
Episode #271
Expeditionary Interventional Radiology: Make the Case for Endovascular Care Forward on the Battlefield- Dr. John Pavlus and Dr. Jonathon Schutt
Bleeding is what kills people after trauma. That single fact sits at the center of this WarDocs episode, in which host Dr. Wayne Causey, a vascular surgeon, sits down with two military interventional radiologists — Dr. John Pavlus of Brooke Army Medical Center and Dr. Jonathon Schutt, an interventional radiology resident at Yale — to examine one of the fastest-moving areas in modern medicine and what it could mean for the wounded service member. Endovascular care, as they describe it, is deceptively simple to explain and remarkably hard to field: a small stick in the groin or the wrist, image guidance instead of an incision, and wires and catheters small enough to be called straws, threaded through the vascular tree to block a bleeding artery or reline an injured one. As one guest puts it, the patient goes home with a band-aid. The conversation moves quickly from definition to system. At Brooke Army Medical Center, a trauma activation commits the interventional team to needle-stick access within sixty minutes of the call, day or night. That standard was not bought with equipment. It was built on years of bi-directional trust with the trauma surgeons, to the point that the team now responds without stopping to relitigate the imaging. Both guests are blunt that ownership is the price of admission: if interventional radiology wants a seat on the trauma team, it has to show up at two in the morning for cases that are neither lucrative nor glamorous. The harder question is how far forward this capability can go. REBOA is scaled today at Role 2, and stent graft and embolization cases in Role 3 remain largely case-reportable events performed by clinicians who brought their own equipment. The limiting factor, both guests argue, is not technique — it is imaging, logistics, and institutional will. Meanwhile, Israeli teams transition to bunker operations within twenty-four hours, and Ukrainian experience with drone-driven injury patterns is already reshaping assumptions about REBOA and embolization that the United States has not yet tested. The episode closes on people rather than platforms: the case for a military interventional community that crosses Service lines and partners with surgical colleagues, the argument for a skill identifier that lets the system find the right clinician, and a practical inventory of what one interventional radiologist would carry in a backpack if told to deploy tomorrow. Chapters (01:11-06:26) Two Pathways Into Military Interventional Radiology (06:26-10:15) Endovascular Care Explained: A Lot Through a Pinhole (10:15-17:02) The Sixty-Minute Trauma Activation at Brooke Army Medical Center (17:02-26:11) Forward Capability: REBOA, Stent Grafts, and the Role 2 and Role 3 Gap (26:11-35:54) Silos, Superpowers, and the Real Cost Equation (35:54-49:56) Allied Lessons, a Military IR Community, and What Fits in a Backpack Chapter Summaries (01:11-06:26) Two Pathways Into Military Interventional Radiology Both guests trace how they arrived at interventional radiology and at military service — one from the Air Force Academy and a fighter pilot track redirected by a day shadowing an orthopedic surgeon, the other from a childhood spent in a pararescue uncle's uniform and an HPSP commissioning. Each was pulled toward endovascular work by the same realization: that the future of the specialty was in doing more through less. Their training routes differ, one through diagnostic radiology and fellowship, the other through an integrated residency pathway. (06:26-10:15) Endovascular Care Explained: A Lot Through a Pinhole The guests define endovascular care in the language they use with patients: a small poke in the groin or the wrist, image guidance rather than an open field, and catheters threaded through the vascular tree like a plumber working pipes. Roughly ninety-five percent of the work is image guided, most often with fluoroscopy. The host adds the surgeon's framing — always ask what can be fixed through the blood vessel before opening a chest or an abdomen. (10:15-17:02) The Sixty-Minute Trauma Activation at Brooke Army Medical Center A blunt trauma patient arrives, CT shows active extravasation from a high-grade splenic injury, and the trauma activation commits the interventional team to needle-stick access within sixty minutes. The guests describe how that pathway was built on bi-directional trust rather than debate over each scan, and why the team now launches without relitigating the imaging. Both stress that owning trauma call — unglamorous, poorly reimbursed, and at all hours — is what earns interventional radiology its place on the team. (17:02-26:11) Forward Capability: REBOA, Stent Grafts, and the Role 2 and Role 3 Gap The conversation turns to what exists downrange. REBOA is scaled today at Role 2, and endovascular hemorrhage control at Role 3 remains largely a set of case reportable events performed with clinician-supplied equipment. The guests explain stent grafts as simultaneous hemorrhage control and reconstruction, and identify imaging, transport, and packaging — not procedural skill — as the true limiting factors on projecting this capability forward. (26:11-35:54) Silos, Superpowers, and the Real Cost Equation One guest argues that interventional radiology has been siloed by civilian incentives the military has no reason to copy, and that the specialty's real advantage is the fusion of diagnostic reading and procedural skill he calls a superpower. The host and guests weigh the higher up-front cost of advanced imaging and devices against the dramatically lower recovery burden of a pinhole procedure. The biggest hurdle, one guest says flatly, is people — convincing decision makers the capability is worth funding. (35:54-49:56) Allied Lessons, a Military IR Community, and What Fits in a Backpack Israeli teams shifting hospitals to bunker operations within twenty-four hours and Ukrainian experience with drone-driven injury patterns are held up as evidence the United States is playing catch-up. The guests describe the effort to build a military interventional radiology community across Services and to partner with the American College of Surgeons military chapter. The episode closes with a practical deployment loadout — ultrasound, micropuncture kits, sheaths, a base catheter, coils, and wire — and a walk through current training pathways into the specialty. Take Home Messages Bleeding is the mission. The immediate cause of preventable death after trauma is hemorrhage, which is why endovascular capability belongs in the operational conversation at all. Every argument for pushing this capability forward reduces to stopping the bleeding fast enough, and doing it without creating a second catastrophe. Framing the specialty this way makes its military relevance impossible to dismiss. Trust is the system, not the equipment. A sixty-minute call-to-stick standard at a level one trauma center was not purchased — it was built over years of bi-directional trust between the trauma team and the interventional service. Once that trust exists, the activation launches without relitigating the imaging, and everything else falls into motion. Any unit trying to replicate the capability should build the relationship before it buys the gear. Ownership earns the seat. Trauma call is unglamorous, poorly reimbursed, and inconvenient, which is exactly why some centers have written interventional radiology out of the pathway entirely. Showing up at two in the morning, reviewing imaging alongside the trauma team, and taking responsibility for the patient is what secures a permanent place on that team. Presence before the activation is what makes the activation work. The limiting factor is logistics, not technique. Everything done at a level one trauma center is technically achievable far forward — the constraint is diagnostic imaging, fluoroscopy, packaging, and airlift, not procedural skill. Progress therefore depends on investment decisions and institutional will rather than on new procedures. Convincing leaders that the capability is valuable is the hurdle, and funding follows conviction. Allies are already ahead, and the injury patterns are changing. Israeli teams move a hospital into bunker operations within twenty-four hours, and Ukrainian experience with drone-driven wounding is already reshaping assumptions about balloon occlusion and embolization. Planning for the last war is the fastest way to arrive unprepared for the next one. Learning from partner nations now is cheaper than relearning under fire. Episode Keywords military medicine, interventional radiology, endovascular care, WarDocs podcast, non compressible torso hemorrhage, REBOA, stent graft, embolization, hemorrhage control, combat casualty care, Brooke Army Medical Center, trauma activation, expeditionary interventional radiology, Role 2 care, Role 3 care, military trauma system, vascular surgery, image guided procedures, John Pavlus, Jonathan Schutt, Air Force medicine, Army medicine, military health system, battlefield medicine, damage control #WarDocs, #MilitaryMedicine, #InterventionalRadiology, #EndovascularCare, #CombatCasualtyCare, #HemorrhageControl, #TraumaCare, #MilitaryHealthSystem Honoring the Legacy and Preserving the History of Military Medicine The WarDocs Mission- WarDocs exists to honor the legacy of Military Medicine, preserve its history, and inspire every generation — across all Services, Corps, and Ranks — to serve with excellence and pride. Through mentorship, coaching, and education, we equip those considering, entering, and serving in military medicine with the knowledge, connections, and community they need to thrive. We celebrate Who we are, What we do, and, most importantly, How we serve Our Patients, the DoW, and Our Nation. Find out more and join Team WarDocs at https://www.wardocspodcast.com/ Check our list of previous guest episodes at https://www.wardocspodcast.com/our-guests Subscribe and Like our Videos on our YouTube Channel: https://www.youtube.com/@wardocspodcast Listen to the “What We Are For” Episode 47. https://bit.ly/3r87Afm WarDocs- The Military Medicine Podcast is a Non-Profit, Tax-exempt-501(c)(3) Veteran Run Organization run by volunteers. All donations are tax-deductible and go to honoring and preserving the history, experiences, successes, and lessons learned in Military Medicine. A tax receipt will be sent to you. WARDOCS documents the experiences, contributions, and innovations of all military medicine Services, ranks, and Corps who are affectionately called “Docs” as a sign of respect, trust, and confidence on and off the battlefield, demonstrating dedication to the medical care of fellow comrades in arms. Follow Us on Social Media Twitter: @wardocspodcast Facebook: WarDocs Podcast Instagram: @wardocspodcast LinkedIn: WarDocs-The Military Medicine Podcast YouTube Channel: https://www.youtube.com/@wardocspodcast

