When Col. Chester “Trip” Buckenmaier III, MC, USA, first went to Afghanistan as an anesthesiologist with the U.S. Army, the only pain medicine at his disposal was morphine. If wounded soldiers got morphine but were still in pain, they’d get “more phine,” he said. Those were the options for pain control. No spinal or epidural analgesia.
It’s better than downing a glass of whiskey and biting on a bullet, I suppose, but you’d think that in an age when satellites can pinpoint an enemy from space and unmanned drones conduct precise bombing raids, the military might have better ways of easing the agony of injured human fighters.
By 2006-2007, the military was beginning to see a link between increasing rates of soldier and veteran suicides and pain issues. They noticed that symptoms in troops with chronic pain were the same symptoms associated with posttraumatic stress disorder and traumatic brain injury. “How could we really diagnose those very important issues if we didn’t have a good handle on pain?” he said.
The military was ripe for new ideas for acute pain control, and in 2009, Dr. Buckenmaier became part of a task force to create a comprehensive pain-management strategy. “We were using words like ‘holistic” and ‘multidisciplinary’ and ‘multimodal’ and not snickering. That was a big change. Just a few years ago if you used the word ‘holistic’ in military medicine, people would kind of smile at you and then you would sit alone in the lunch room. That’s not the case any more,” he said at the annual meeting of the American Academy of Pain Medicine.
The task force report in 2010 established guidelines for state-of-the-art acute pain medicine services in combat zones prior to air evacuation of casualties to their countries of origin, a document that the U.S. military had never had before, he said. Before this, pain was always thought of as something else — the consequence of having a leg blown off, perhaps — and the military approach was to try and fix that other medical issue and assume that the pain would then take care of itself. Today, there is greater understanding that pain itself “is a disease process and that acute pain, if not managed well, can lead to the devastating disease process of chronic pain,” Dr. Buckenmaier said.
An Acute Pain Medicine Service in Afghanistan seems to have made a drastic difference in the war zone, he reported. Data from April to July 2009 showed that 160 of 392 surgical trauma patients (including 61 Afghans) were managed by the Acute Pain Service (41%). Another 40% were too wounded — paralyzed, sedated, or on a ventilator — for the service to be useful, and the rest were soldiers with minor problems that didn’t need the service, such as ankle sprains and basketball injuries.
When first seen by the Acute Pain Service, the patients rated their pain level as 5 (severe pain) on a Visual Analog Scale. Within 24 hours, the average rating dropped to 0.7, Dr. Buckenmaier reported.
In a survey of 64 military health professionals including 26 physicians and 32 nurses who were asked to rate the Acute Pain Service on a scale of 0 (not at all helpful) to 10 (extremely helpful), respondents gave the Service an 8 for satisfaction, an 8 for being beneficial, and 8.5 for the importance of deploying the Acute Pain Service.
Seventy-four percent of respondents said that patients got greater levels of pain relief from the Acute Pain Service, and 65% said the patients reported decreased levels of pain. Overall, 74% said the Acute Pain Service had a significant impact on patient outcomes.
The military personnel needed for Acute Pain Services already exist in other roles and can be tasked with becoming the medical officer, chief nurse, and ward pain nurse champions that make up an Acute Pain Service, Dr. Buckenmaier said.
That way, there may be more outcomes like that of a British soldier who got his left foot blown off. A tourniquet was not well placed, and he had bled out by the time Dr. Buckenmaier saw him as the trauma anesthesiologist. As he put the soldier under, Dr. Buckenmaier told him, “Don’t worry. When you wake up, you’ll be pain free.” After surgery and transfusions and Dr. Buckenmaier’s ministrations wearing his Acute Pain Service hat, Dr. Buckenmaier looked in on the soldier later in the recovery room.
The young man was sitting up, talking on the phone. “Mum, I had to give ‘em a foot,” he said, “but I’m okay and I’ll see you in a few weeks.”
Dr. Buckenmaier thought, ‘That’s the standard that we should be achieving.”
He reported having no financial disclosures.
–Sherry Boschert (@sherryboschert on Twitter)