4ϩ portable x-ray units
AGFA PACS
Note.—The Radiology Department was comprised of US Navy personnel only. IR ϭ
interventional radiology; PACS ϭ picture archiving and communication system.
Ferrara • 291Volume 20 Number 3

4. understanding of the patients. The
military mission the ship’s planners
had in mind assumed that the medical
care would come from doctors treating
military personnel of a substantively
identical culture. OUA was not that
kind of mission at all. Success required
creating and implementing solutions
to challenges that were not found in a
training manual; first and foremost,
this meant gaining a sensitivity to the
Muslim culture of the Acehnese peo-
ple and to the immensely alien nature
of an American hospital ship. The
Mercy would call for a Muslim chap-
lain, a culturally sensitive diet, and
placards 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 allowing
each patient to bring a family member
to the ship to stay with them during
their entire hospital course. Although
this created a crowded and often
strangely aromatic atmosphere on the
wards (astutely skeptical of hospital
fare, family members would often pre-
pare local recipes right at the bedside),
it was an essential part of gaining the
trust and confidence of a people who
had minimal, if any, firsthand knowl-
edge of Americans—and who were
meeting us under the absolute worst
of circumstances.
Advanced party liaisons who had
met with medical and governmental
officials on the ground in Banda Aceh
had determined that Mercy would be
most helpful by serving in a dual ca-
pacity: she would be the tertiary care
medical facility for the sickest patients
who exceeded the capabilities of the
field hospitals, and she would deploy
primary care and preventive medicine
teams to outlying villages to serve
those unable to make the trek to Banda
Aceh. Three primary categories of pa-
tients needed our assistance: (i) those
with injuries and illnesses caused di-
rectly by the tsunami; (ii) those with
chronic medical illnesses who could
no longer receive medical care as a
result of the devastation of the local
infrastructure (including the destruc-
tion of local hospitals and the death of
many local physicians); and (iii) those
who suffered acute trauma or had be-
come ill after the tsunami had struck
but who had nowhere else to be
treated.
What Mercy’s radiology depart-
ment lacked in manpower, it made up
for in attitude (Table 3). The initial
queue of critically ill medical and sur-
gical patients requiring CT scans was
nearly 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-arm
intraoperative fluoroscopy. Ultimately,
many orthopedic patients went on to
receive inferior vena cava (IVC) filters
as well (n ϭ 12). Because of the high
prevalence of tuberculosis, every pa-
tient, as well as his or her family mem-
ber escort, required a screening chest
radiograph before they could be dis-
positioned out of the CASREC. This
would 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 USNS
Mercy during OUA. (b) Shortly before discharge, the boy and his uncle take in the view from the Mercy’s flight deck.
292 • Diagnostic and Interventional Radiology in 2005 Tsunami Relief March 2009 JVIR

5. 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 air
space and cavitary lesions following sea water aspiration. (b)
Contrast-enhanced head CT with one of several cortical, ring-
enhancing lesions and extensive surrounding white matter
edema secondary to septic embolic phenomena. (c) AP chest
radiograph in the same patient after left tube thoracostomy
placement with improvement in left-sided pneumothorax.
Ferrara • 293Volume 20 Number 3

6. flow of patients had it not been for the
incredibly hard-working young x-ray
technologists who unselfishly pooled
together for the common good regard-
less of subspecialty expertise.
For the medical staff and crew that
had been with the ship since San Di-
ego, a seemingly endless number of
planning meetings and reviews of pos-
sible scenarios had taken place. For
teammates who had joined us in Sin-
gapore, the service they had pledged
weeks earlier was finally about to be
realized. So many people clearly
needed our help, and so much good
was waiting to be done—our eager-
ness and optimism were peaked. And
although no one was really sure what
to expect or just how well we would
perform, when the first inbound pa-
tient-laden helicopter was announced
over the 1-MC (a Navy ship’s public
address system), the anticipation was
palpable.
ORGANIZED CHAOS
Deluged with patients, every clini-
cal service scrambled to triage individ-
uals who represented (it seemed) ev-
ery combination of age, sex, and
diagnosis. Yet despite this frenzied at-
mosphere, each patient found a way to
make a personal impact on each of us
who participated in his or her care.
One of the first and most memorable
patients was a 13-year-old boy named
Iqbal who had lost both his parents in
the tsunami and had been found after
having clung to a piece of driftwood
for 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 intubated
for nearly 1 week, but showed steady
improvement until he eventually tran-
sitioned to the ward and ultimately on
to the normal activities of a 13-year-
old (Fig 3b). Iqbal’s tragic family story,
unfortunately, was more the rule than
the exception. What made his case so
unforgettable was that it was our first
unequivocal success with a critically ill
patient, otherwise certain to die, who
lived and could go on to thrive be-
cause of the Mercy.
Not only was Iqbal a clinical suc-
cess on an individual basis, his illness
represented the first of many pulmo-
nary syndromes we would see so fre-
quently in the ensuing weeks. Al-
though the massive aspiration of sea
water was lethal for so many, a num-
ber of children and teenagers had the
pulmonary reserve to survive the ini-
tial insult. The virulence of the marine
organisms, however, wreaked havoc
not only in the lung but in the central
nervous system as well. Several pa-
tients referred to the ship after Iqbal
had primary neurologic diagnoses
such as hemiplegia with associated fe-
ver, cough, and shortness of breath.
Most had already received short
bursts of a variety of available oral or
intravenous antibiotic therapy with
limited success. Referred to Mercy pri-
marily to undergo head CT examina-
tions as part of their neurology
workup, screening chest radiographs
revealed a more complicated and sin-
ister process. Cavitary lesions, consol-
idations, effusions, and even pneumo-
thoraces were found in the setting of
multifocal brain abscesses (Fig 4a,b).
This process, initially referred to collo-
quially as “tsunami lung,” was a con-
dition in which a polymicrobial mix of
aggressive marine bacteria eroded
through pulmonary parenchyma and
sometimes pleura, ultimately gaining
access to the left circulation and on to
the cerebrum (3). Fortunately, a clini-
cal conundrum that had frustrated the
physicians ashore became readily elu-
cidated with the assistance of modern
imaging 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 severe
respiratory distress. (b) AP chest radiograph (prone) after left chest tube placement shows marked improvement in left empyema.
294 • Diagnostic and Interventional Radiology in 2005 Tsunami Relief March 2009 JVIR

7. ments ensued: prolonged intravenous
antibiotic therapy with imipenem or
meropenem, as well as percutaneous
chest tube drainage in some cases (Fig
4c), 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. This
sustained antimicrobial regimen was
made possible by the importation of a
simple interventional procedure taken
for granted daily in the United States,
the lowly peripherally inserted central
catheter.
Figure 6. Images from a 21-year-old man after a motor vehi-
cle accident who experienced respiratory failure during air
transit to USNS Mercy. (a) Chest CT reveals dense dependent
pulmonary consolidation secondary to aspiration pneumonia
and contusion. (b) Portable AP pelvic radiograph reveals
proximal left femur fracture. (c) Fluoroscopic image after
placement of Gu¨ nther Tulip retrievable IVC filter. The filter
was placed prophylactically as a result of the inability to
provide 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 open
reduction and internal fixation, right femoral external fixation, and IVC filter placement.
Ferrara • 295Volume 20 Number 3

8. 296 • Diagnostic and Interventional Radiology in 2005 Tsunami Relief March 2009 JVIR

9. INTERVENTIONAL
RADIOLOGY:
FUNDAMENTALLY
ESSENTIAL
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 simple
procedure was not available before
Mercy’s arrival, yet it became a main-
stay of therapy and the turning point
for numerous patients with polymi-
crobial infections. Another interven-
tional procedure that saved the lives of
several critically ill patients was the
percutaneous tube thoracostomy. Not
surprisingly, given the mechanism of
catastrophe, a vast number of near-
drowning patients who had survived
were suffering from large empyemas.
On several occasions, particularly in
children, these patients experienced
decompensation into respiratory fail-
ure on the helicopter flight inbound
and 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, excellent
clinical 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 the
ship’s angiography suite and gener-
ally represent the higher-complexity
vascular cases, whereas the remaining
70% of cases were performed at the
bedside or in the CT suite. More than
2,700 additional radiology examina-
tions were also performed, making ra-
diology the “nerve center” of the med-
ical treatment facility (MTF). Every
patient received a radiographic exam-
ination, ranging from screening chest
radiography to CT angiography to re-
nal artery stent placement. One of the
most remarkable features of this expe-
rience was that it definitively proved
that imaging is what truly defines
first-world medicine; and less intu-
itively, although interventional radiol-
ogy services are casually perceived as
a high-tech luxury in the delivery of
health care, they are actually integral
to the most basic community standard
we have come to expect in every facet
of American health care. This became
astonishingly apparent as specialists
and subspecialists from every facet of
clinical medicine clamored for mini-
mally invasive, innovative solutions to
the unique and often incredibly diffi-
cult clinical challenges this mission
routinely 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 or
host nation limitations that precluded
patients from continuing their medical
regimen after the ship departed. An
example of the latter involved several
crush victims from Nias Island with
massive and complex orthopedic
trauma. Many of these often young
patients would require weeks of im-
mobilization with a typical need for
prophylactic anticoagulation. How-
ever, given the circumstances, no
enoxaparin would be available after
they left the ship. Fearing the short-
term orthopedic surgical success
would be complicated by the cata-
strophic long-term complication of
pulmonary embolism, through a rigor-
ous multidisciplinary approach we
opted to place prophylactic IVC filters
in these patients (Fig 6). Although no
data 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. This
chess game–like approach to medical
practice, however, is one of the many
things that made this such a profes-
sionally fulfilling experience.
Further examples of interventional
radiologic procedures that elevated
the level and complexity of care in this
austere 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, in
this case papillary thyroid carcinoma,
who were able to undergo successful
resection for at least palliation and
perhaps increased survival (we did
not have the ability to give I-131 or
other systemic antineoplastic thera-
pies) because of the ability to perform
preoperative embolization. In this na-
tion in which the populace had mini-
mal, if any, access to health care, the
number of untreated benign and ma-
lignant neoplasms we encountered
was staggering.
Figure 8 depicts a young woman
with a massively protuberant abdo-
men who was referred for imaging
evaluation. Contrast-enhanced CT re-
vealed a giant fibroid uterus, and
upon seeing the engorged pelvic vas-
cular channels, the surgeon was ini-
tially reluctant to operate for fear of
life-threatening hemorrhage. Reas-
sured by the ability to have the tumor
preoperatively devascularized, how-
ever, the patient underwent an un-
eventful hysterectomy after uterine ar-
tery embolization.
In the treatment of another young
woman with an abdominal mass, this
time a teenager (Fig 9), we found a
congenital ureteropelvic junction ob-
struction. At presentation, the pa-
tient’s serum creatinine and potassium
levels were markedly increased, but
after image-guided percutaneous ne-
phrostomy tube placement, her chem-
istry values normalized to the extent
to which she could safely undergo a
unilateral nephrectomy and contralat-
eral pyeloplasty operation. Presum-
ably because of the heavy mineral con-
tent in the drinking water, exacerbated
by the baseline state of relative dehy-
dration suffered by the general popu-
lation in this equatorial climate, ob-
structive urinary calculi was a
frequently encountered condition. An
even 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
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Figure 7. Images from a 58-year-old man with papillary thyroid carcinoma. (a) Photograph after US-guided needle biopsy of two
distinct areas within a large right-sided neck mass. (b,c) Axial images from contrast-enhanced neck CT depicts a large, heterogeneous
mass in right neck with areas of necrosis as well as avid enhancement resulting from hypervascularity. Right external carotid
arteriograms before embolization (d) and after embolization with 300–500-␮m polyvinyl alcohol particles (e,f).
Ferrara • 297Volume 20 Number 3

10. Figure 8. Reproductive-aged woman referred for evaluation of
large abdominal mass. (a) Coronal reformatting of contrast-en-
hanced abdomen/pelvis CT shows a large mass arising from
the 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 in
uterine vascularity is seen.
298 • Diagnostic and Interventional Radiology in 2005 Tsunami Relief March 2009 JVIR

11. Figure 9. Images from a 15-year-old female patient
with abdominal mass and abnormal serum creatinine
and potassium levels. (a) Axial contrast-enhanced CT
reveals marked bilateral hydronephrosis, right greater
than left. (b) Coronal reformat suggestive of bilateral
congenital ureteropelvic junction obstruction. (c) Late
phase of intravenous pyelogram reveals markedly di-
lated left collecting system with no apparent right-sided
renal function. (d) Left nephrostogram (prone) after
percutaneous nephrostomy tube placement.
Ferrara • 299Volume 20 Number 3

12. Figure 10. Images from a 58-year-old man with 1
week of anuria and a serum creatinine level of 31
mg/dL. (a) Kidney/ureter/bladder radiography
reveals extensive urolithiasis with several stones
forming apparent “casts” of the ureteropelvic junc-
tion. (b,c) Longitudinal sonographic images dem-
onstrate massive bilateral hydropyonephrosis, left
greater than right, and nephrolithiasis. (d) Spot
fluoroscopic image after bilateral nephrostomy
tube placement. (e) Right-sided (prone) antegrade
nephrostogram after left nephrectomy and right
pyeloplasty. Residual stones were removed percu-
taneously.
300 • Diagnostic and Interventional Radiology in 2005 Tsunami Relief March 2009 JVIR

13. radiographic findings, his serum cre-
atinine level was greater than 31 mg/
dL. A trial of bilateral percutaneous
drainage was performed, which re-
sulted in marked improvement in se-
rum creatinine level, decreasing to 1.5
mg/dL after 3 days. The cause of the
anuria was an obstructive urethral
stone that was successfully removed
surgically in conjunction with open
stone removal with right-sided ne-
phrectomy and left-sided pyeloplasty.
ROUTINELY
EXTRAORDINARY
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 the
greater success—the experiment that
proved that a vastly diverse group of
professionals could be thrust together
halfway around the world, united by
nothing more than their passion to
help others, and accomplish amazing
feats. Additionally, the Mercy mission
further confirmed that advanced diag-
nostic imaging is what defines first-
world medicine while the ability to
perform image-guided, minimally in-
vasive procedures defines what we
have come to expect from routine
American medicine. Simply put, the
addition 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 a
sense of camaraderie among physi-
cians in my career. Maybe it’s because
this mission of mercy had subselected
for a certain type of personality, at
least 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 was
the fact that we were practicing med-
icine for desperately needy people that
made us all feel so dedicated to the
mission and each other. Or perhaps
we were having the professional time
of our lives because we were liberated
from the economic and administrative
burdens that can distract us from our
everyday practices, and this allowed
us to focus on our real passion—doing
sometimes straightforward, some-
times complex, but always amazing
procedures for people who desper-
ately needed our help. It was medicine
distilled down to the most basic, pure,
and beautiful concept: that of provid-
ing excellent care, unencumbered by
external influences so readily apparent
in the practice of modern medicine to-
day.
The beauty of “medical diplomacy”
is the mutual regard it engenders. It is
even 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 the
Mercy in Dili, East Timor. Logistical challenges including limited helicopter availability
sometimes required ship-to-shore transport of patients by small boat operations.
Figure 13. The Mercy’s pathologist, LCDR Mike Favata, prepares
a slide during a CT-guided spine biopsy.
Ferrara • 301Volume 20 Number 3

14. proval rating in Indonesia, the world’s
most populous Muslim nation, was
only 15% before the tsunami, it more
than doubled to 38% after Mercy’s
2005 visit. Although America is far
from being popular there, this kind of
positive movement is quite hard to
achieve with the use of traditional dip-
lomatic methods, and the US govern-
ment has clearly taken notice. During
Mercy’s return home from Banda
Aceh, the previously distant Indone-
sian government requested Mercy’s
help after another massive earth-
quake, this time afflicting Nias Island
off the Sumatran coast. Mercy imme-
diately steamed to assist, and no
sooner had OUA ended when OUA II
begun. Since that time, the Mercy and
her 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, we
continue to strive to improve and re-
fine our methods of providing the
most effective humanitarian assistance
possible. The mission of humanitarian
assistance varies greatly from disaster
relief, however, and each journey pre-
sents its own unique challenges. Sim-
ply defining the goals of the mission
can be a daunting task, requiring mod-
ulation of a host of variables including
individual skill sets, equipment, and
time on station—not to mention trying
to meet the goals of those we have
been charged to help. It is important to
remember that the 2005 mission in In-
donesia marked the first time this
form of civilian/military collaboration
had occurred, placing this sort of ini-
tiative in its very infancy. The good
news, nonetheless, is that the US
government (through the Navy) has
made a commitment to this effort,
and through continued collaboration
with the civilian community, the
process will undoubtedly mature
and improve. For further informa-
tion on how to volunteer for your
own “experience of a lifetime” med-
ical humanitarian assistance mission,
visit www.projecthope.org.
There is no sign that this strategy to
reveal the “gentler side of America” is
going to disappear anytime soon. Mer-
cy’s 2008 trek is already planned, and
whatever its geopolitical payoff, the
medical benefits for some needy peo-
ples in these far-off lands will be tre-
mendous.
References
1. US Geological Survey. Most destructive
known earthquakes on record in the
world. Available at http://earthquake.
usgs.gov/regional/world/most_destructive.
php. Accessed January 12, 2008.
2. United States Agency for International
Development. USAID Earthquake and
Tsunami Reconstruction. Available at
http://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 and
hemiparesis after surviving a tsunami.
N Engl J Med 2005; 352:2628–2636.
4. Kohut A. America’s Image in the
World: Findings from the Pew Global
Attitudes 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?AnalysisIDϭ
1019. Accessed December 27, 2007.
302 • Diagnostic and Interventional Radiology in 2005 Tsunami Relief March 2009 JVIR