Pain is usually considered a symptom, not a life-threatening medical problem.
But for Army veteran Richard Dejarnette, 52, constant excruciating pain in his right leg made his life intolerable, and he believes he wouldn’t be alive today if a physician anesthesiologist at the VA West Los Angeles Medical Center hadn’t been there to help him.
On December 14, the Department of Veterans Affairs announced the wise decision to keep physician anesthesiologists at the head of the anesthesia care team at VA hospitals nationwide, ensuring that veterans like Mr. Dejarnette will continue to receive first-class anesthesia care. While the VA’s new Advanced Practice Registered Nurses rule will allow nurse practitioners and midwives to practice independently, anesthesia and pain management are considered so complex and high-risk that physician oversight is crucial to safe patient care.
Mr. Dejarnette was stationed in Germany in 1986 when he dislocated his right knee during a routine morning run with his battalion. He had no idea then that the injury would spiral into an 18-year battle with a debilitating condition known as complex regional pain syndrome (CRPS).
CRPS, while rare, is usually the aftermath of an injury or an operation on an arm or leg. Abnormal hyperactivity of the nerves leads to severe, unrelenting pain. In the worst cases, the limb becomes swollen, stiff, and so painful that it can no longer function. Opioids — drugs such as morphine or oxycodone — can ease the pain, but they don’t treat the cause, and their chronic use can lead to addiction, overdose, and death.
I first met Mr. Dejarnette when I was a medical student, and I was shocked at the sight of his right leg — purplish, ulcerated, cold, and useless. He was sitting in a wheelchair, unable to care for himself and suffering intense pain at the slightest touch to his leg. He needed anesthesia just to allow the leg to be cleaned. He had consulted many physicians, but none had been able to help him, and he had already made two suicide attempts. He was considering a move to Oregon where he could have access to legal assisted suicide.
“I was surviving, but I wasn’t living,” Mr. Dejarnette recalled. “I had mentally dissociated the limb from my body years ago. It just hung there like dead weight.”
Complex pain syndromes can be notoriously difficult to diagnose and treat. This is why pain medicine is a specialty in its own right. Harkirat Chahal, MD, the physician anesthesiologist who led Mr. Dejarnette’s treatment, had completed medical school, four years of residency training in the specialty of anesthesiology, and further fellowship training to become board-certified in pain medicine.
Mr. Dejarnette had begged in the past for doctors to amputate his leg, believing that to be the only way to alleviate his pain for good. But amputation carries its own risks in the setting of CRPS, which may develop in other limbs. Amputation also may result in phantom limb pain, where the perception of pain persists even though the limb itself is gone.
The condition of Mr. Dejarnette’s leg had deteriorated to the point that gangrene and life-threatening infection were real risks. Amputation was the only solution. But would it solve his pain problem, or would he be left as badly off as before?
Dr. Chahal’s team at the VA hospital developed a novel treatment plan. A peripheral nerve catheter was inserted into Mr. Dejarnette’s thigh during the surgery, infusing a continuous solution of local anesthetic (numbing medicine) to block nerve conduction to and from the leg. They continued the infusion for four weeks, to make sure that phantom limb pain didn’t develop after the amputation.
Now, two years later, Mr. Dejarnette says, “I’m so active that my family can’t even keep track of me!” With a new prosthetic limb, he is independent and completely free of pain without any medications. He can go to the gym, walk his dog, drive a car, and enjoy life in ways he never thought he would experience again.
Though his case was extreme, Mr. Dejarnette isn’t alone in his experience of prolonged suffering. Increasing numbers of veterans today are returning from service with debilitating, painful injuries. Physician anesthesiologists fulfill a critical role in the operating room, and those with expertise in pain medicine also help veterans heal and overcome chronic pain. After their selfless service, our veterans deserve the highest quality of care from the best pain experts available.
The recent VA rule protecting physician-led anesthesia care comes as a relief to veterans like Mr. Dejarnette. Veterans, concerned citizens, and physicians sent over 100,000 letters and emails to the VA opposing any change to the current practice where physician anesthesiologists lead the anesthesia care teams at VA hospitals. We hope that the VA will hold fast to this decision and withstand any pressure to reverse it.
After suffering for so many years, Mr. Dejarnette walked his daughter down the aisle on her wedding day — a dream come true for him and his family, thanks to his physicians’ innovative and successful pain management. All our injured veterans deserve no less.
Ajit Rai is an anesthesiology resident.
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