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Anesthesiology:
doi: 10.1097/01.anes.0000290587.82027.6b
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Forward-deployed Anesthesiologists and Pain Treatment in Combat Support Hospitals: Making Decisions about Deployment of Anesthesiologists in Support of the Global War on Terrorism

Harris, Kenneth C. M.D.*; Rathmell, James P. M.D.†

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THE primary mission for an anesthesiologist deployed in the US Army is to work in a combat support hospital (CSH) supporting the operating room. One of us (Dr. Harris) is an anesthesiologist and the physician who is currently responsible for making recommendations regarding deployment of anesthesiologists on active duty within the US Army in support of the Global War on Terrorism. The composition of personnel in the CSH includes two anesthesiologists working together with one or more certified registered nurse anesthetists. Because of the availability and high deployment tempo for active duty certified registered nurse anesthetists over the past several years, the Army anesthesiology community has filled many CSH-certified registered nurse anesthetist billets. This has resulted in a higher-than-usual proportion of anesthesiologists at several CSHs, allowing for the creation of an interventional pain clinic at one location, the Ibn Sina Hospital in Baghdad, Iraq. Major Ron L. White and Colonel Steven P. Cohen had the foresight to prospectively record the treatments rendered at this unique clinic between October 2005 and September 2006, and they detail their findings in this issue of the Journal.1 There are many types of military missions that necessitate medical support and each of these may require specific specialty involvement. In combat operations, the concern is naturally focused on care of the acutely wounded. As an operation matures and stabilizes, more specific and tailored medical support is often required. It is tempting to conclude from White and Cohen’s article that each CSH should have a pain clinic staffed by a physician with subspecialty training in pain medicine. However, no clear link can be made between the high return-to-duty rates they observed and the treatments rendered in this clinic. The reality of making decisions about deployment of anesthesiologists is that it will not always be possible to establish a pain clinic staffed by a practitioner with pain medicine subspecialty training within each CSH. Nonetheless, the basic pain interventions rendered in this study should always be available to our military personnel.
Less than 10% of active duty Army anesthesiologists are pain medicine fellowship trained. Although every anesthesiologist is exposed to pain management during training, some have more interest and ability in this area than others. Occasionally, a fully trained pain management specialist is deployed and will further engage the process, but this is the exception rather than the rule. It is not equitable to demand that these few individuals be repeatedly deployed to have full-service interventional pain management support. Deployments are one of the main reasons that many anesthesiologists leave the Army each year. Several years ago, a plan was introduced to make deployments more equitable. In the current operations, active duty Army anesthesiologists are deployed for 6 months at a time. The intent was and is to deploy every eligible anesthesiologist once before deploying an individual a second time. In general, this system has been well received by anesthesiologists. Thus, there is no plan to selectively deploy pain management specialists to each CSH at this time.
In an environment as vast as Iraq, movement of personnel to a level III facility, like that assembled at Ibn Sina Hospital in Baghdad, can be extremely hazardous, and only those with serious conditions should be transported. The authors report that pain management helped many patients, but it is likely that most of those treated in this clinic came from nearby areas and not from a forward operating base. As in any large population (100,000+), there will be pain issues that necessitate medical attention, and that is the value of this report: It clearly demonstrates the common painful conditions that have arisen in our military personnel on active duty in Iraq. Indeed, acute cervical and lumbar radicular pain (often associated with new disc herniations), thoracic back pain, lumbosacral pain associated with facet arthropathy, and groin pains were among the most common conditions treated in this cohort. Our understanding of the consequences of the under treatment of acute pain has grown enormously in recent decades. There seems to be a clear link between the magnitude of acute pain after surgery2 or the onset acute herpes zoster3 and the subsequent incidence of chronic pain. Although the actual effectiveness of the treatments rendered the patients treated in the pain clinic at Ibn Sina Hospital cannot be judged from the current article, it is tempting to believe that early treatment of pain may well have reduced the development of chronic pain and long-term disability in at least a small number of these individuals who received prompt treatment.
Arguably, a general anesthesiologist should have the basic skills to treat the more common ailments (e.g., the majority of the workload in this report came from epidural steroid injections, trigger points, and facet injections). Indeed, the Accreditation Council for Graduate Medical Education requires that all anesthesiology residents have basic training in pain medicine, and this requirement has been expanded to 3 full months of training in pain medicine in the new the Accreditation Council for Graduate Medical Education program requirements that go in to affect in 2008. All Army anesthesiology residents receive significant exposure to pain medicine, and they are more than adequate to deal with basic pain issues. For those with more involved cases, there is a mechanism for evacuation to a large facility for complete evaluation and management services.
It is unclear from White and Cohen’s report that there is any link between the treatments rendered in this clinic and the observed high return-to-duty rates. The authors state, “only soldiers who were motivated to return with their units were referred for pain treatment.” This type of selectivity indicates that the patient population was highly skewed. These motivated soldiers would be likely to return to duty regardless of the results of their pain intervention. Indeed, there are no real outcomes reported on the patients who were treated, because the majority returned to their units within 48 h after treatment without any subsequent follow-up. The authors also comment that “the return-to-duty rate in this study was likely inflated by the treatment of soldiers who would not have opted for medical evaluation even in the absence of a forward-deployed pain treatment center.” Therefore, these limited data alone would not alter deployment plans to establish a forward-deployed interventional pain clinic.
The authors do recognize the limitations of their work and tell us, “Whether our high return-to-duty rate is a function of forward-deployed pain treatment, a carefully selected and highly motivated patient population, or a combination thereof, is a question that needs to be determined.” In reality, this type of investigation is unlikely to ever be possible in the context of an ongoing war. Military duty is fraught with dangers and is physically demanding; therefore, acute and chronic pain problems will arise. Assuming that the early and aggressive treatments provided by this innovative pain clinic in Iraq did effectively treat many common pain conditions, it is clear that basic pain management must be readily available for existing personnel and more advanced care must be promptly accessible on a case-by-case basis. The provision of early, effective pain treatment may well prove to be the most effective strategy to reduce the incidence of chronic, disabling pain among our military personnel. Although it is unlikely that we will ever have enough pain medicine specialists to create pain clinics in every CSH, perhaps these much-needed services can be offered through the development of a pain management medical augmentation team, a group of medical personnel with the needed expertise and training to provide optimal pain care, that could be used in specific situations to provide better interventional pain management support in a mature theater.
Kenneth C. Harris, M.D.,*
James P. Rathmell, M.D.†
*Medical Corps, US Army, Fort Sam Houston, Texas. †Harvard Medical School, Massachusetts General Hospital Pain Center, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts. jrathmell@partners.org
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References

1. White RL, Cohen SP: Return-to-duty rates among coalition forces treated in a forward-deployed pain treatment center. Anesthesiology 2007; 107:1003–8

2. Kehlet H, Jensen TS, Woolf CJ: Persistent postsurgical pain: Risk factors and prevention. Lancet 2006; 367:1618–25

3. Jung BF, Johnson RW, Griffin RJ, Dworkin RH: Risk factors for postherpetic neuralgia in patients with herpes zoster. Neurology 2004; 62:1545–51

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