The adoption of a team-based multimodal approach to the management of pain, anxiety and delirium most feasibly commences at the level of Role 3 care and should be continued throughout Role 4 and subsequent CONUS care. This multimodal management includes the establishment of an APMS starting at the Role 3 and continuing for the duration of the casualty’s care. The physician with the most, and preferentially extensive, training and experience in pain medicine (usually an Anesthesiologist) directs the APMS and serves as the consultant. At the Role 3, the APMS is staffed from existing personnel and should include a physician consultant, a chief pain nurse, and ward pain nurse champions.1,8,9

The APMS personnel should interact directly and frequently with the primary treating service, typically led by a trauma surgeon and/or intensivist. This is best accomplished by including the APMS in daily rounds led by the primary trauma team and by incorporating the assessment and plan for pain management as a mandatory component of patient rounds. If is it not feasible to incorporate the APMS into trauma rounds, then the APMS is responsible for daily pain medicine rounds, pain medicine consults, and reports to the trauma team leader.

The APMS should be available to all patients that are admitted to the Role 3. The primary mission of the APMS is to provide effective alleviation of pain to promote functional rehabilitation enabling return-to-duty and facilitate movement through the evacuation chain, as well as assisting in the prevention and treatment of anxiety and delirium in any injured patient. There are standardized and validated scoring systems for the assessment of PAD, including the:

- DoD/VA Pain Rating Scale (Appendix B and Appendix C)
- Richmond Agitation Sedation Scale (RASS) (Appendix D)
- Confusion Assessment Method (CAM) (Appendix E)

The Defense and Veterans Pain Rating Scale (DVPRS) and supplemental questions have undergone, and continue to undergo, validation studies.10 The DVPRS should be used to assess pain, the RASS score should be used to assess anxiety, and the CAM should be used to assess the presence of delirium. Consider potential surgical and medical causes of increased pain and anxiety prior to treating.

The APMS should consist of an interdisciplinary team of physicians, nurses, and pharmacists that is available 24/7. In addition to participating in daily trauma rounds, the APMS consultant is responsible for the coordination of pain management plans with the validating flight surgeon, medical evacuation team, and the receiving MTF. Additionally, the APMS should include a tracking and performance improvement system that follows all patients on the service listing their injuries, therapeutic interventions, and care plan; this should be electronically maintained along the continuum of care.

To facilitate implementation and utilization of the APMS a ‘pain treatment cart’ with all of the needed supplies for regional anesthesia should be stocked in the anesthesia services section. The regional anesthesia area should have immediate access to Advanced Cardiovascular Life Support (ACLS) medications and 20% intralipid. An ultrasound machine should be available for the APMS and anesthesia use to facilitate regional blocks. APMS order sets can be utilized and should include pain management goals using the minimum amount of medication to achieve patient comfort. The goal for patients with delirium is to achieve a delirium free state as measured by the CAM.

See Appendix H for a sample order set including medication options and dosing.

See Table 1 in Appendix A for a summary list of recommendations.