Dr. Chester “Trip” Buckenmaier in Iraq. Photo courtesy of DVPMI.

As chief of acute pain medicine and regional anesthesia at the Walter Reed Army Medical Center, Army Col. Chester “Trip” Buckenmaier’s days are filled with helping others mitigate their pain. Pain, as he explains it, is a subject that touches every aspect of medicine.

“You name a medical specialty and I will tell you how pain is related,” he said. “In fact, if you talk to any health care professional about why they got into medicine in the first place, it was to relieve pain and suffering. Pain is really at the foundation of everything that we do in medicine.”

For the military, pain has been a particularly important topic because advances in military medicine now mean that servicemembers with extreme polytrauma are surviving battlefield injuries that they would not have survived in previous conflicts. Many of these soldiers who sustain serious battlefield injuries return from war in considerable pain.

The Defense and Veterans Pain Management Initiative (DVPMI) has a mission to improve the management of pain for these servicemembers from the point of their injury on the battlefield through their eventual transition from a military hospital to the civilian sector or VA, according to Dr. Buckenmaier, who serves as its president. “When there is a question of pain in the military our phone eventually rings,” he said.

The initiative evolved from the Military Advanced Regional Anesthesia and Analgesia (MARAA) and the Army Regional Anesthesia and Pain Management Initiative (ARAPMI). ARAPMI was initially created in 2000 to improve the Army’s response to pain on the battlefield through regional anesthesia techniques and other pain management modalities that had not been previously used.

“We got started back before Sept. 11, 2001, really as a desire to improve our medical response on the battlefield from an anesthesia perspective, specifically from a logistics standpoint,” said Dr. Buckenmaier. “We thought that regional anesthesia was underutilized and had proven itself in previous conflicts. We really had not advanced the science of pain in the military much beyond the use of morphine.”

Regional Anesthesia on the Battlefield

In 2003, the Army became very concerned about the number of injured soldiers coming home from Iraq who were complaining of the extreme pain they were in on the flights back to Landstuhl Army Regional Medical Center in Germany, and then back to the United States. At that time, morphine, a 200-year-old drug, had been the traditional battlefield painkiller. While effective, morphine can produce unwanted side effects like vomiting and nausea.

In response to the complaints of pain, Dr. Buckenmaier was dispatched to Iraq to show that regional anesthesia was a viable option for controlling pain both on the battlefield and en route out of the theater.

Regional anesthesia, as opposed to general anesthesia, allows for a patient to remain cognizant during an operation. It involves the placement of a catheter through which the local anesthetic is administered to a specific area where the patient is experiencing pain. A continuous peripheral nerve block (CPNB), for example, involves a catheter being placed near the nerves serving the wounded area. A small pump administers doses of anesthetics that block pain. The nerve block is localized so the patient can remain awake.

While in Iraq, Dr. Buckenmaier performed the first CPNB on the battlefield in the 21st Combat Support Hospital in Iraq on a wounded servicemember in 2003. This allowed the servicemember to be transported out of theater without pain. That experience proved that the CPNB, which had not been used on the battlefield prior to this time, could be effective on the battlefield and could reduce the pain that injured soldiers were experiencing without the type of side effects associated with morphine.

Understanding Pain

Since then, Dr. Buckenmaier and his colleagues at DVPMI have continued their work on research and education on the use of regional anesthesia as a battlefield tool. Dr. Buckenmaier emphasizes that morphine is a very important tool in controlling pain, but it is just one tool that should be used on the battlefield.

“If there has been a success in this group it has been the education of the DoD on the advantages of multimodal therapy in the military,” he said. “What that means is using a variety of tools and technologies, a variety of different drugs that work by different mechanisms, improving the overall pain care of the patient, reducing the side effects of any one drug.”

While morphine is still the standard drug used on the battlefield for pain, Dr. Buckenmaier sees progress being made in using other pain management techniques.

“So, the reality today is if you are wounded in Iraq or Afghanistan there is an inconsistent application of many of these advanced pain modalities,” he said. “I think the military leadership is aware of that and they are working towards improving that situation. We have certainly made great strides at Walter Reed and our other medical centers in providing these pain services, and we have pushed that forward to Landstuhl. We have traveled quite a distance, but we still have a long way to go.”

Pain Research

The pain research that DVPMI is conducting is important to better understand the mechanisms behind pain. “We still don’t really understand what pain is. We don’t have a good measure of pain. Unfortunately, soldiers don’t come with meters on their foreheads that say, ‘I am in severe pain,’” he said.

What is known about pain is that it is not simply a symptom of another disease process, according to Dr. Buckenmaier. “We used to think of pain as simply a symptom of some other disease process. What has changed in the late ’90s and into the 21st century is we now recognize that pain in and of itself is a disease process. It influences many critical functions of your body adversely,” he said.

Pain can depress the immune system and be detrimental in the recovery of injured servicemembers. “Anything that depresses their immune systems is certainly going to set them back in their recovery,” he said. “We look at pain as sort of the third leg to the polytrauma stool. What I mean by that is the seat of the stool is the trauma itself, and the issues that sort of hold that up are TBI, PTSD and pain. The symptoms are extremely correlated and interrelated. You can’t really understand TBI or PTSD unless you have a very good understanding in a management program for pain.”

The DVPMI has a unique opportunity to study pain in that the injured servicemember population is otherwise young and healthy, according to Dr. Buckenmaier. “It is an opportunity to understand pain mechanisms you just can’t do in an elderly patient with many other comorbidities like diabetes, heart disease, or what have you,” he said.

As part of its research, DVPMI has looked at pain issues that injured servicemembers deal with. “Positively and sadly we have the only data available right now in the current conflict on just asking the soldiers about their pain and where these issues are,” he said. “One of the places we identified as an area where we needed improvement was the flights. It is a very austere environment, and until recently, there were not an awful lot of tools to treat pain, so it was a pretty difficult experience for a lot of soldiers.”

Related Research

An example of other research conducted by DVPMI is a CPNB study that it is currently being conducted with the Philadelphia VA. “We are looking at our continuous peripheral nerve blocks in a study. We work with soldiers over a period of two years, asking them questions about the influence of our advanced anesthetic techniques, if they received them or not, and their outcomes,” he said.

Efforts of what was then known as ARAPMI and MARAA have also led to the approval of peripheral nerve infusion pumps and patient-controlled analgesia (PCA) pumps for the battlefield and for flights on military aircraft. The initiative also collaborates with the Conemaugh Health System in Johnstown, PA., which allows research in regional anesthesia to benefit both the civilian and military population.

Congressional funding has been instrumental in the work the group is doing. “Congressman (John) Murtha saw the need for improved pain management—not in just the military—but in medicine in general. He has been supporting us and I can safely say that if it wasn’t for his support many of the advances that we have brought to the battlefield just wouldn’t have happened,” he said.

Continued Improvement in Pain Management

Pain management in the military continues to improve, Dr. Buckenmaier points out. “It’s not that we were not doing pain management before 9/11, we were. But we were achieving a community standard that I think as medical science and pain has matured we now recognize is not where we should have been. So it has been an actual progression to this understanding that management is not only a team approach, in terms of doctors and nurses being involved, but it is also a multidisciplinary approach.”

Last year, WRAMC hired its first acute pain nurses for its pain service. Acute pain nurses are very important in the work that is done in the program because they are able to educate patients who are experiencing pain about their pain management options and answer any questions that they may have.

In addition, Dr. Buckenmaier points to other advancements, such as the recently completed anesthesia handbook called, “The MilitaryAdvanced RegionalAnesthesia and Analgesia Handbook.” It serves as a resource for managing the pain of battlefield trauma, and its purpose is to educate anesthesiology residents in advanced regional anesthesia techniques and acute pain medicine. It is the first text for battlefield pain care and is available online.

“The fact that for the next war someone will actually have a guidebook to start from sets the bar at another level,” noted Dr. Buckenmaier, who is senior author of the book.