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Prehospital Emergency Care, Apr/Jun 2009 by Black, Ian H, McManus, John

ABSTRACT

Pain management in the U.S. Military, particularly in combat, shares many of the same principles found in civilian heath care organizations and institutions. Pain is one of the most common reasons for which soldiers seek medical attention in the combat environment, which mirrors the civilian experience. However, the combat environment exacerbates the typical challenges found in treating acute pain and has the additional obstacles of a lack of supplies and equipment, delayed or prolonged evacuation times and distances, devastating injuries, provider inexperience, and dangerous tactical situations. These factors contribute to the difficulty in controlling a soldier’s pain in combat. Furthermore, civilian health care providers have also learned the importance of practicing pain management principles in austere and tactical environments because of recent natural and man-made domestic disasters. Pain management research, education, and treatment strategies have been created to try to achieve adequate battlefield analgesia, and these lessons learned may aid civilian health care providers if the circumstances arise. This article presents a brief history and current overview of pain management for combat casualties on today’s battlefield. Recent natural disasters and increased threats for terrorist acts have proven the need for civilian health care providers to be properly trained in pain management principles in an austere or tactical environment. Key words: pain; pain management; battlefield; combat

PREHOSPITAL EMERGENCY CARE 2009;13:223-227

INTRODUCTION

The U.S. Military’s response to battlefield pain control has been shaped by the nation’s conflicts and the pain management technologies available. During the Revolutionary War, prior to the development of anesthesiology as a medical specialty, which was not to occur for almost a century, “anesthetic” medications for war surgery were limited to opium, wine, grog (rum), vinegar, or, more commonly, nothing at all. Pain relief depended on the speed and dexterity of the operating surgeon. One physician describing pain care of those injured on the battlefield in 1776 commented, “act in all respects as if your are entirely unaffected by their groans and complaints, but at the same time behave with such caution as not to proceed rashly or cruelly, and be particularly careful to avoid unnecessary pain.”1 The Civil War saw army physicians administering morphine for pain control and, occasionally, cannabis for tetanus and head injuries.2 Beecher conducted landmark research in World War II, showing that 75% of casualties arriving at a field hospital did not want analgesic agents or had minimal pain after having received morphine at least five hours previously.3 During the Vietnam War, regional anesthesia (particularly neuraxial anesthesia) was used to increase operating room efficiency.4 In Somalia, neuraxial anesthesia was used to ensure that a patient could be immediately air-evacuated after debridement. During the present conflict, Operation Iraqi Freedom (OIF), the Tri-service Military Advanced Regional Anesthesia and Analgesia (MARAA) group has championed the use of accepted, cutting-edge analgesic technology and techniques.

While all of these examples demonstrate the Army’s commitment to analgesia, the fundamental questions that Beecher’s study raised remain unanswered: is combat pain different from noncombat pain, when should pain first be treated in the battlefield, and how does acute pain control affect both immediate and long-term outcomes? Previous studies have shown that failure to recognize and appropriately treat acute pain may result in an increased incidence of chronic pain5 and posttraumatic stress disorder (PTSD).1,6 The U.S