A 29-year-old veteran came to the ED complaining of headaches and uncontrolled pain in his upper quadrant. He had been discharged from the military after he sustained a blast injury during duty as a Marine in Iraq. His right arm had been amputated.
Since military discharge, the patient had been receiving care at a local VA center. He stopped going to the VA 2 weeks before he presented to the ED because he believed that he was not receiving adequate care for his pain. The patient reported that he had no pain medication and was unable to sleep. He told the ED staff, “I am scared I am going to hurt my family if I don’t get this pain under control.”
A release of information was obtained to communicate with VA physicians who explained that they had been trying to regulate the patient’s use of opioid medications by combining narcotics with physical therapy and other nonpharmacological interventions for his chronic pain. This change in the treatment plan had been initiated both at the request of the patient’s family and because VA staff were concerned the patient was abusing his opioids, which they believed were clinically indicated.
According to the VA physicians, the patient had been receiving treatment for PTSD and a moderate traumatic brain injury that had impaired his executive function and working memory. On further questioning, the patient admitted to drinking alcohol(Drug information on alcohol) to intoxication every night since leaving VA care to self-medicate his pain and trauma.
The veteran had a history of aggressive behavior before he entered the military. Because of concerns about domestic violence, the ED social worker placed a call—with the veteran’s permission—to his spouse to assess her safety. The wife denied any history of domestic violence or fears her husband would harm her or their children. She did express great concern for her husband’s well-being and corroborated his report of frequent nightmares and unrelieved pain.
Discussion
Sadly, this case represents a typical presentation of the veteran suffering from polytrauma and its psychiatric complications. Improvised explosive devices, like the one that led to this patient’s arm amputation, are the leading cause of disability and death in Iraq. Soldiers who would have previously died on the battlefield from devastating injuries now regularly survive as a result of the impressive advances in military medicine.1 Recovery from these multiple mental and physical wounds is long and arduous. The expertise of a VA polytrauma program that can also treat PTSD is the optimal type of care.2,3 Hence, the overall goal of the ED physician may be to discuss with the veteran that receiving care at the VA is probably his best chance for recovery of function.
The more immediate task of the ED doctor is to treat what is real physical pain while balancing justified concerns about abuse of opioids and an ongoing alcohol problem. A chief complaint of pain can often (particularly in a busy non-VA ED) lead to a focus on the medical problems when the psychiatric ones are at least as serious. Either the ED physician or (if available) a mental health clinician should screen the patient for suicidality and (especially in this case) homicidality. The patient’s fears that he may hurt someone if he does not obtain adequate pain control and sleep must be taken seriously. Increased anger and aggressive behavior have been noted in returnees.4
In addition, patients like this veteran—with executive function impairments from traumatic brain injury—may be impulsive, with poor frustration tolerance.3 As part of an overall plan to reduce the violence potential, judicious use of opioids in the ED may be warranted. However, a prescription for narcotics is not prudent given the patient’s history of opioid abuse and aggression and the need for comprehensive pain management.5
A nonjudgmental but straightforward explanation from the ED physician that he shares the VA clinician’s view of the need to treat chronic pain with an interdisciplinary approach and in tandem with substance use disorders and PTSD treatment is warranted. Such an explanation may help the veteran see that the VA is not being arbitrary or uncaring but is in fact acting in the patient’s long-term best interests. This case also underscores that treatment of veterans also means caring for the spouse and family. Involving the spouse in the treatment plan is essential to its success. The spouse would also benefit from referral to VA or community support groups.6
