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Pain is weakness leaving the body

by U.S. Medicine

September 6, 2012

I do not think it is possible to spend any time in the military without hearing this quote at least once. A friend recently purchased a T-shirt at the Pentagon with the adage proudly displayed. It is a mark of pride among servicemembers that they can endure hardship and harsh conditions with stoic acceptance.


Editor-in-Chief, Chester ‘Trip’
Buckenmaier III, MD, COL, MC, USA.

 In my own house, the prevailing military family rule is, “Thou shall not whine!” I think most military families can relate to this cultural norm. Americans depend on the moral strength and willingness of our servicemembers and their families to place the immediate needs of the country first, before their own needs and comfort.

This is a key and essential attribute of the men and women in our armed services, particularly because our society demands so much from the 1% that guards our freedoms. When it comes to health and the practice of effective medicine, these same attributes that we depend upon for success on the battlefield can greatly interfere with the rehabilitation and recovery of our wounded.

Like most Americans, I was stunned and shocked by the events of Sept. 11, 2001, and, like most, I can still recall my personal activities that day as if it happened yesterday. I was at Duke University Medical Center in Raleigh, NC, completing my fellowship in acute-pain medicine and regional anesthesia. I spent that day desperately trying to get back to Walter Reed Army Medical Center in Bethesda, MD, to possibly assist with casualties and sadly learning that I was not needed, for there were far more dead then wounded from the Pentagon.

 As a response, I spent the next eight hours with many hundreds of others trying to donate blood, something positive to do  in the face of such overwhelming tragedy. I have never felt more powerless and useless before or since that defining day. In the eight hours spent standing in line, I had plenty of time to ponder how these events were going to change my military career and the lives of my family members forever. I could not have guessed that the rest of my career as a fully trained physician, from that moment until now, would be defined by war.

I had been sent to Duke due to the farsightedness of my then-leaders, who knew we needed to better manage analgesia in the changing casualty evacuation paradigm and believed regional anesthesia could play an important role in the next war. I never could have imagined (in the same way I could not imagine 9/11) the central role that pain medicine would play in my own medical career or the focus this issue would require in the recovery and rehabilitation of our wounded.

“Pain is weakness leaving the body.”

Since 9/11, the improvements in managing acute and chronic pain on the battlefield and at home have been a remarkable achievement of federal medicine. Until recently, pain has always been thought of as a symptom of some other disease process or trauma. Providers believed that, if they took care of the physical problem, the pain would take care of itself. Like most things in medicine, it just is not that simple.

Pain, like the other “signature” disease processes of post-traumatic stress injury (PTSI) or traumatic brain injury (TBI), if not appropriately managed, can develop into a chronic, lifelong, debilitating disease. Perhaps most tragic in the management of the polytrauma triad of PTSI, TBI and pain is the stigma that often accompanies these injuries, particularly in a military culture that prides itself on unusually high levels of physical and mental performance under high stress.

Frank Ochberg, in the Time magazine article, “Honor, Stigma … and PTSD” (May 24, 2012), comments on the recent request of former Vice-Chief of Staff of the Army, Gen. Peter Chiarelli (ret.) to change the PTSD (“D” for disorder) to PTSI (“I” for injury) as a needed step to de-stigmatize this condition within our culture. Because the injuries of PTSI, TBI and pain are usually not clearly visible, they lack the “Red Badge of Courage” honor that more clearly visible wounds afford the wounded veteran. This is a serious cultural error, because the wounds inflicted on the warrior from PTSI, TBI and pain are no less devastating or life-changing than any other injury sustained in defense of this country.

To paraphrase Ecclesiastes 3, there is a time and place for everything. The Pentagon T-shirt has its desired effect in creating a culture that hardens the body and mind for the important work of defending this country. That motivational spirit must be coupled with cultural maturity to recognize that the wounds of war are not always visible, represent no less of a sacrifice from the warrior and deserve no fewer honors. From a perspective that I understand and applaud, the Pentagon T-shirt has a place as a motivational tool in our military culture in building resilience in young men and women as they prepare for war. I just hope we remember, when the fighting has stopped and the warrior has returned, T-shirts with the slogan, “Weakness is leaving a body in pain,” are no less appropriate.

U.S. Medicine issues last month and next month (October) will focus on the disease process of pain and its impact on our military. I, for one, am extremely pleased that federal medicine is having this important conversation, for it has been the defining discussion of my federal medicine career.

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