chapter 1 – the military advanced regional anesthesia and analgesia initiative- a brief history

8/12/2019 Chapter 1 the Military Advanced Regional Anesthesia and Analgesia Initiative- A Brief History

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1. THE MILITARY ADVANCED REGIONAL

ANESTHESIA AND ANALGESIA INITIATIVE:

A BRIEF HISTORY

He who would become a surgeon should join the armyand follow it.

Hippocrates

The history of warfare parallels the history ofmedical advances. In the field of anesthesia, warshave resulted in marked technical, chemical, andprocedural advances, including the first battlefielduse of inhalational anesthesia (Mexican-AmericanWar), first widespread use of anesthetics and in-halers for the application of inhaled anesthetics(US Civil War), use of the eye signs chart for safemonitoring by lay practitioners (World War I), de-velopment of specific short course training centersfor predeployment anesthesia training (World WarII), and the establishment of military anesthesiaresidency programs in response to shortages ofspecialty trained doctors (Korean War). The currentwars in Iraq and Afghanistan are no exception tothis historical trend (Figure 1-1), and perhaps themost significant advance resulting from these con-flicts is the Military Advanced Regional Anesthesiaand Analgesia Initiative (MARAA).

MARAA is the collaborative effort of like-minded anesthesiologists who perceived a needfor improvement in battlefield pain management.

Deployed military anesthesiologists recognized adisconnect between battlefield and civilian analgesiccare that needed to be bridged. As one provider putit, pain control in Baghdad, 2003, was the same asin the Civil Wara nurse with a syringe of mor-phine. Colonel (Retired) John Chiles was the firstto voice the potential benefit of increasing the use ofregional anesthesia in the Iraq war. With LieutenantColonel Chester Buckenmaier, Chiles started theArmy Regional Anesthesia and Pain ManagementInitiative in 2000. Dr Buckenmaier administered

the first continuous peripheral nerve block inOperation Iraqi Freedom on October 7, 2003.Upon his return, Buckenmaier, Chiles, LieutenantColonel Todd Carter, and Colonel (Retired) AnnVirtis created MARAA, following in the tradi-tion of the Anesthesia Travel Club created by JohnLundy to rapidly disseminate research advances topractitioners.

MARAAs purpose is to develop consensus rec-ommendations from the US Air Force, Army, andNavy anesthesia services to implement improve-

ments in medical practice and technology that willpromote regional anesthesia and analgesia in thecare of military beneficiaries. The organization alsoserves as an advisory board to the individual ser-vice anesthesia consultants to the surgeons general(see the MARAA charter, the attachment to thischapter). Initial support was provided indirectlyby the publics demand for better pain control forwounded soldiers and directly via congressionalfunding through the John P Murtha Neuroscienceand Pain Institute, the Telemedicine and Advanced

Figure 1-1.As Long As There Is War, There Will Be Wounded, byLieutenant Michael K. Sracic, MD, MC, US Navy, 2008.

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1 MARAA: A BRIEF HISTORY

MARAA also spearheaded the regional anesthesiatracking system (RATS), designed to provide real-time continuous pain management informationon patients from Iraq to the United States. RATS iscurrently being integrated into the Armys onlineTheater Medical Data Store as part of the militarycomputerized patient record. These initiatives have

led to greater pain control for wounded soldiers, andtheir success has been widely recognized in profes-sional and lay journals from Newsweek to Wiredmagazine.

The need for comprehensive pain managementhas recently been recognized at the national legisla-

tive level with the introduction (and passage by theHouse May 26, 2008) of HR 5465, the Military PainCare Act of 2008, which will require that all patientsat military treatment facilities be assessed and man-aged for pain throughout their recovery period. Inaddition, all patients must be provided access tospecialty pain management services, if needed. If the

bill is passed, MARAA is in position to organize itsimplementation.

Already, MARAA is expanding its role beyondimproving the care of military beneficiaries by en-couraging civilian attendees at its Annual Compre-hensive Regional Anesthesia Workshop (Figure 1-2),

TABLE 1-1

ATTENDEES AT THE FIRST MEETING OFTHE MILITARY ADVANCED REGIONALANESTHESIA AND ANALGESIA INITIATIVE

COL John Chiles, Army Service Consultant

LTC Chester Buckenmaier,Army

Service Consultant designee;MARAA President

Lt Col Todd Carter, AirForce

Service Consultant

CAPT Ivan Lesnik, Navy Service Consultant

CDR Dean Giacobbe,Navy

Service Consultant designee

MAJ Peter Baek, Air Force Service Consultant designee

As the service primarily responsible for transport-ing wounded soldiers from the battlefield to theUnited States, the Air Force supported the initiativeand almost immediately issued a memorandumoutlining specific directives to Air Force providersbased on MARAA recommendations. By October2006 MARAA meetings had grown to include over30 senior military anesthesiologists. Nursing supportof anesthesia was recognized early on, and a certi-

fied registered nurse anesthetist from each servicewas added to the board in April 2006. Initial meet -ings focused on approval of the Stryker PainPump2 (Stryker; Kalamazoo, Mich) for use on Air Forcemilitary aircraft and the need for patient-controlledanalgesia pumps on the battlefield and on evacua-tion aircraft. The organization developed a series oftraining modules and consensus recommendationson pain management for anesthesiologists prepar-ing for deployment (available at: www.arapmi.org).

Technology Research Center, and the Henry MJackson Foundation. The first MARAA meeting washeld in February 2005 (Table 1-1).

Figure 1-2. MAARA Annual Workshop faculty; l-r: Scott M Croll, Alon P Winnie, Chester Buckenmaier.


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held at the Uniformed Services University of theHealth Sciences in Bethesda, Maryland. This yearmarks the 7th year of the workshop, directed by DrBuckenmaier and taught by senior anesthesiolo-gists from around the nation. This years facultyincluded doctors Alon P Winnie, NorthwesternUniversity; Andre P Boezaart, University of Florida;John H Chiles, former anesthesiology consultant tothe Army surgeon general and currently at INOVA

Mount Vernon Hospital; Laura Lowrey Clark,University of Louisville; Steven Clendenen, MayoClinic; Scott M Croll, Uniformed Services Univer-sity and Walter Reed Army Medical Center; John MDunford, Walter Reed Army Medical Center; CarloD Franco, Rush University; Ralf E Gebhard, Uni-versity of Miami; Roy A Greengrass, Mayo Clinic;Randall J Malchow, Brooke Army Medical Center;Karen C Neilsen, Duke University; Thomas C Stan,Far Hills Surgery Center; and Gale E Thompson,Virginia Mason Medical Center.

Although the recognition of MARAAs successhas so far been directed to its immediate achieve -mentsimproved and systematic pain control forwounded soldiersits ultimate contribution maybe broader in scope. Pat ient care is a multispecialtyteam effort that MARAA recognizes. Therefore,MARAA solicits, evaluates, and appreciates inputfrom other physician subspecialists and from nurs-ing providers; much of the spring 2006 meeting

was devoted to astute flight nurse observationscollected by Lieutenant Colonel Dedecker, a USAir Force nurse in charge of the Patient MovementSafety Program. MARAA meetings remain open toany person interested in attending, and all meetingnotes, data, and recommendations are freely avail-able. As impressive as MARAAs contributions topatient care have been, history may view its greatercontribution as a modern model of how a smallgroup of persons with vision and energy can dra -matically improve an entire field of care.

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MARAA: A BRIEF HISTORY 1

CHARTER OF THE

MILITARY ADVANCED REGIONAL

ANESTHESIA & ANALGESIA

JUNE 2005

ARTICLE I: NAME AND OBJECT

1. Name. The name of the organization is MilitaryAdvanced Regional Anesthesia & Analgesia (MARAA).

2. Object. The object of the organization is the promotionof regional anesthesia and improved analgesia formilitary personnel and dependents at home and on thenations battlefields.

3. Purpose. The organization will work to developconsensus recommendations from the Air Force, Army,and Navy anesthesia services for improvements inmedical practice and technology that will promoteregional anesthesia and analgesia in the care of military

beneficiaries. The organization serves as an advisory

board to the individual service anesthesia consultants tothe surgeons general.

ARTICLE II: MANAGEMENT

The organization will consist of the anesthesiologyconsultant of each military service (or their designee)and a second appointee by each service anesthesiologyconsultant (six member board). Each member of

the organization has one vote on issues that requireagreement/collaboration between services. All decisionswill be made by a simple two thirds majority. Issuesthat fail to obtain a two thirds majority consensus will betabled and re-addressed at the next meeting called by thePresident of the organization.

ARTICLE III: DIRECTORS

The organization will select a President of theorganization from organization members each fiscalyear by simple majority vote. The President will

be responsible for soliciting meeting issues frommembers and setting meeting agendas. The President

will be responsible for generating organizationposition white papers on decisions made by theorganization. The position white papers will provideeach service anesthesia consultant with collaborativerecommendations for issues considered by theorganization. The President can assign the writing ofdecision papers to committee members. The presidentwill have final editorial authority over any whitepaper recommendations submitted to the serviceanesthesiology consultants.

ARTICLE IV: MEETINGS

1. Meetings. The organization will meet twice yearly.

One formal meeting will be at the Uniformed ServicesSociety of Anesthesiology meeting during the AmericanSociety of Anesthesiology conference. A second meetingwill be scheduled during the Spring. Meetings will becoordinated by the organization president. Organizationmembers can send proxies to attend meetings intheir place (proxy voting is allowed) if approved bythat members service anesthesiology consultant.Teleconferencing is an acceptable means of attending ameeting. Meetings will only be held when a quorumof members (or their proxies) are available. A quorumwill be defined as a majority of voting members withrepresentation from each service.

2. Special Meetings. The president can call for a specialmeeting by organization members on issues requiringprompt attention.

3. Conduct of Meetings. Meetings will be presided overby the President or, in the absence of the President, amember of the organization designated by the President.

4. Meeting Agenda. The President will provide members

with the meeting agenda one week prior to scheduledmeetings. Members may add new items to the agendaduring meetings with the Presidents request for new

business. Meetings will be concluded with review of oldbusiness.

ARTICLE V: ORGANIZATION SEAL

The organization seal is represented at the head of thisdocument.

Ammendment 1 (6 April 2006): The voting MARAAmembership will include one CRNA vote per service.Representatives will be chosen by each servicesanesthesiology consultants. There will now be 9 total

votes (2 physician and 1 CRNA per service).

chapter 1 – the military advanced regional anesthesia and analgesia initiative- a brief history

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