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IMPROVING PAIN CARE FOR RETURNING TROOPS --
They call it the coming tsunami, veterans
returning
from Iraq who will suffer chronic pain years
from now.
Story here...
http://www.wtopnews.com/
ndex.php?nid=106&sid=1134631
Story below:
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Improving Pain Care for Returning Troops
By LAURAN NEERGAARD
AP Medical Writer
WASHINGTON (AP) - They call it the coming tsunami, veterans returning
from Iraq who will suffer chronic pain years from now. Get ready,
military doctors are warning pain specialists _ even as they hope that
slowly improving battlefield pain control may stem the tide.
The idea: Block the agony faster, and the body's pain network may not go
into the overdrive that sets up the injured for lingering trouble long
after they're officially healed.
"It's going to take the military to stop thinking of pain as a symptom,
a consequence of war," says Lt. Col. Chester "Trip" Buckenmaier III, an
acute pain specialist at Walter Reed Army Medical Center who is pushing
for that change.
"Pain really is a disease. If you don't manage it early, it leads to
serious consequences."
At risk aren't just troops who suffered severe wounds such as loss of a
limb, but others with varying types of pain that goes untreated, or
undertreated.
Why? "If you don't ask, they don't report" pain, says Dr. Robyn Walker,
a psychologist at the James A. Haley Veterans Affairs Hospital in Tampa.
Troops with traumatic brain injuries, a signature of the war, may not be
able to express pain adequately. More common is a tough-it-out
mentality, she says, a fear that admitting pain might block return to
duty _ or hesitancy because they know wounds could have been worse.
Remarkably, Walker says it's not unusual to discover fractures or
shrapnel previously missed because a soldier didn't acknowledge
continued pain until her office pushed for details.
"Most pain doctors won't see the severely injured. The VA will keep
them," says Dr. Michael Clark, chief of chronic pain rehabilitation at
the Tampa VA.
But other veterans eventually will seek community care, Clark warned an
American Pain Society meeting last week: "This is going to impact you
for decades to come."
Doctors have long known that suppressing acute pain aids short-term
recovery. But it's also a factor in whether patients develop a long-term
misery, chronic pain.
Consider: Injured nerves send distress signals to the brain. If those
signals go unabated, the brain can essentially memorize pain and become
hypersensitive. An infamous example is the phantom limb pain that often
strikes amputees. But less severe injuries can spur chronic pain, too,
which in turn is linked to post-traumatic stress disorder, other anxiety
disorders, and disability.
At the war's beginning, "we were using Civil War-era pain management, "
is Buckenmaier's grim assessment. Morphine was the main option as the
wounded were evacuated to Germany on excruciating plane flights. But
many were deemed too vulnerable for doses in the air, where nurses could
do little if the drug depressed their breathing, he explains.
While morphine is a crucial painkiller, it doesn't actually block pain
signals from reaching the brain.
What can? Continuous nerve blocks, developed at civilian hospitals using
increasingly portable drug-infusion pumps. Doctors trace the roots of
nerves signaling certain pain, such as from arm or leg wounds. They
insert tiny catheters that allow drugs to bathe those nerves and block
that signal. It requires an anesthesiologist or other specialist trained
in nerve anatomy.
Buckenmaier delivered the first battlefield nerve block in October 2003.
A rocket-propelled grenade tore out a chunk of a soldier's lower leg;
eventually, it would be amputated. But minutes after receiving the nerve
block at a field hospital, he said he was pain-free. He sat up and joked
with buddies instead of being in the usual post-surgery drug stupor. The
infusion pumps lasted through evacuation to Landstuhl, Germany, and on
to Walter Reed, including several operations over 16 days.
Hundreds of troops now have received nerve blocks, although Buckenmaier
says they're "applied inconsistently" in battlefield hospitals with few
acute-pain specialists. Last month, he helped open an acute pain center
in Landstuhl to expand pain-control options there.
Does that early care truly prevent chronic pain after such extreme
wounds? Buckenmaier and Dr. Rollin Gallagher of the University of
Pennsylvania are beginning to track injured troops to find out.
Immediately after the injury isn't the only vulnerable time, and nerve
blocks aren't the only solution. A recent Johns Hopkins University study
tracked pain after leg trauma and amputations, and found that patients
who took narcotic painkillers for three months after leaving the
hospital were less likely to develop chronic pain.
Nor is severe trauma the only concern. Clark is seeing lots of chronic
knee pain; perhaps jumping out of trucks wearing 60-pound packs is too
hard on the joints, especially for older troops.
Then there are those high-powered blasts, where bystanders can walk away
seemingly unscathed. Doctors are increasingly concerned that they may
suffer nerve damage, perhaps signaled by headaches. Any doctor seeing an
Iraq veteran should ask about headaches, Clark told last week's pain
meeting.
"The usual course of pain treatment is failure, failure, failure, then
go to a pain specialist," laments Pennsylvania's Gallagher. "We want
early intervention."
Lauran Neergaard covers health and medical issues for The Associated
Press in Washington.
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Larry Scott --
