Pain Following Combat Trauma In the 21st Century: A New Look at an Old Problem
PPM: What prompted the PTF?
A: The Army Surgeon General, Lt. Gen. Eric B. Schoomaker chartered the PTF in August 2009 to review current military pain practice and make recommendations for a pain management strategy “that was holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for soldiers and other patients with acute and chronic pain.”1
PPM: Who makes up the PTF?
A: The PTF comprises a variety of medical specialties and disciplines representing the Air Force, Army, Navy, TRICARE Management Activity, and Veterans Health Administration.
PPM: What were the findings of the PTF?
A: The PTF found that military pain management practices were consistent with community standards of care and that there were many instances of superior pain management practices throughout the system. Unfortunately, it also was recognized that there was an absence of a comprehensive pain management strategy that resulted in unwarranted variations in care between military facilities and fragmentation of best pain care practices.
Perhaps the most concerning product from the lack of synchronization of pain management across the DoD was an apparent overreliance on opioid-based medications for pain management and subsequent instances of medication misuse, abuse, and dependence. The PTF report included 109 recommendations for the development of a DoD pain management strategy to achieve the Army Surgeon General’s goals for a comprehensive, holistic, and multidisciplinary approach that would standardize and optimize pain management for warriors and their families.
The PTF report and the resulting Army Pain Campaign Plan that is presently under way to implement the PTF recommendations are epic in scope and ambitious in their goal to reorient military healthcare’s culture toward a more integrative approach to pain management.
PPM: What has changed to necessitate such revolutionary change within a military healthcare system during a time of active conflict?
A: Advances in trauma surgery and critical care management of wounded soldiers has improved greatly during the conflicts of the 21st century, culminating with the latest statistic of fewer than 10% of wounded soldiers dying once they enter the military medical system.2 The evolution of pain management of these same casualties has been far less dramatic. At the onset of the Afghanistan and Iraq wars, reliance on morphine as the sole battlefield analgesic had essentially remained unchanged from the 19th century. Morphine was the answer for battlefield pain following September 11, 2001, and if the soldier continued to complain of pain, he or she received, “More-phine.” The relatively static development of pain management options within both military and civilian medicine likely relates to a general lack of understanding of the impact that poorly managed pain has as a disease process involving both the peripheral and central nervous systems.3
Additionally, the wounded in previous conflicts tended to remain static for days to weeks within the war theater until they were “stable” enough for transport. Exclusive morphine management of pain in this situation was likely a viable strategy because the stationary nature of patients would allow appropriate monitoring and titration of the drug over time. This has not been the case in contemporary conflicts because the current paradigm for casualty management relies on rapid air evacuation of “stabilized” casualties out of the theater within hours to days. The exclusive use of morphine in this challenging, relatively austere, aeromedical environment has not been ideal owing to the inherent challenges in patient monitoring and the potentially life-threatening side effects associated with opioid medication.
Concerns regarding the difficulties in managing pain in the new, rapid-evacuation environment forced medical leaders to reassess battlefield pain practices and quickly develop new, innovative ways of managing pain. In order to coordinate this effort across the three services, the Military Advanced Regional Anesthesia and Analgesia (MARAA) organization was formed in 2002. MARAA consisted of pain specialty leaders from the Air Force, Army, and Navy and tasked itself with finding novel pain treatments and technologies that effectively and safely managed pain, addressed modern rapid air evacuation realities, and were consistent with the most modern pain medicine science.
PPM: What have been some of the lessons learned from the current military conflicts?
A: One of the most significant advancements in battlefield pain management developed from the current conflicts has been the re-emphasis of regional anesthesia in Combat Support Hospitals (CSH), specifically the techniques of epidural and continuous peripheral nerve block (CPNB) catheter placement and management technology. Since 2003 when the first CPNB catheters were used to evacuate a casualty from Iraq to Landstuhl, Germany, CPNB has been notably effective in the management of traumatic limb amputations that result from signatory use improvised explosive devices in the current conflicts.4-6 The use of CPNB in theater has been greatly enhanced during the first decade of the 21st century with the integration of ultrasound technology to regional anesthesia.7 The ability to visualize target nerves and surrounding structures greatly enhances accuracy of CPNB needle placement. In providing acute pain services (APS) in Afghanistan, ultrasound technology has proved indispensible in managing pain patients with traumatic limb amputations.8
In order to realize the benefits of continuous analgesia provided by infusions of local anesthetics to target nerves in evacuating wounded, pain medication pump technology had to be introduced to the aeromedical environment. MARAA, working in a triservice manor, was able to overcome service-specific differences and requirements, to coordinate the introduction of the first military pain infusion pump in 2004.9 MARAA also coordinated the creation of protocols and standards for using epidural and CPNB infusions during aeromedical flights.
The incorporation of pain infusion pump technology also opened up other treatment possibilities that are unique to the current conflicts. For example, the pumps also are used for patient-controlled analgesia (PCA) with morphine, hydromorphone, or ketamine. This capability is significant because patients are now in control of their pain medication, and there is less reliance on limited nursing resources for pain needs both at the CSH and on the evacuation flight.10,11 These technological advances greatly enhanced the efficiency and capability of military clinicians to provide enhanced pain management plans beyond intermittent boluses of morphine. In fact, the wounded could now be transported with a local anesthetic CPNB and a PCA infusion, which represented the first truly multimodal approach to pain management during evacuation.