Comfortably Numb

In December, commenting on Atul Gawande's NEJM piece on the advances in trauma surgery underway Iraq, I wrote:

One comes away with a greater appreciation of what the tiny number of army physicians and surgeons have accomplished in Iraq. There are implications for our civilian trauma management, as well (lengthy stabilization in the field or community hospital may not be in the patient's best interest).

Now it's clear the potential for changes in civilian surgery aren't just limited to transport management. Steve Silberman has an eye-opening article in this month's Wired on potentially far-reaching progress in anesthesia. Some wounded soldiers are receiving hi-tech regional blocks instead of general anesthesia:

The blocks used by Buckenmaier and his team are made possible by the recent invention of small, microprocessor-controlled pumps which bathe nerves in nonaddictive drugs that discourage the transmission of pain signals. The pumps also can be used for weeks after surgery, enabling soldiers to adjust the level of medication themselves as they need it.

For soldiers evacuated from the battlefield, the advantages of nerve blocks over traditional methods of pain control are clear. The wounded troops flying in and out of Landstuhl are often in misery or a narcotized stupor, while those treated with blocks remain awake and pain-free despite massive injuries.

He goes into some excrutiating detail about setting up a regional block at the scene of a trauma:

Wilhelm had been carried into the OR for debridement, the harrowing process of removing dirt and dead tissue from a wound. Buckenmaier got out his bag and went to work.

First he used a millivolt stimulator to probe for leg nerves that were still functioning. The soldier's ankle flexed - a sign that the stimulator had found the nerves serving the injured area. Then Buckenmaier placed two blocks by inserting ultrafine catheters into Wilhelm's back and thigh to bathe his sciatic and lumbar nerves in a drug called mepivacaine.

Throughout the 85-minute operation, Wilhelm remained awake and talking. At one point, a technician lifted his wounded leg to clean it, and the weakened tibia fractured with a sharp crack that sent shudders through the surgical staff. But the blocks were so effective, Wilhelm didn't even feel it.

The typical scene in the recovery tent is a somber one: friends touching the sides of the bed around an unconscious soldier in a silent show of support. By contrast, when Wilhelm's operation was over, 15 of his buddies crowded around, laughing and joking with him.

Later, Wilhelm's catheters were connected to pumps, each about the size of a TV remote control and weighing only about 6 ounces, with tiny LCD screens. Hooked up to a supply of ropivacaine, they would provide continuous anesthesia for 48 hours on two AA batteries. The entire apparatus fit in a fanny pack.

And finally, if one accepts the research that chronic pain can be nipped in the bud, by quickly covering short-term pain, then the regional blocks will improve outcomes down the road, as well.