Abstract
Abstract
Robert L. Koffman, MD, Capt, US Navy, reports his experiences using acupuncture in clinical environments in Afghanistan, recounting his success with the “Koffman Cocktail” and several auricular patterns. He animates his report through e-mails and transcripts of telephone conversations from the war theater. His experiences underscore the clinical value and professional satisfaction that acupuncture provides in the broad range of military medicine and psychiatry.
Introduction
A tall order, indeed. This could only be accomplished with extensive fieldwork, specifically, circulating continuously among all embattled regions. Thus, I became an itinerant psychiatrist. I was always eager and ready to provide individual behavioral health care to service members (SMs). Stigma regarding receiving psychiatric care, however, remains the greatest challenge in the delivery of mental health services, even though attitudes have improved in recent years.
Everybody in the military experiences pain, lives with pain: back pain from wearing at a minimum 40 pounds of “battle rattle,” each day, every day; back pain from bouncing around in the back of an armored vehicle over rocks and crater-ridden roads; back pain from sleeping on beds so worn out that the springs do not support the weight of the mattress. Headaches abound too. Lingering mild traumatic brain injuries (mTBIs) and the ensuing postconcussive syndrome contribute to chronic, unrelenting headaches, themselves made worse with exercise. After 10 years of war, many of our service members are on their third, fourth, or fifth deployment. They live with daily agonizing musculoskeletal complaints. Chronic insomnia, persistent hyperarousal, and lingering nightmares are problematic in a war zone and add to the challenge of achieving restorative sleep. 1 One can readily see why polypharmacy is prevalent. In this document, I record, with very few edits, several of the score of e-mails and conversations I had with Joe Helms (Joseph M. Helms, MD, of the HMI), my former teacher, during my 7 months' downrange. These items recount the stunning impact that acupuncture had on my ability to care for physically and emotionally damaged service members and the psychologically traumatized caregivers tending to them.
E-Mail Number 1
I need to tell you about the tremendously beneficial opportunities I have had to care for service members wounded in this combat environment. Just yesterday, I took care of [several] soldiers involved in a complex IED [improvised explosive device] attack that killed [many] of their fellow soldiers. Almost all of the surviving soldiers had blown TMs [tympanic membranes], pounding headaches from mTBI, and assorted musculoskeletal injuries. They were extremely angry, having been informed about the loss of their friends. All were amenable to doing something about the unrelenting, pounding headaches. [following standard of care treatment].
With … litters abreast I proceeded to do BFA [Battlefield Acupuncture, see article in this issue] with several additional ear points for sedation and relaxation, and my favorite: four gates [LI 4, LR 3] and the requisite GV cocktail points [GV 20 plus Yin Tang]. The response was amazing: 0–1 headache pain down from 7 or 8; no more shoulder pain or back pain; more importantly, a more subdued demeanor which they hadn't experienced since being attacked three days earlier. They are to return to see me tomorrow after the memorial service.
E-Mail Number 2
Please read the excerpt below from an unclassified “memorandum for the record” written by [a senior officer] in charge following the recent mass casualties from IEDs:
Self and buddy aid, as well as the need for the group to rely upon one another as the most powerful source of support, was reinforced and each SM was encouraged to obtain acupuncture treatment. All [wounded] men received acupuncture treatments during early evening hours, with extraordinarily positive results in every case. Acupuncture treatment involved a primary focus upon wellness, reduction of both acute and chronic pain, and diminished painful affect regarding grief and loss.
Each of the…Soldiers reported markedly decreased objective and subjective pain ratings for the treatment of headaches secondary to blast injuries, shoulder pain, [and] lower back pain, and that they generally had not felt this relaxed in a very long period of time before the traumatic incident. The treating doctor plans to provide further follow-up care for all of these Soldiers within the next days.
It is my opinion that battlefield acupuncture treatment should very clearly serve as a strong endorsement for the widespread use of integrative medicine in the combat theater of operations. The need is unmistakable and the benefits are quantifiable. Soldiers receiving acupuncture treatment continue to ask for additional treatment sessions because of the magnitude of benefits experienced.
E-Mail Number 3
The unit I described in the previous e-mail, the one that is seeing so much enemy action, has asked me to travel to its forward operating base (FOB). Apparently, the soldiers that I treated previously want more treatment; others want to try some needling. I wrote:
“This week I treated two [soldiers] who were victims of an IED. Both experienced mTBI with LOC [loss of consciousness], soft tissue injuries, pounding headache with negative head CT [computed tomography] findings. With pain in excess of 8/10, both of them responded beautifully to the auricular trauma protocols [ATPs] taught by HMI [see article in this issue] with GV 20 and 24.5 [Yin Tang] as my standard first set of needles. Thirty minutes after the treatment the two soldiers were essentially pain free and resting comfortably. Interestingly, the photophobia in one of them also subsided.
“At another FOB I turned my new-found needling acumen to caregivers (corpsmen, nurses, surgeons) involved with urgent resuscitative care (“meatball surgery”). I found a quiet corner and offered all comers a calming treatment consisting of four gates—GV cocktail, and the ATP points on both ears. I literally had a line of weary, worn providers seeking a little respite. All those treated retreated to a restful repose where there had been little restorative rest previously.
“Also on this site visit, [another] senior [officer] was experiencing shoulder pain with significant restriction of internal rotation. After the usual round of steroid injections and physical therapy (he was about ready to fire his medical officer), I used the barrier points of the shoulder, scanned his ear, and threw in GB 34 for good measure. Thirty minutes later, he was shocked as was now able to not only internally rotate his arm and tuck in his shirt with his affected arm (something he hadn't been able to do for two months), but this right-handed senior officer was also able to start wearing his M-9 pistol back on his right side.”
Finally, as another follow-up, I treated a group of soldiers suffering from severe headaches following [yet another] an IED attack. One of the soldiers had an immediate and dramatic response, the other's relief came…in the morning. They were able to go off narcotics, which is important, particularly in head injuries, when trying to measure military acute concussion evaluation [MACE] scores accurately.
I received an e-mail from the ward nurse asking me to return as soon as possible. It sure feels good to be able to offer these worn, weary, and traumatized warriors some relief.
Telephone Conversation Number 1
In an individual who is sleep deprived, recently concussed, and grieving over the losses in his unit, I find it most useful to apply autonomic leveling before going to specific points for the pain. I give just about everybody the Koffman Cocktail…before I reevaluate them. I add [the] auricular trauma protocol, line them up cot-along-cot, turn down the lights and turn up my tranquil sound machine. Without fail, worn warriors drift off to a place they would rather be.
I am absolutely convinced that sleep deprivation, hair-cell-damaging auditory discharge (war is nothing if not replete with cacophony), and chronic muscle tension, contribute to massive depletion. Body armor weighing around 40 pounds, and one's weapon, is always slung over the shoulder and adds to that depletion. Consequently, [many service members] I see in follow-up gets a piezo or surface release of their neck[s] and traps. Mega-Mu-Shu follows, all in a safe and empathetic environment.
Reviewing our survey data, at least 40% of the fighting force complains of some form of chronic lumbar pain. Lumbar PENS [percutaneous electrical nerve stimulation] to the rescue! Truly, I haven't needed to do much more in the field to treat those low-back problems.
Telephone Conversation Number 2
I'm currently traveling on what will be my second-to-last sweep through Afghanistan. My experiences continue to excite the force.…Just last week at the outlying FOB I visited, [a coalition partner] Special Forces doc found out I was there and decided to bring some of his soldiers over for treatment. While the range of care I can provide here (Koffman Cocktail, ATP, surface release, piezo, PENS, scar deactivation, Kidney tonification) hasn't changed; what has changed is the different populations I now treat. I now have a couple of orthopedic surgeons—typically the most resistant of all providers—interested in not only referring patients but coming to see me for their hip pain and shoulder pain
Yesterday, in Kabul, the Armed Forces Network interviewed a young soldier/body builder who was in the clinic conducting an inventory of equipment and volunteered to be filmed. He had an impingement of his left shoulder for 2 months and couldn't work out. Upon removing the needles I asked him to do some pushups. Everyone held their breath. After banging out a quick set of pushups—an exercise he could not have done 20 minutes earlier—he proclaimed: “The pain is gone!” With the soldier beaming to the camera, I made my point that acupuncture is a critical combat enabler.
Discussion
Cheap but deadly roadside bombs have become the insurgents' weapon of choice. Attacks are increasing in number and severity. Many troops are returning home with symptoms of mTBI. Nearly a fifth of Iraq and Afghanistan veterans who seek care at Veterans Administration (VA) facilities and complete the VA's TBI screening instrument, test positively for mTBI. 2 A positive result indicates at least the past history of a blast exposure and possibly the persistence of postconcussive symptoms. Should an SM incur other blast-related physical injuries, the chance of sustaining a TBI increases to 60%. 3 When evaluating mental health issues, the Rand Corporation found in a population-based survey that almost 1 in 8, nearly 12% of SMs, suffer from some form of psychological difficulty upon returning home, chiefly PTSD or depression. 4
The recently updated Department of Defense/Veterans Administration PTSD management guidelines recommend (at Level B) using acupuncture for PTSD symptoms, particularly when they are associated with symptoms of chronic pain, depression, insomnia, anxiety, or substance abuse. 5 In addition to activating various neurohumoral pathways and stimulating neural connections associated with the autonomic nervous system, another benefit of acupuncture is the physician's engaging with the patient. Not only do patients feel empowered with the opportunity to make choices regarding their health care, they may very well be inclined to talk about sleep, nightmares, and the constant vigilance and arousal they are experiencing. This does not suggest that I am a “Trojan psychiatrist,” using my needles to gain the confidence of patients who are uneasy with psychiatry. On the contrary, I inform the patients I treat that I am a psychiatrist. I add that I am, however, specially trained to help them by using a more holistic approach replete with several complementary techniques. This integrative approach has led to my slogan: “Come for the needles, stay for the therapy.”
Conclusions
Since including medical acupuncture in my approach to psychiatry and management of wounded warriors, I feel I can truly bill myself as a provider of holistic medicine. Just as I incorporate needle patterns creatively to meet each patient's specific needs, I might augment the patient's experience with breathing exercises, biofeedback, mediation, or other approaches that complement the acupuncture. Truly, acupuncture is the foundation for what I now consider “full spectrum operations.”
Footnotes
Disclosure Statement
No financial conflict exists.