Interview: 21st Century Battlefield Pain Management

Abstract

Colonel Chester ‘Trip‘ Buckenmaier 3rd, MD, speaks to Dominic Chamberlain, Assistant Commissioning Editor: Colonel Buckenmaier is the current Director of the Defense and Veterans Center for Integrative Pain Management (MD, USA) and Fellowship Director of the Acute Pain Medicine and Regional Anesthesia program at Walter Reed National Military Medical Center in Washington DC (USA). He is an Associate Professor in Anesthesiology at the Uniformed Services University of the Health Sciences in Bethesda (MD, USA), and a Diplomat with the American Board of Anesthesiology. He attended Catawba College (NC, USA), on a Reserve Officers‘ Training Corps (ROTC) scholarship, graduating with a degree in Biology and Chemistry in 1986. He then attended East Carolina University in Greenville (NC, USA), receiving a Master in Science in Biology in 1988. In 1992, he graduated from the Uniformed Services University of the Health Sciences, completing his Anesthesia Residency at Walter Reed. In addition, he completed a 1-year Fellowship in Regional Anesthesia at Duke University (NC, USA) in 2002, resulting in the creation of the only Acute Pain Medicine Fellowship in the US military at Walter Reed (Washington, DC, USA). In September 2003, he deployed with the 21st Combat Support Hospital to Balad (Iraq), and demonstrated that the use of advanced regional anesthesia can be accomplished in a forward deployed environment. He performed the first successful continuous peripheral nerve block for pain management in a combat support hospital. In April 2009, he deployed to Camp Bastion (Afghanistan) with the British military and ran the first acute pain service in a theater of war. The Defense and Veterans Center for Integrative Pain Medicine (DVCIPM) is dedicated to improving pain management throughout the continuum of care for service personnel and their families.

Q What first drew you to study anesthesiology and pain management?

My interest in anesthesia came about after I spent considerable time out in the field working in the surgical subspecialties. I started out as a general surgery resident; however, that didn‘t appeal to me as much as managing patients‘ pain. I enjoy working in an environment where you have an issue that you need to deal with, such as providing conditions for surgery, using the different medications and the instant gratification you get from the success of that medication plan. I didn‘t plan to focus on pain but I was very interested in a technique called regional anesthesia, which is anesthetizing a region of the body, and at the time there was a big change in the related technology: nerve stimulation, new needle systems and new techniques. My boss at the time, Colonel (retired) John ‘Jack‘ Chiles (US Army), at Walter Reed Army Medical Center (Washington, DC, USA), and I spent a lot of time discussing the advantages of using regional anesthesia in a conflict. I am not taking anything away from the Second Gulf War, but we ended up winning the war in about 300 h; there were maybe between 300–500 casualties in total, and it was at this point that we realized that these massive field hospitals were not going to be the future. Our conversations centered on how we could provide anesthetic care on the battlefield without some of the logistic burden that comes with general anesthesia. General anesthesia like you have in civilian hospitals is very common, but those massive machines are all driven by 55 psi of oxygen. While that is easy in the UK or the USA, in a place like Iraq or Afghanistan, someone has to bring that oxygen to the field hospital, which can be a life-threatening trip on the roads of Iraq or Afghanistan. So we were looking for ways of providing anesthetics that had a lower logistic footprint, which led to my involvement with regional anesthesia. I became involved in pain management following the events of 9/11 and the following conflicts. Initially, in the Afghanistan and Iraq conflicts we had a very different system of combat medicine and evacuation, which has turned out to be one of our true success stories: we have a less than 10% ‘died-of-wounds‘ rate right now, which has never been achieved in the history of warfare. I attribute this to advances in body armor, highly trained medics and our rapid evacuation system, where we literally have an intensive care unit in the air, which allows us to stabilize patients for transport to the next node in the care system. However, this was causing us some very difficult issues for standard pain management, which at the time was morphine. Morphine has been the gold standard for many decades, and many wars. When patients were relatively static, meaning they weren‘t leaving the battle field rapidly like they do today, morphine was probably OK. However, in the current environment you are passing through many, if not hundreds, of healthcare providers in the space of a few days, and these aircraft are very difficult environments to practice medicine in: they are loud, they are not insulated like civilian aircraft, they vibrate and patient monitoring does not work very well. Nurses were therefore presented with very difficult decisions. If they gave patients morphine, a drug that is known to cause respiratory depression and sedation, in this environment where it is difficult to monitor them, they may stop moaning in pain, but how do they know if the patient stops breathing?

And that was a real problem in 2003/2004 and this is what got me into acute pain management. Lieutenant General (retired) James B Peake (US Army) who was the Army Surgeon General at the time, wrote an email to my boss Jack Chiles saying: “The soldiers are arriving in Landstuhl Regional Medical Center (Landstuhl, Germany) in agony, what are you going to do about it?” Jack and I believed regional anesthesia was a possible solution, so we saw this opportunity to deploy and demonstrate the value of these techniques on wounded warriors. I went to the 21st Combat Support Hospital, Camp Anaconda (Balad, Iraq) with the regional anesthesia technology and the equipment needed. I essentially, although I did not know it at the time, established the first acute pain service in the theater of war for the Americans. The first soldier we worked on, an Army Specialist named Brian Wilhelm (US Army; he allows us to use his name), had a rocket propelled grenade injury to his left calf which had essentially blown his left calf off, and although he had received considerable amount of morphine, Brian was in 10/10 pain. I began to prepare him for his block when he said to me “Doc just stop, I don‘t care what you do just make this pain go away.” So we went ahead and did a sciatic continuous peripheral nerve block, and a continuous lumbar plexus block, and brought his pain from 10 to 0. The catheters that I placed, in this case, would go on and serve this young soldier for five additional operations, innumerable dressing changes and 15 days of analgesia, which offered far better than average pain management between operations and flights from Landsthul back to the USA. Brian was the first soldier in our system to ever evacuate with continuous peripheral nerve catheters – we recognized that here we were bringing something that was rare in most of our medical institutions to a system that was still just using morphine (a civil war era analgesia).

Q Can you tell us about the added challenges of pain management in the battlefield and how you overcome these barriers?

I want to preface these statements by saying these barriers are not specific to the military. Military medicine is a reflection of civilian medicine, and I feel quite confident saying the challenges we were facing in the US military were being mirrored in the USA or UK support hospitals. Morphine has been the gold standard for battlefield pain management since the civil war. Discovered in 1804, it was a godsend for battlefield medicine. For the first time there was something that worked every time and was relatively easy to manufacture; it has been used to great effect in the Franco–Prussian wars, the American Civil War, and then pretty much every conflict since. However, the saying goes, “when all you have is a hammer the whole world is a nail” – when the only tool you have to manage pain on the battlefield is morphine you use it. Unfortunately, you get the very unpleasant side effects of respiratory depression, nausea and vomiting. We also now know that excessive use of opioids increases sensitivity to pain. These were all things that were really punishing us in our rapid evacuation system. In addition, we had these archaic attitudes and misunderstandings about pain; we thought if we mended the bone or wound, then the pain would take care of itself. However, after 12 years of conflict we have learnt that that is not the case, pain along with post-traumatic stress disorder and traumatic brain injury continue to harm the soldier long after the outward signs of their injuries have healed, and can be just as devastating as an amputation or any other type of wound.

Q How has the field of battlefield pain management changed over your career?

We recognized that we had a problem, and my current boss Major General Richard W Thomas (US Army), who is the chair for the Pain Management Task Force that I was later involved in, often says war is a catalyst for medical change. Medicine in general was slowly moving towards a better understanding of pain and the need for multimodal care, which allows you to minimize use of any one drug and reliance on any one technique, thus minimizing the side effects of those drugs and techniques. I am not for or against morphine, but I see it as one tool in a broad spectrum of tools that we could have been applying in the battlefield, and because war is a rapid catalyst for change, we were able to convince our leadership that we needed to do something new for pain management on the modern battlefield, such as getting pain infusion pumps, which we instituted in 2005 for the first time in US Military history. That allowed us to employ epidurals, not only on the ground, but also during evacuation flights. In addition, we could now utilize infusions of local anesthetic and provide continuous peripheral nerve blocks to effectively turn off nerves to an amputated or mangled arm or leg. We also started using drugs that were new to the battlefield, the most significant probably being ketamine. When I deployed in 2009, I always had morphine and ketamine available when I was working in trauma and not once during that deployment did I pick up morphine, but always preferred ketamine for initial analgesia. These changes are now in place in our military and are impacting on soldiers both in the UK and the USA on a relatively routine basis. It is not as consistent as I would like, but I think what we have learnt on the battlefield is influencing much of the discussion in our civilian anesthetic and pain meetings in the USA.

Q Does the fact that the patients are soldiers, and the wounds often more brutal than those seen in a regular hospital, affect your pain management approach?

It is hard for me to describe how horrific these wounds are, and it is certainly far beyond what I have experienced in civilian medicine. The sad truth about my career is that 9/11 happened as I was finishing my training as a fellow at Duke University, and essentially, my career has been centered around the wars ever since. The intensity of pain associated with these wounds mean we have to apply techniques more aggressively than necessarily our civilian counterparts would be willing to. But the changes I spoke of have made all the difference in refocusing thinking on the requirement for having acute pain services. These services consist of people like myself, an acute pain physician, who are focused on pain around a trauma or any operation, which is just another type of trauma (surgeons hate it when I say that), alongside specialized pain nursing care and other ancillary personnel who are focused on managing the pain to maximize function in the patient as well as the stress response. The patient cannot begin the work for recovery, following surgery and wound healing, until the pain has been properly managed, and there is now good evidence that poor management of the acute pain leads to chronic pain. In fact, we see a relationship between poorly managed acute pain and the development of phantom limb pain in amputees and chronic pain in many of our wounded soldiers, and certainly some of the psychological issues they have from war (post traumatic stress disorder being one of the most prevalent) are negatively impacted on by pain. So aggressive pain management is as important as the blood products we use or the surgery we are doing on the battlefield, it is just not as obvious. It makes sense for a surgeon to sew up a wound or fix a bone; other war-related injuries such as pain, post-traumatic stress disorder or traumatic brain injury, are not as visible and are, therefore, more difficult to treat.

Q There have been great changes in the ‘died-of-wounds‘ rate. Can you describe why this has come about and if you think it can improve even further?

It is difficult to imagine improving on that statistic because a less than 10% ‘died-of-wounds‘ rate is very significant. However, because we have always improved from conflict, it would be just as dangerous to say that we would not be able to impact on that statistic. We were doing better than that when I deployed with the British at Camp Bastion in 2009, we had a 5% died-of-wounds rate, and we were seeing significant trauma. I attribute this to the now highly trained combat medics and the combat support hospitals. The combat support hospitals and air evacuation has certainly contributed to survival; if you walked into a combat support hospital in Afghanistan and the next day into an operating theater in the UK you would see essentially no difference, so the ability for the USA and the UK to establish that medical presence in the battlefield is a tremendous and an awesome example of power projection, but also makes us a better fighting force, because our soldiers know they are backed by that system. Additionally the improved body armor and all the technology preventing shrapnel and the bullets from entering abdominal, chest and head cavities improves survival. I am often quoted as stating, because I truly believe it, that the best place to be shot or be hit by a bus is Afghanistan, because it has the best trauma system on the planet.

Q In September 2003, you deployed to the 21st Combat Support Hospital in Balad, Iraq. Can you tell us of your experiences and any lessons you have learnt with respect to pain management?

I deployed after the aforementioned email from General Peak. I went out to the battlefield with this really advanced 21st century technology and that‘s when we were shocked to learn we were still just using morphine. Therfore, this solidified my thinking and many other like-minded officers at the time, thus, we created MARAA (Military Advanced Regional Anesthesia and Analgesia), in a tri-service manner with officers from the army, navy and air force as a way to come up with suggestions to our leaders on things that could be changed to improve the care of soldiers on the battlefield. This brought about the idea of building or establishing acute pain services: physicians and nurses who were focused on pain, who would be trained to do things other than just administer morphine. They would use other drugs such as NSAIDs, opioids and even acetaminophen (Tylenol^®). People roll their eyeballs when I mention acetaminophen, but it was something I learnt from the British. I was fascinated at how effective it was given intravenously (not available in the USA at the time) as a foundation drug (as I like to call it) in building a multimodal pain plan.

Q Are there any particular pain management success stories or events that have particular meaning to you?

I have many. Brian Wilhelm represents one of hundreds if not thousands of both American and British soldiers who have benefited from these techniques. I can recall one story in particular, which illustrates what we are working towards. I had a British lieutenant, who had his right foot blown off, he had bled a lot and would go on to have a massive transfusion. He was, however, alert and in considerable pain and understood how his still relatively young life as an officer had changed dramatically. We had done all our trauma surveys and it was time for him to go up to the CT scanner, immediately followed by an operation, and he said “Please give me something,” and I said “I am going to give you something now and when you wake up I am going to take care of the pain,” which was a pretty risky thing for anyone to say to a trauma patient like this. So I used my ketamine, took care of his pain and then we went and did his anesthetic for the amputation, which was a relatively significant operation because of the blood loss. When the surgeons were done, I was able to bring in a portable ultrasound machine, a new technology that I didn‘t have in 2003, that gives a detailed view of the internal anatomy allowing me to see the nerves and the vessels which I needed to avoid hitting. I was therefore able to place these blocks in the anesthetized patient, before I had to wake him up. I dropped him off in the recovery room, went back to finish other trauma cases that day and returned to see him about 30–45 min later, and although I did not get to talk to him, I observed him sitting up in bed talking to his mother, and as I recall he said “Mom I had to give them a foot, but I am okay and I will see you in a few weeks.”

He was pain free and he had just had his lower extremity blown off. To me, not only were we doing the right thing by having him not have to experience the pain in addition to the trauma, but already he was healing psychologically and thinking about the future. If we didn‘t have that technology or we didn‘t have the acute pain service, he certainly wouldn‘t be on the phone to his mother and he would not have begun the process of healing. I actually got an email from a British colleague of mine who saw this patient later, and the soldier remembered me and asked for my email and wrote to me to thank me for the pain management I provided in Camp Bastion, which was very touching.

Q You established the Defense & Veterans Center for Integrative Pain Management (DVCIPM). What was the aim of the center, and can you describe what your role and responsibilities are?

It started out with MARAA, which was a group of anesthesiologists who wanted to improve pain management on the battlefield, then we had some significant successes which I mentioned, but realized we were having issues in pain not just in the battlefield, but throughout the care continuum. Pain is part of what we call the polytrauma triad. The polytrauma triad – pain, post-traumatic stress disorder and traumatic brain injury – are relatively common conditions following combat trauma. One can think of this triad as three legs of a stool, if you are ineffective at managing any one of these issues the stool (the patient) falls over. We have been doing an incredible job since 2007 with investments of over US$700million in the areas of traumatic brain injury and post traumatic stress disorder, but we have not been aggressive, historically, in managing pain because, again, like our civilian colleagues we were still looking at pain as a symptom rather than a disease. Fortunately after the year 2000, that thinking has been rapidly changing, we now recognize that pain is a disease process. Headed by Lieutenant General (retired) Eric B Schoomaker (US Army) we have been changing the culture of military medicine in its attitudes towards pain. Changing medicine alone is a big deal, but changing military medicine has added issues. In 2010 General Shoomaker created the Pain Management Task Force and if you go to the Army Medicine website you can see the May 2010 Army Pain Management Task Force document, which he commissioned [1]. This document details our top–down look at how we were managing pain throughout the continuum in the military, particularly because we had an over-reliance on opioid medication, which was causing us problems with substance misuse and in some cases abuse. There are 109 recommendations and some of the principal recommendations are being actively implemented right now. We are building what are called Integrative Pain Management Centers in major hospitals, and using a variety of new technologies: one called ECHO involves leveraging modern telecommunications to link our pain management specialists at the Integrative Pain Management Center to primary care providers dealing with pain issues at smaller medical institutions around the world. We are also leveraging a previous investment by the NIH to the tune of US$100 million for a project called PROMIS^®, which is a patient health question databank where we are going to start collecting outcomes data to drive the decisions we are making for care [2]. Finally, we are seriously looking at integrative medicine, like acupuncture, yoga and licensed massage therapy, modalities that, just a few years ago, would have got you a polite snicker. The DVCIPM was established to serve as the Military Health System level coordinating activity between the Services and the Veterans Health Administration for these exciting changes to military pain care. We also provide a robust intramural pain research program. However, we also focus on pain education and clinical medicine, so the DVCIPM, which I direct, as well as serving as the primary investigator, is involved in not just looking at acute pain care, my personal focus, but the entire spectrum of pain medicine. I think we have a very good trauma and disease management system in the USA; however, I believe that the data support the statement that we don‘t necessarily have the best health maintenance system in the USA, and both our military and civilian systems are looking for improvements. One of the things you can look up at DVCIPM.org [3], is our new defense and veterans pain rating scale [1]. One of the frustrations that we saw with the numeric 0–10 pain scale is that people will often say that 10/10 pain is the worst pain you can imagine. Well I have never been blown up so I cannot imagine what that is like. To describe things further, they say it is like being nailed to a cross or burned at the stake, fortunately I haven‘t experienced those things either, so I don‘t know what to do with that information. This pain scale has clear functional language, associated with each of those numbers 0–10, as well as a color guide of green, yellow and red, as well as faces to assist the patient in describing their pain level numerically. We designed this scale to be used in a variety of clinical environments, for example in Afghanistan. However, this is a big change that is being rolled out. We are going to have everyone in the military ask the pain question in the same way with this functional language and the scale will also take into account how pain is impacting on general activity, sleep, mood and stress. It is fulfilling to practice in pain medicine because it transcends every border in medicine, there is no aspect of medicine (with maybe the exception of pathology) where pain doesn‘t have a role, it is as critical a health problem as cancer, diabetes, heart disease or any other health problem that plagues human beings. It is time for us to be moving in this direction, and giving this field of medicine its proper due, after neglecting it for so long as a symptom of other disease processes.

Q What do you view as the highlight of your career so far, and what do you hope to achieve in the next few years?

I have had an incredible career; to pick any one highlight would be difficult. I think the times that soldiers have expressed to me that the things we are working on are making a difference or family members have expressed that we have made a difference in their lives are highlights. I cannot think of a more fulfilling statement for a military physician from a patient. There have been many personal successes, but I attribute those to the patients I take care of and the people I work with. My organization now has 24 employees, as well as countless relationships with universities and military providers, and I am the spokesperson for this, and it is a great position to be in because I love talking about the incredible work the DVCIPM team does. However, the patients are the real heroes in this, along with the pain nurses and physicians at Walter Reed who care for them daily. I would say that my greatest achievement is to have the opportunity to represent both them and the US military.

Q Do you have any closing comments or messages for our readers?

To patients, I say that they should not settle with their pain. If they are having issues with their pain they need to make sure those issues are addressed when talking to their caregivers. I think there are many people who tend to suffer, and sometimes they are not suffering just from the pain, they are suffering from some of the cures that we have traditionally used. I think that opioids are one of those issues; prescription drug abuse in the USA is a big problem, and it has already surpassed the issues we may have with street drugs like heroine or marijuana, it is not all about pain, but certainly I think that the way that we have managed pain historically has contributed. When I went to medical school, I received no training in pain as a disease process, my training was always about how pain was a symptom for some other issue. I think what I would suggest to your readers is that, as a society, we need to demand of our medical system that we provide better training for our health providers, and patients have to be better consumers of their pain management. What I mean by that is that they need to be wary, if they are just getting pills, particularly opioids, they need to be aware that there are many different modalities and techniques that might be more effective with fewer side effects, and if they feel that they are not on the receiving end of a more modern, interdisciplinary, multimodal approach to pain, they should seek it out.

Disclaimer

The opinions expressed in this interview are those of the interviewee and do not necessarily reflect the views of Future Medicine Ltd.

Financial & competing interests disclosure

C Buckenmaier 3rd has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.