Walter Reed Pioneers Pain Management Program
By Rudi Williams
American Forces Press Service
WASHINGTON, May 26, 2004 Third in a Three-Part Series
Regional anesthesia, technically known as a continuous peripheral nerve block, theoretically can be used on all combat-wounded patients, noted Army Lt. Col. (Dr.) Chester C. Buckenmaier III, chief of the regional anesthesia section at Walter Reed Army Medical center here. But he pointed out that the military medical profession isn't at that point -- yet.
Army Lt. Col. (Dr.) Chester C. Buckenmaier III, chief of the
regional anesthesia section at Washington's Walter Reed Army Medical Center,
discusses continuous peripheral anesthesia blocks with George Washington
University Medical Center Drs. Olya Quitkin, right, and Lavern Bentt. The
visiting doctors from that facility, also in Washington, were at Walter Reed
observing the technique. Photo by Rudi Williams
(Click photo for screen-resolution image);high-resolution image available.
"Like so many wars, this war occurred before we were ready," he said. "These blocks here at Walter Reed have only been around since 2000. We're very busy building a program. It takes money, and the hospital's budget is for the hospital's daily function. I have to get resources to build this program so we can do the training and the academic research that is developing this anesthetic for the battlefield."
It takes money and time to train Army anesthesiologists, Buckenmaier said. "We've been very fortunate with Congressman John P. Murtha of Pennsylvania, through the John P. Murtha Neuroscience and Pain Institute, who supported us with $1.2 million last year," he said. "We're looking for between $6 million and $8 million this year to do the research and the academics that it takes to get this to the field (and make it) commonplace."
Regional anesthesia is being used on the battlefield, but not to the level Buckenmaier would like it to be. "My belief is that it will be there for the next war," he said.
Regional blocks are only a slice of the Army's regional anesthesia and pain management initiative, which includes traditional narcotics, other medications and the whole gamut of professionals -- physical medicine, psychiatrists, rehabilitation specialists and other health care professionals.
"We're eventually going to move that concept out to the battlefield, where the anesthesiologist will be the pain management physician for the battlefield," Buckenmaier said. "Pain is our brass ring, and we're already doing a better job on the battlefield. But with this training, doctors will be able to give each soldier a more comprehensive pain management picture."
He said when people have surgery, they're going to have pain. "If you go to war and you get an injury, you expect to have pain," he continued. "Well, our society has advanced now to where pain is the 'fifth vital sign.' He termed this a euphemism in the medical community, where pain is looked as importantly as the traditional vital signs temperature, blood pressure, pulse and respiratory rate.
"A patient having to accept pain is no longer allowed," he said. "We as physicians have to treat that. So we're getting better training on how to manage pain. We're learning more about what pain is every day.
"It's pretty significant when you're able to use an anesthetic all the way through the levels of care," Buckenmaier added.
Turning to George Washington University Medical Center's Drs. Olya Quitkin and Lavern Bentt, who were observing the procedure, Buckenmaier asked: "Have you ever stubbed your toe and it hurts really bad, but the next day, it really hurts? That's a phenomenon called wind-up, which is a protective mechanism. Your body has been injured, and it doesn't want you to injure that area again. "That's great when you stub your toe, but when you've had your ankle blown off, that quickly becomes counterproductive," Buckenmaier said.
He explained that the body gets overwhelmed by pain signals, and the patient experiences "hyperalgesia," or super pain in layman's terms.
"If I do anything to this patient that has had his leg or arm blown off, like start an IV or inject a little bit of local anesthetic to get the IV in, they're like screaming sometimes," the doctor told the two visitors. "If I was to do that to you right now, you'd just bear it; it's just a little pin prick - - no big thing," Buckenmaier told the visiting doctors. "But in these guys, every nerve ending is on fire. But when we do these blocks and we stop those pain signals, we find that they don't develop this hyperalgesia."
Bentt said she and Quitkin wanted to see how Buckenmaier performed continuous regional anesthesia procedures and how the technique would apply in treating orthopedic injuries. They also wanted to obtain an idea of how Buckenmaier's section is organized at Walter Reed.
Doctors at George Washington have been performing regional anesthesia and providing regional anesthesia for a long time, but they haven't been doing continuous peripheral nerve blocks, Bentt noted.
"Some of our frustrations as physicians are that the public is afraid of the needle," Bentt noted. "In many cases, the nerve block technique is actually preferable to a general anesthetic, which is like using a hammer to put a stitch in when you could use a small needle. And there are fewer requirements for pain medications with the blocks.
"Many patients will resist that because of the fallacious idea that abounds in society, that if I have this, it will damage my nerves or I'll be paralyzed," said Bentt, co-director of GW's pain management center. "So the biggest obstacle is public acceptance."
She said patients normally have little or no recollection of the nerve block procedure because they're sedated. "You can't be completely asleep, because you don't want to risk injuring a nerve and the patient not being aware enough to tell you," Bentt said. "Most patients end up being very happy and say, 'If I'd known this is how good it would be, I probably would have done this a long time ago.'
"The biggest obstacle is public perception," she noted. "People should know that the needles are so small that the pain from the needle is minimal. In addition, it's done with sedation, so people have very little recollection of it happening."
Regional anesthesia minimizes some of the side effects of general anesthesia, such as nausea, vomiting, remaining in the recovery room for a long time trying to get their pain under control, and having to be admitted to the hospital overnight because their pain isn't well-controlled, Bentt said.
Quitkin said GW is trying to develop a regional anesthesia division that will do more anesthesia blocks. "We hardly do any now," said Quitkin, attending anesthesiologist at GW's regional anesthesia center. "Walter Reed already has an established service, and it seems to work quite well. So we decided since theirs work so well, we should go and see how they set it up so we can do the same thing.
"I haven't been trained in doing continuous peripheral blocks, and that's another reason I wanted see how they're done at Walter Reed," Quitkin pointed out, adding that the blocks are useful for a wide variety of patients.
Quitkin, who attended a workshop conducted by Buckenmaier last year, said she has already put to use a lot of what she learned at Walter Reed. She said using continuous peripheral anesthesia blocks would save GW time and money. It also greatly lessens the pain experienced by patients for such surgery as total knee replacements.
"Total knee replacement is probably one of the most painful operations in terms of postoperative pain," the doctor noted. "But when you place one of these peripheral catheters in, patients wake up comfortable, therefore their stay in the recovery room is much shorter, and that translates into dollars. It also saves time in nursing care. It can decrease their postoperative stay entirely. It's great for outpatients, because they can go home with these continuous catheters that they can remove by themselves. So their discharge time is also decreased."
Time is also saved when the blocks are put in before the patient is taken to the operating room.
"Patients who have this are thrilled with it," Quitkin said. "They come back and request it. But it's one of those things that's not well-known to the general public, and many people are still a little bit wary of it."
Quitkin said the procedure hasn't been publicized more because it's relatively new. "It has been around in Europe for a long time, but in the U.S. for some reason it hasn't really taken on," she said. "Every procedure involves a certain risk. When you put a needle in your nerve, there's always a chance that you might injure that nerve. But the way the technique is done now, that's so minimized that it's almost negligible."
Some patients also fear being awake during their operation, Quitkin said. "When you tell the patient that they're going to be sedated, to them that automatically means you're somewhat awake," she said. "It's basically been the fault of our profession for not presenting it appropriately to the patients."
Buckenmaier said he believes that regional anesthesia is making the process less fearful. "It's a historical issue," he noted. "Dr. (John) Snow was the first anesthesiologist in England who gave ether to the queen, and we've been going down the gas route ever since."
Snow administered chloroform to assist Queen Victoria with the birth of her son, Prince Leopold, on April 7, 1853.
Many patients fear anesthesia because, Buckenmaier said, "You never knew who your anesthesiologist was, because he showed up in the operating room, had a brief interaction and the next thing you know he has knocked you out. When you wake up, you're nauseated from that gas and you don't feel well. So when the anesthesiologist came back to see you, you weren't all that pleased to see him. That's because you're in pain, you're nauseated, and this is the guy that's sort of causing it all."
That doesn't happen with regional anesthesia, he said, noting a patient interaction that had just taken place. "I was actually building a relationship with that patient that they didn't have before with their anesthesiologist," he said. "I'm also becoming a true preoperative physician. One of the problems with anesthesiologists is that we put ourselves in the (operating room) and do an awesome job, but we pigeon-hole ourselves in there."
About two weeks after his shoulder operation, that patient Army Sgt. Jonathan M. Oliver Sr. -- said there was a world of difference in the intensity of pain after his knee surgery last January and his more recent shoulder surgery with regional anesthesia.
"That anesthesia was my friend," Oliver said during a recent telephone interview. "I didn't feel any pain at the surgery site. The block lasted longer than the general anesthesia I had during my knee (surgery). I didn't have any pain for more than a day after the (knee) surgery. But after the anesthesia block wore off, the pain kicked in, and I started paying the price. I'm still paying the price!"
Though he takes two strong drugs for pain, they don't control the pain as well as the anesthesia block does, said Oliver, 38, of the Army Reserve 400th Military Police Battalion at Fort Meade, Md. Oliver was activated for service in Iraq on Feb. 20, 2003. He wanted do his part in Iraq, but didn't go there because of a training accident. He slipped and fell on his shoulder and had to have surgery to repair the damage.
Buckenmaier said he needs to be interested in a patient's pain before, during and after the operation. "I need to be their perioperative medicine physician," he said. "I need to discharge them compassionately. If I do a block and when the patient gets through the operation I kick him out the door, have I really done him a service when that block wears off at 3 o'clock in the morning and he's in agony again? I would argue no.
"But with these continuous peripheral nerve blocks, I can put a catheter in this patient and send him home with a disposable infusion pump. Then that patient can control his own pain, take the traditional narcotics, and in many cases remove the catheter by himself a few days later."
Plans are under way at Walter Reed to follow up on patients in six months to a year and compare the pain experiences of those who had regional anesthesia with those who were treated traditionally with just morphine on the battlefield.
Pointing out that the majority of battlefield wounds are extremity wounds, Buckenmaier told the visiting doctors, "If I can turn off any of any extremity I want at will, you can see the power in that."
Noting that only a handful of major medical institutions perform the procedure routinely, Buckenmaier said Walter Reed is at the vanguard of regional anesthesia research and is taking the leadership role in developing these techniques throughout the country.
"We're doing things here at Walter Reed that nobody else is doing," said Buckenmaier, who received his training at Duke University Medical Center in Durham, N.C. "We've been driven to it because of the nature of the soldiers we're taking care of."
Buckenmaier said he wants to see the Army's regional anesthesia pain management initiative expanded to include the other services. He's starting a fellowship program in July and is looking at the Air Force and Navy "to train with us to be the proponent for regional anesthesia in those services," he said. "The Air Force is very interested, and (Air Force medical officials) think in the next three to five years they're going be coming right along with us."
He pointed out that spinals and epidurals, used in almost half of the casualties in Vietnam, are "really powerful tools" that deal with the spinal cord. But continuous peripheral anesthesia blocks involve the peripheral nerves that have already left the spinal cord."
"So it's the next level of regional anesthesia," Buckenmaier said. "We're all very good at spinals and epidurals, and if you open a standard textbook, that's what you're going to read about." Advanced regional anesthesia is taking it to the next level."
Calling regional anesthesia "the Cadillac of pain control," Buckenmaier said, "patients come to us literally in agony, and we have the ability to almost flip a switch and they go from being really miserable to almost entirely different human beings. Their entire outlook changes."
When a patient is in tremendous pain and a physician can switch that off, "it's a tremendous power," he said. "It makes you feel very good, particularly since these are American soldiers, the finest citizens we have in the country."
As with any medical procedure, regional anesthesia is not totally risk-free, the doctor said. "Any time I stick a needle anywhere, there's a risk of injury or infection," he explained. "Any time I'm working with nerves, there's a risk of injury to the nerve. Fortunately, because of the training we go through, those risks are very small."
No cases of a patient having a problem with toxicity from a continuous infusion of local anesthetic have turned up so far in the medical literature or in his own experience, Buckenmaier said.
"You can't say that for morphine," he noted. "You saw (in) the movie 'Saving Private Ryan,' when the medic gets hit and they use all those morphine ampules in his thigh? They basically euthanize him on the battlefield. I shudder to think in the history of medicine in the military, how many soldiers we've euthanized in that manner in the name of compassion."
Morphine, when it's your only choice, is a very difficult drug to use in a battlefield environment. But morphine and other opioid medications can be used with impunity in a hospital environment, he said.
"We're changing the way anesthesia is done on the battlefield today as we speak," Buckenmaier said.