Regional anesthesia on the battlefield

[Sacamuelas]

Doctor Recalls First Battlefield Use of Regional Anesthesia in Iraq
By Rudi Williams
American Forces Press Service

WASHINGTON, May 25, 2004 – Doctors at Walter Reed Army Hospital here have been using regional anesthesia for years, but Oct. 7, 2003, was the first time they used it on the battlefield.

Regional anesthesia involves placement of a catheter through which local anesthetic can be administered to a specific area where the patient is experiencing pain.

"Army Spc. Brian Wilhelm was the first individual that ever had a continuous peripheral nerve block on the battlefield that was used during evacuation," said Army Lt. Col. (Dr.) Chester C. Buckenmaier III, chief of the regional anesthesia section at Walter Reed. "We kept him pain-free from Iraq to Landsthul and from Germany back to Walter Reed by redosing him through those same catheters we inserted in Balad, Iraq. We also used the same catheters during five operations.

Wilhelm was suffering from a rocket-propelled grenade wound to the back of his leg that blew off the hamstrings.

"Specialist Wilhelm was awake during the operation, just slightly sedated," the pioneering anesthesiologist said. "He was wide awake at the end of the case, interacting with his buddies. It was a happy time, rather than a sorrowful time like it usually is after a general anesthetic, where patients are groggy and feel so bad about what's happened to them, and you can't really talk to them.

"With this anesthetic, they're alert, they're awake, and they're talking to you like I'm talking to you right now," Buckenmaier said. "The first time we used regional anesthesia on the battlefield was a very powerful moment. Brian went through a horrible experience. And, yes, it was a horrible wound. Brian went on to lose his leg, but he's pain-free!"

Buckenmaier was on a forward surgical team with the 31st Combat Support Hospital in Balad. He said the first definitive surgery wounded soldiers get is at a combat support hospital, and that's where anesthesiologist work and where regional anesthesia techniques are used.

"I'm unaware of it being used in Afghanistan, but I do know that it's being used at the 31st Support Hospital in Baghdad and in Balad," he noted. Army Col. (Dr.) Jack Childs, the consultant to the Army surgeon general for anesthesia, is in Baghdad, he added, and Maj. (Dr.) Todd Williams is in Balad.

Buckenmaier said the Army surgeon general was concerned about wounded soldiers being flown from the battlefield in excruciating pain. The surgeon general sent an e-mail to Childs, who was Buckenmaier's boss at the time, asking if anything could be done to mitigate pain in wounded soldiers being medically evacuated from Iraq.

"Well, here at Walter Reed, we'd been working with regional anesthesia for a long time," Buckenmaier pointed out. "We'd been preaching that we could do this for years. So finally, the surgeon general said 'put your money where your mouth is. Why don't you go and prove it?'"

Buckenmaier went to Iraq hoping to get a case or two, but it turned out to be much more than he expected. "I wanted that index case, which Brian Wilhelm was, to prove that we could do this," Buckenmaier said. "But it exploded. It's such a good idea that the surgeons ceased allowing us to just put it in Americans. They immediately (realized) 'I don't have to take this Iraqi prisoner back to the operating room to do a dressing change every time. I can have this doctor put this block in, and he can dose the catheter and do the dressing change right at the bedside.'

"That's where this is really impacting in Iraq," he continued. "Most of the American soldiers get injured and they're out of the country within 48 hours. Some of them are moving so fast that we don't have time to get a block in them. But when the Iraqis get injured, they don't go anywhere. So these catheters are being used every day in Iraqis."

http://www.defenselink.mil/news/May2...200405252.html

[rogerabn]

Being that this is my area of expertise I am going to wade in on this with my two cents worth.

Regional anesthesia has regained popularity with the Anesthetist and Anesthesiologist more and more over the recent past. The numerous hazards of general anesthesia in the first half of this century influenced many anesthetists to look towards regional techniques as a safer method that had fewer risks and negative side effects. But as the development of safer general anesthetic agents came into the practice, regional methods of anesthesia became less popular. Now it is seen being used more and more in hospitals, and stand alone outpatient/ambulatory surgical centers. Also it is used as an very effective technique in post operative pain management.

The history of regional anesthesia dates all the way back to 1884, when Dr’s Hall and Halsted introduced the concept of injecting cocaine for mandibular nerve blocks. (Cocaine is one of the earliest discovered local anesthetics) Soon after, Corning, a neurologist experimented with the application of cocaine to the spinal nerves, and injecting cocaine solutions between the spinous process of the inferior dorsal vertebras. His description of the technique is similar to the techniques and the developments used in modern day epidual anesthesia.
With over 120 years of research and development, regional anesthesia has become a major component of pain management and anesthesia for surgery.

The most common preoperative blocs are:
Wound infiltration
Extremity blocks: Bier, axillary, interscalene and ankle
Spinal
Epidural
Caudal

The advantage of an Epidural is that the indwelling catheter can be placed and remain for up to three days. This allows you to not only dose for pain control, it also allows you to bolus the epidural and have good surgical anesthesia.

Perhaps the greatest potential disadvantage of regional anesthesia is the need to develop adequate regional skills. In my particular anesthesia program that I attended there was little emphasis in instruction on regional techniques. After graduation and entering practice I personally found that I was not alone, and that many of my colleagues also suffered from this lack of preparation. But in practice I found it not that difficult to become proficient in regional anesthesia.

In the context of military medicine, specifically in the Special Operative arena, it can allow fully trained 18D’s to provide emergency anesthesia for certain types of surgery and other painful procedures and bypass many of the potential sources of minor and major morbidity associated with general anesthesia, i.e. trauma to lips, teeth, pharynx, vocal cords, broncho spasm, aspiration, loss of airway and death. The required drugs and supplies take little room and are light weight (a major factor when you consider that the medic is already hauling a heavy load), safe to use when properly trained, and allow more definitive treatment sooner to the patient.

Roger Coleman,CRNA,MS

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[Eagle5US]

that this has not been SOP until just now?!? FAST Teams have been forward deployed since the beginning of all this in 2001. It would have made significant sense for them to have been doing this type of pain control.
Of note...it may also be worth mentioning that "the battlefield" with respects to the article is actually referring to the Combat Support Hospital and not the Battalion Aid Station or the actual "field".
I have used simple blocks for transport out of an environment (hematoma blocks, digital blocks, a single ankle attempt that was -thankfully- successful), and recommended the simpler ones (digitals) to my medics after I trained and certified them. In my bag I have a little waterproofed version of the "Regional anesthesia pocket guide"...has 18 plates about the size of 3x5 cards with detailed diagrams, injection points, dosages, landmarks etc....very handy.
When bubba is hurting...that is what is on his mind..."Doc, stop the hurt". Even when in a less than favorable situation.
If he needs to concentrate on something else...like bad guys / bad terrain / bad whatever...and still be cognizant, blocks work great.

Eagle