I'd be interested to see what comes out of this pain "conference", there's been a major shift in culture of pain management. If the military can help push technology forward in so many other areas, it's about time it was used to treat wounded veterans.
Better armour, treatment saves more wounded soldiers, but many left in chronic pain
BY SHARON KIRKEY, POSTMEDIA NEWS APRIL 18, 2012 3:03 PM
When the pain hits hard, it feels as if Maj. Mark Campbell's left foot has been set on fire.
EDMONTON - Major Mark Campbell who lost both legs to an explosion in Afghanistan talks about his physical rehabilitation in Edmonton, January 19, 2012.
Photograph by: Bruce Edwards , Edmonton Journal
Except, there is no foot. Campbell's legs were blown off on a midday in June 2008, when a buried improvised explosive device was detonated beneath him during a Taliban ambush in Afghanistan.
His left leg was all but vaporized in the explosion; his right leg barely hung on by a few strands of shredded bone and tissue.
Today, he suffers phantom limb pain where his left leg below the knee used to be — an excruciating kind of torment so severe he needs methadone to manage it. He's on maximum allowable doses of other pain medications, their list of side-effects long. "But I have no choice," the 47-year-old father of two says. "It's that, or I don't want to live."
As the nation's largest military deployment since the Second World War ends, a new and constant companion will follow many wounded soldiers from the battlefield: Chronic, life-altering pain.
Leaders in Canada's pain community say the unprecedented numbers of soldiers who survived injuries that in past wars would have killed them will need a high level of care in a country where pain is under-treated, and under-funded. U.S. doctors are reporting that half of Iraq and Afghanistan vets treated at military hospitals are experiencing some form of persistent and significant pain.
"We owe Canadian warriors the best pain care possible," says Dr. Mary Lynch, director of research at the Pain Management Unit at the Queen Elizabeth II Health Sciences Centre in Halifax.
"But if the military has to rely on the civilian system of complex pain care, it will be grossly inadequate," she said. Canadian civilians are facing waits of more than a year at specialized pain clinics. Vast areas of the country have no access at all.
A first-ever Canadian pain summit to be held next week in Ottawa will hear how a U.S. army-led task force on pain has led to an overhaul of how wounded soldiers are being treated, from the battlefield through rehabilitation once home. Specialized pain clinics are being set up at civilian and army medical centres across the U.S. that take a holistic approach. A military criticized for over-relying on opioids to manage pain — leading to high rates of addiction among injured soldiers — is now embracing acupuncture, meditation, yoga and other alternative therapies.
"We know that this is something that we need to be aggressively managing," states Col. Chester (Trip) Buckenmaier III, program director for the U.S. Defense and Veterans Center for Integrative Pain Management.
"We've been talking about the 'rock stars,' if you will, of the conflict — those soldiers that have obvious injuries from an IED, for example, where there's a limb missing," he said.
"But the business of being in the military and the business of being in the war zone is hard, it's hard on human beings," Buckenmaier said. "We have these guys now in 40 pounds of body armour. They're often running around with rucks that are another additional 50 pounds."
Soldiers are returning from war with severe back strain, joint pain and other musculoskeletal injuries, as well as constant headaches from exposure to multiple blasts.
"When a soldier comes back broken, that impacts everybody," Buckenmaier said. "And until you've managed the pain adequately, they can't focus on anything else. We really become the basest, the most base that we can be as human beings," he said. "We're animals. All you can think about is escaping the pain."
Until the military began offering a combination of therapies, many people did just that by using opioids to excess, "because you could essentially send yourself into oblivion."
While post-traumatic stress disorder and traumatic brain injury have been called the "signature injuries" of war, Buckenmaier says there is a third: Pain.
No land army in the history of warfare has achieved the level of survival as seen in the war in Afghanistan, he said.
"We have a less than 10 per cent died-of-wounds rate, and I'm pretty sure the Canadian military is enjoying a similar statistic."
In the Second World War, 30 per cent of wounded troops died.
According to the Canadian Forces Surgeon General report in 2010, if a wounded CF soldier, sailor or airman makes it to the military hospital at the Kandahar Airfield with vital signs, they have a 97 per cent chance of making it back to Canada alive.
Advanced body armour, advanced trauma life support provided by medics on the battlefield and rapid evacuation of the wounded — all are factors behind the improved survival rates.
Still, more than 600 Canadian soldiers have been wounded in action in Afghanistan; more than 1,400 others have sustained non-battle injuries (such as injuries from traffic accidents or the accidental discharge of a weapon).
Many of these injuries will result in pain that is relentless, Lynch says. In addition, research in the U.S. shows that more than half of military personnel suffering physical pain from combat wounds are also plagued by depression, anxiety, panic disorder and other psychological problems — a phenomenon experts have dubbed "post-deployment multi-symptoms disorder," or PMD.
Blast-related injuries can dominate — wounds from IEDs and landmines and rocket-propelled grenades. The blast force can cause head-to-toe trauma, from "de-gloving injuries" — stripping of skin and soft tissue from bones — avulsion of limbs requiring amputation, shattered pelvic bones, genital amputation, bowel and bladder injuries, hand or finger amputation, punctured lungs and traumatic brain injury.
Soldiers can survive their wounds only to be left with complex regional pain syndrome — "nerve damage that causes pain that is excruciating," says Lynch, past president of the Canadian Pain Society, co-host of next week's pain summit. "Even the touch of a cotton ball can be painful, or the sound of a plane overhead or a newspaper rustling in the same room."
Until Canada pulled out of its combat role in Afghanistan, Lt.-Col. Markus Besemann received casualty and wounded reports regularly.
"Amputees are certainly the most graphic ones," said Besemann, head of the CF's rehabilitation program. But other severe injuries involve "multiple orthopedic trauma" — broken bones, shattered pelvis — nerve damage, head trauma, spinal cord injuries and internal organ damage from blasts.
Most military hospitals in Canada were shuttered in the 1990s, their role handed to the civilian sector. Military personnel who need specialized care are treated at civilian hospitals and rehabilitation centres, with followup care provided by their base health clinics. But not all have multi-disciplinary pain programs.
The Canadian Forces has two chronic pain management programs — one in Halifax, the other in Ottawa — that teach patients breathing techniques, mindfulness meditation and other exercises to help manage their pain. The plan, Besemann said, is to expand them to major bases across the country.
Patients are sent to the teams after everything that can be done medically is done, he said.
In addition, doctors specializing in rehabilitation medicine are being hired for bases in Gagetown, Edmonton and Quebec City.
He said soldiers needing complex care could be fast-tracked to civilian pain clinics within a matter of months.
Lynch says the decision on who should take priority should be made on the basis of urgency of need, "and not whether a person is a civilian or in the military."
"The whole system needs to be fixed," she said. "There is massive ignorance about the appropriate treatment for chronic pain."
Pain researchers, doctors and patient groups across Canada want a national pain strategy that would see more investment in training doctors — civilian and military — in pain and more specialized pain clinics.
But for soldiers, there are other challenges in seeking care: The "tough-it-out" mentality embedded within the military can make soldiers fearful that their careers will end if they report that they're in pain.
"I guess it's inbred in their training to suck it up," Besemann says. "They often come back and tell me that: I was basically taught as an infanteer I have to just suck it up and get on with it."
Many delay seeking care until their pain becomes chronic, he said.
"People are desperately wanting to maintain their careers, and so they'll push through pain. . . . And those are significant challenges, trying to convince people, 'Look, you need to come to us earlier, rather than later.' "
Pain isn't a threat to a career, he said, "so long as the condition they have is treatable."
Yet a recent Postmedia News series on Canada's combat mission in Afghanistan told how the number of soldiers being "medically released" jumped from a low of about 675 a year in 2002 to almost 1,200 a year in 2006.
Many of these were forced out, their injuries from Afghanistan leaving them unable to fulfil the military's requirement that all personnel be physically able to go into combat. Then-chief of defence staff Rick Hillier would later promise to exempt any soldier wounded in Afghanistan from that requirement — a promise some have complained is inconsistently applied.
Campbell, of Edmonton, says for serving soldiers with pain, "the career is on the line, and every soldier knows it." For those with back pain, knee pain, shoulder pain: "You walk it off, you suck it up, and you do what you've got to do."
The difference for him is that, "I'm done."
"I'm never going to be an infantry officer again. I'm finished. My career is over," he says. "What's holding me back from saying: 'Hell, I hurt. I want it fixed.' "
It took two tourniquets on each leg to stop his severed femoral arteries from bleeding him out. He was lucid — and in "indescribable agony" — the entire time it took soldiers to run with him on a carpet stretcher, through irrigation ditches and with gunshots and grenades exploding around them, to a secure area where an evacuation helicopter could safely land.
Campbell spent two months at Edmonton's Glenrose Rehabilitation Hospital — a rehab centre that a 2008 Senate committee report on national security and defence said stands out in Canada "like a 2009 Lamborghini on a car lot dotted with too many 1970 Ladas."
After Campbell was discharged home, the phantom pain was so severe he couldn't sleep most nights. His military psychiatrist referred him to a University of Alberta Hospital specialized pain clinic, where his doctor suggested methadone.
"Campbell remembers thinking: "The pain is so bad that I need a heroin treatment for it?"
The drug, he says, has been a "life changer."
It allows him to sleep; it helps keep him from thinking about the pain.
For Campbell, the road to rehabilitation has been long. "You don't ever fully recover from wounds like mine," he says.
His pain, he says, is exacerbated by the struggle for fair compensation from the government of Canada.
"One moment you're in combat, then the next thing you know you're in a hospital bed, and you've got no legs," he said. "The last thing you remember was that whole horrible incident you hope was just a nightmare.
"Except once the drugs wear off, you realize, 'this isn't a nightmare. This is real.'
"And the nightmare never really lets up."
With files from Lee Berthiaume, Postmedia News
skirkey@postmedia.com
Twitter.com/sharon_kirkey
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