Military Medicine Works on Managing Pain

WASHINGTON — Mil­i­tary med­i­cine is seek­ing addi­tion­al ways to help patients man­age their pain instead of just pre­scrib­ing pow­er­ful drugs, the chief of staff of the Army’s pain man­age­ment task force said here today.

Col. Kevin Gal­loway told the Defense Writ­ers Group that the mil­i­tary had to start look­ing at pain com­pre­hen­sive­ly.

“We were always asked how pain relat­ed to sol­dier sui­cides, to drug abuse, and so on,” said Gal­loway — a reg­is­tered nurse. “As we looked at our strat­e­gy in Army med­i­cine, very hon­est­ly, we did­n’t think it was as com­pre­hen­sive as it should have been.

Com­bat becomes a cat­a­lyst for med­ical inno­va­tion, the colonel said. “It has to,” he added. The mil­i­tary com­bat­ed yel­low fever, malar­ia and oth­er infec­tious dis­eases, he not­ed, and pio­neered use of antibi­otics on a grand scale, as well as the use of blood prod­ucts and plas­ma.

Get­ting casu­al­ties from bat­tle­field to the hos­pi­tal and triag­ing casu­al­ties was an out­growth of mil­i­tary med­i­cine, Gal­loway said, and mede­vac pro­ce­dures and aeromed­ical evac­u­a­tion once belonged exclu­sive­ly to the mil­i­tary med­ical realm.

But in pain man­age­ment, the progress has not been as far or fast as mil­i­tary lead­ers wish. Gal­loway told the sto­ry of Con­fed­er­ate Lt. Gen. Thomas “Stonewall” Jack­son at the Bat­tle of Chan­cel­lorsville in 1863. Jack­son was griev­ous­ly wound­ed in a friend­ly fire inci­dent.

How he was han­dled was the state of the art for the time. He was evac­u­at­ed in an ambu­lance and was first treat­ed at what today’s sol­diers’ would call a bat­tal­ion aid sta­tion. In addi­tion to a shot of whiskey, doc­tors gave him mor­phine. Jack­son called the relief of pain from the wound “an infi­nite bless­ing.”

Jackson’s ini­tial treat­ment to ease his pain was a good-news sto­ry. The final result was not so good: Jack­son lat­er died of pneu­mo­nia.

Flash for­ward to 2001, and the bulk of the pain-relief arse­nal was not a lot dif­fer­ent. “It was still based around opi­ates,” Gal­loway said.

Medicine’s goal was “to knock that pain down to zero,” the colonel said. “And we can do that.” But fam­i­lies began to com­plain.

“When the kids leave for school in the morn­ing, Dad’s on the couch. The pain is con­trolled,” Gal­loway said. “Vic­to­ry for us and med­i­cine — we did a good job. But when the kids come home from school in the after­noon, Dad’s still on the couch.

“Med­i­cine is still say­ing it’s doing its job because the pain is con­trolled, but this person’s qual­i­ty of life is prob­a­bly not what they want it to be, def­i­nite­ly not what the spouse wants it to be, [and] not what their fam­i­ly wants it to be,” he added.

The goal should­n’t be to knock the patient out, but to max­i­mize func­tion, Gal­loway said.

The task force devel­oped rec­om­men­da­tions that led to a com­pre­hen­sive pain-man­age­ment strat­e­gy. The strat­e­gy uses both tra­di­tion­al and non­tra­di­tion­al pain-treat­ment options. Treat­ment with drugs is appro­pri­ate in many cas­es, Gal­loway said, but so is treat­ment with acupunc­ture, biofeed­back or mas­sage.

“The Army for the past year has been embarked on oper­a­tional­iz­ing … an ambi­tious, com­pre­hen­sive, soup-to-nuts recal­i­bra­tion of how we look at pain, how we treat pain, how we resource pain in our orga­ni­za­tion, and being part of the DOD col­lab­o­ra­tive effort on this, to change the way it’s done in the mil­i­tary health sys­tem,” he said.

The mil­i­tary is unique­ly poised to make changes in a way that those on the out­side can see and relate to, he said.

The task force had three over­ar­ch­ing find­ings from the task force, the colonel said.

“The first is we meet cur­rent stan­dards of care,” he said. “We weren’t lack­ing, but we weren’t hap­py with what was going on.”

The sec­ond find­ing is that best prac­tices occurred in Defense and Vet­er­ans Affairs orga­ni­za­tions, “but they were being imple­ment­ed and exist­ing in iso­la­tion,” Gal­loway said. “They weren’t being repli­cat­ed.”

The third, he said, is unwar­rant­ed vari­abil­i­ty. “We did­n’t have a com­mon ori­en­ta­tion across our orga­ni­za­tions,” he explained. “When you talk pain — some­times between shifts in a facil­i­ty, there were dif­fer­ences.”

Gal­loway said the mil­i­tary is look­ing to change the cul­ture toward treat­ment of pain. It will take time, he acknowl­edged, adding that offi­cials will con­tin­ue to look for new ways, tech­niques and pro­ce­dures. They also will insti­tu­tion­al­ize best prac­tices across DOD and VA, he said.

“Years from now,” Gal­loway said, “they will look back and say what med­ical ben­e­fit came from these wars and it will be this strat­e­gy on pain that is the break­through.”

U.S. Depart­ment of Defense
Office of the Assis­tant Sec­re­tary of Defense (Pub­lic Affairs)