Prevalence and Predictors of Pre-hospital and Emergency Department Pain Assessment, Pain Severity, and Pre-hospital Analgesic Use in Military Trauma Patients in a Combat Zone

Persistent pain after traumatic injury is a significant clinical problem. Pain assessment increases likelihood of pre-hospital (PH) and emergency department (ED) analgesic administration in civilian settings. Military health systems deliver sophisticated trauma care, yet little is known about combat zone PH and ED pain care. Because combat casualty care includes different challenges than civilian emergency care, military-specific research is needed. This dissertation explores pain physiology and how physiologic theory provides a compelling rationale for early analgesic intervention and examines PH and ED pain assessment and PH analgesic intervention practices among US military combat zone trauma patients. Chapter 1, the Introduction, provides an overview of the problem of combat injury pain and its impact on clinical care and outcomes. Chapter 2 reviews physiologic theories of pain processing and transition from acute to persistent pain. Pain management in PH and ED is proposed as an essential trauma care component that may reduce long-term morbidity from persistent pain. Chapters 3 and 4 describe two original retrospective, cross-sectional studies of combat zone pain care practices in US military patients from 2010-2013. Multiple logistic and linear regression analyses, as appropriate, were used to build explanatory models of PH and ED pain assessment documentation, PH analgesic administration, and PH and ED pain severity score (0-10) using demographic, clinical, and health system variables. Analyses revealed that 18.6% of records (n = 1,258) had PH pain assessments, and this increased to 37.8% if PH vital signs were also recorded. PH analgesic administration was reported in 25% of the sample (n = 1684), increasing to 51.5% if patients had pain assessment, and 82.2% if patients had a pain severity score of 4-10. ED pain assessments were found in 60.5% of records (n = 3339). Mean pain severity was 5.5 for both the PH and ED samples. Documentation improved each year in both samples. Chapter 5 provides a synthesis of the work and discusses implications for research and clinical practice. Pain after traumatic injury can become a chronic, persistent condition that robs survivors of quality of life and creates an economic burden. Findings from this dissertation suggest that even in the austere combat zone PH and ED environments, pain assessment and analgesic interventions are possible. More research is needed to determine how these interventions influence the patient's trajectory of pain experience