Treating Pain on the Battlefield: A Warrior’s Perspective

Development of a mobile application for acute pain management in U.S. military healthcare

One of the most significant challenges faced by the U.S. military health system is effective pain management. In resource-denied environments such as En Route Care (ERC), patient care begins with effective acute pain management and is vital to ensure optimal long-term patient outcomes. An electronic, mobile pain management application (app) called the Bee Better app was developed to address the gaps in acute pain management for patients transported throughout the ERC system. The app enables patients to track self-reported acute pain data, provides education and evidenced-based non-pharmacologic interventions during transport. The Delphi method was used as a novel approach to solicit feedback from subject matter experts to systematically enhance the app development process. In its current state, the app tracks patients' reported pain data and information regarding medication intake and provides educational resources about medications and the flight environment. Optimally in the future, the app will deliver real-time therapeutic pain interventions, integrate with the electronic health record and communicate with providers in real-time during care, enabling better patient-centered pain management in the austere ERC environment. Initial usability scores were above industry standards indicating a potential benefit in using a rigorous process for healthcare app development. These mobile apps may enable increased self-management and autonomy in resource-limited environments and optimize outcomes of acute pain management.

Effective testing of personal protective equipment in blast loading conditions in shock tube: Comparison of three different testing locations

We exposed a headform instrumented with 10 pressure sensors mounted flush with the surface to a shock wave with three nominal intensities: 70, 140 and 210 kPa. The headform was mounted on a Hybrid III neck, in a rigid configuration to eliminate motion and associated pressure variations. We evaluated the effect of the test location by placing the headform inside, at the end and outside of the shock tube. The shock wave intensity gradually decreases the further it travels in the shock tube and the end effect degrades shock wave characteristics, which makes comparison of the results obtained at three locations a difficult task. To resolve these issues, we developed a simple strategy of data reduction: the respective pressure parameters recorded by headform sensors were divided by their equivalents associated with the incident shock wave. As a result, we obtained a comprehensive set of non-dimensional parameters. These non-dimensional parameters (or amplification factors) allow for direct comparison of pressure waveform characteristic parameters generated by a range of incident shock waves differing in intensity and for the headform located in different locations. Using this approach, we found a correlation function which allows prediction of the peak pressure on the headform that depends only on the peak pressure of the incident shock wave (for specific sensor location on the headform), and itis independent on the headform location. We also found a similar relationship for the rise time. However, for the duration and impulse, comparable correlation functions do not exist. These findings using a headform with simplified geometry are baseline values and address a need for the development of standardized parameters for the evaluation of personal protective equipment (PPE) under shock wave loading.

Battlefield Analgesia in Tactical Combat Casualty Care

At the start of the Afghanistan conflict, battlefield analgesia for US military casualties was achieved primarily through the use of intramuscular (IM) morphine. This is a suboptimal choice, since IM morphine is slow-acting, leading to delays in effective pain relief and the risk of overdose and death when dosing is repeated in order to hasten the onset of analgesia. Advances in battlefield analgesia, pioneered initially by Tactical Combat Casualty Care (TCCC), and the Army's 75th Ranger Regiment, have now been incorporated into the Triple-Option Analgesia approach. This novel strategy has gained wide acceptance in the US military. It calls for battlefield analgesia to be achieved using 1 or more of 3 options depending on the casualty's status: 1) the meloxicam and acetaminophen in the combat wound medication pack (CWMP) for casualties with relatively minor pain that are still able to function effectively as combatants if their sensorium is not altered by analgesic medications; 2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress, and are not at significant risk for developing either condition; or 3) ketamine for casualties who have moderate to severe pain, but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioid medication. The present paper outlines the evolution and evidence base for battlefield analgesia as currently recommended by TCCC. It is not intended to be a comprehensive review of all prehospital analgesic options.

Altered gene expression of the innate immune, neuroendocrine, and nuclear factor-kappa B (NF-κB) systems is associated with posttraumatic stress disorder in military personnel

Whole transcriptome analysis provides an unbiased examination of biological activity, and likely, unique insight into the mechanisms underlying posttraumatic stress disorder (PTSD) and comorbid depression and traumatic brain injury. This study compared gene-expression profiles in military personnel with PTSD (n=28) and matched controls without PTSD (n=27) using HG-U133 Plus 2.0 microarrays (Affymetrix), which contain 54,675 probe sets representing more than 38,500 genes. Analysis of expression profiles revealed 203 differentially expressed genes in PTSD, of which 72% were upregulated. Using Partek Genomics Suite 6.6, differentially expressed transcription clusters were filtered based on a selection criterion of ≥1.5 relative fold change at a false discovery rate of ≤5%. Ingenuity Pathway Analysis (Qiagen) of the differentially expressed genes indicated a dysregulation of genes associated with the innate immune, neuroendocrine, and NF-κB systems. These findings provide novel insights that may lead to new pharmaceutical agents for PTSD treatments and help mitigate mental and physical comorbidity risk.

Pain management in military trauma

The wounded warrior requires immediate care, and at times, evacuation from injury. Care may be self-regulated, or may require more advanced care under the direction of medics or advanced practitioners, including physicians and surgeons. While survivability is the immediate priority, pain management has become a military initiative, recognizing that poor management of acute pain may lead to the development of chronic pain and post-traumatic stress disorder. This article reviews current initiatives used in current conflict situations, as well as those in continued care following initial stabilization.

Proximal sural traction neurectomy during transtibial amputations

Symptomatic neuroma formation after trauma-related transtibial amputations remains a clinical problem. The sural nerve is frequently overlooked in its vulnerable subcutaneous location in the posterior myofasciocutaneous flap and commonly leads to chronic pain and decreased prosthesis use. The standard sural traction neurectomy may actually predispose the sural neuroma to form in a region that becomes symptomatic with prosthesis wear. The proposed modified proximal sural traction neurectomy using a standard or extended posterior flap begins with identification of the sural nerve in the subcutaneous tissue of the distal flap in identical fashion to a standard sural neurectomy. In the proximal posterior flap, a limited anterior approach is then performed and gentle traction on the distal end of the sural nerve aids in the identification of the most proximally accessible portion of the medial sural cutaneous nerve. After locating the medial sural cutaneous nerve proximally, a neurectomy at this location is performed, allowing the retraction of the nerve into a healthy tissue bed substantially more proximal than with a standard sural neurectomy. This technique ensures that the resulting neuroma does not form directly at the distal end of the residual limb where it is, in our experience, more likely to become symptomatic.

The role of pain management in recovery following trauma and orthopaedic surgery

War often serves as a catalyst for medical innovation and progressive change. The current conflicts are no exception, particularly in the area of pain management of wounded warriors. Morphine administration has served as the primary method of battlefield pain management since the American Civil War. Although traditional opioid-based pain management is effective, it has significant side effects that can complicate recovery and rehabilitation following injury. These side effects (eg, sedation, nausea and vomiting, ileus, respiratory depression) can be fatal to persons wounded in combat. This fact, along with recent research findings indicating that pain itself may constitute a disease process, points to the need for significant improvements in pain management in order to adequately address current battlefield realities. The US Army Pain Management Task Force evaluated pain medicine practices at 28 military and civilian institutions and provided several recommendations to enhance pain management in wounded warriors.