- Email: [email protected]
Post-Traumatic Stress Disorder: A Less Visible Sign of War
GLOBAL CONNECTIONS
Post-Traumatic Stress Disorder: A Less Visible Sign of War Joni M. Brady, MSN, RN, CAPA ON A BEAUTIFUL SUNNY MORNING last fall, my family and I boarded a flight at Washington Reagan Airport in the nation’s capital, where we reside. Our destination was Miami for a weeklong vacation with our son, Michael, before his upcoming active duty military deployment to Afghanistan. A departure flight from Washington, DC, commonly includes traveling military service members, some in uniform on official business and others in civilian clothing en route to some other destination. On this early Saturday morning, the flight contained an abundance of both. We settled into our seats and proceeded to an on-time departure. Shortly after reaching the altitude at which the seat belt sign is turned off, a nervous sounding announcement was made over the loudspeaker by a flight attendant asking for a doctor or nurse to please provide medical assistance. Looking back from my seat up front, some commotion was visible in the rear section of the plane. A second nervous call for medical assistance quickly followed. I and another woman stood and identified ourselves as registered nurses and then followed a flight attendant to the person needing assistance. The events that transpired left a permanent vision in my mind. A young physically fit gentleman nicely dressed in slacks and a buttoned-down shirt appeared slumped forward in his seat, unresponsive to verbal or touch stimuli. The other nurse and I quickly formed a team—she watched his breathing and tried to elicit a response while I asked for oxygen, a blood pressure cuff, and Joni M. Brady, MSN, RN, CAPA, is an International Perianesthesia Nursing Consultant and Pain Management Nurse, Nursing Administration, Inova Alexandria Hospital, Alexandria, VA. Conflict of interest: None to report. Address correspondence to Joni M. Brady, Nursing Administration, Inova Alexandria Hospital, 4320 Seminary Road, Alexandria, VA 22304; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.03.009
Journal of PeriAnesthesia Nursing, Vol 28, No 3 (June), 2013: pp 159-162
stethoscope to make further assessments. His airway was patent with a respiratory rate of 22 to 24 per minute, with a palpable and regular radial pulse at 128 beats per minute. Care delivery was quite challenging in the confines of this space, but everyone present was supportive and helpful. I began to interview adjacent passengers and learned that this young man was not personally known to them, appeared ‘‘normal,’’ and identified himself as a military service member while conversant with his seat mate before takeoff. Soon after takeoff, he reportedly began ‘‘shaking violently and then passed out.’’ I asked the flight attendant to check with other passengers to learn if he was traveling with someone else from his unit, in hopes that we could obtain some history. After an initial period of unresponsiveness, his eyes suddenly opened, followed by extremely combative behavior without purposeful responses to verbal interaction or commands. Several uniformed military members came to provide assistance at the request of a flight attendant, while another young man came forward to identify himself as a unit mate and traveling companion of this gentleman. I learned that the young men had previously deployed to Iraq for 9 months and only recently returned from another 6-month combat action assignment in Afghanistan. While there, the combative young man reportedly sustained a head injury currently under medical investigation but, thus far, all neurological tests performed were negative. When asked if his buddy had been diagnosed with post-traumatic stress disorder (PTSD), he replied, ‘‘Yeah, we both have it, but I’ve never seen him do anything like this before.’’ I then asked everyone in the vicinity to refrain from loud verbal interactions and physical restraint and began quietly and directly addressing the affected man by his name to which he responded with some words and a blank stare. He eventually became relaxed and quiet and then became unresponsive for a second time. The pilot sent a flight attendant to ask us what he should
159
160
do. We recommended a return to Washington, DC, for further evaluation and treatment. Soon, the pilot made an announcement, the plane turned around, and we continued to monitor his progress. After a sustained period of minimal responsiveness with stable vital signs, he opened his eyes and appeared dazed on landing, communicated slowly but effectively, and had no recollection of any events that transpired since takeoff. After giving handoff report to emergency medical team (EMT) members who boarded the plane, the gentleman was capable of verbal communication and at his preference slowly shuffled off the plane with the EMT crew.
Behavioral Health and Perianesthesia Practice After returning to my assigned seat, many thoughts ran through my mind, including deep gratitude for the selfless dedication of those who volunteer to serve our country and worry about this young marine and his family. One thought involved some level of surprise that passengers and crew members expressed such admiration for the calm and skilled way in which nurses responded to the situation. As practitioners, we understand all that is required to perform at a high level each day; nurses must continue to educate the lay public on the advanced skill set and consistently important contribution to be made for optimal care outcomes by our profession. My most recurrent thought surrounded over 10 years of war fighting by Americans in Iraq and Afghanistan, and the growing number of redeploying service members diagnosed with traumatic brain injury (TBI) and PTSD. These are the less visible signs of war, and more and more of these patients will enter our work settings across the country. Perianesthesia nurses need to be prepared to deliver the most appropriate care possible to this patient population throughout the perianesthesia continuum. PTSD results from some horrific event involving actual physical harm or the threat of harm, such as assault, disaster, or combat.1,2 The affected person may have witnessed a horrendous situation involving another person or experienced a shocking direct injury. The syndrome is characterized by hyperarousal, avoidance of eventassociated stimuli, emotional numbing, and frequent re-experiencing of the original trauma. Those af-
JONI M. BRADY
fected frequently feel frightened or stressed in the absence of danger and relive the event in a nightmare or in thoughts while awake. PTSD is often accompanied by comorbidities resultant from chronic stress, depression, substance abuse, and additional anxiety disorders. Treatment generally includes psychotherapy and medication management to control symptoms.1
PTSD in the Perianesthesia Setting A recent national survey estimated American adult PTSD prevalence at 6.8%, while the Center for Military Health Policy Research examined PTSD prevalence in Iraq and Afghanistan veterans citing a 13.8% incidence.3 Less than 1% of the US population volunteers to join its military, comprising more than 2 million Americans presently serving in uniform.4 Subsequent to a decade of war fighting in Iraq and Afghanistan, and Department of Defense (DoD) budgets facing deep fiscal cuts, American veterans may increasingly require care inside and outside the military medical system. Therefore, perianesthesia nurses working in all types of health care facilities must understand the unique needs of and be prepared to deliver care to this patient population. Unlike those who sustained disfiguring battlefield blast injuries, the military TBI and PTSD population may have no apparent physical injuries and the presence of PTSD may not be immediately identifiable to a health care worker. For this reason, a thorough preanesthesia assessment should be conducted to identify and document the presence of PTSD. A paucity of studies address behavioral health issues in the perianesthesia practice setting.1 Although some studies are emerging, more perianesthesia research is required to establish best practices for the PTSD patient population. McGuire5 investigated risk factors and incidence of emergence delirium (ED) in military combat veterans and reported an increased incidence of depression, anxiety, PTSD, and ED among service members returning from Iraq and Afghanistan. Wilson and Pokorny6 conducted a phenomenological study on the experiences of military certified registered nurse anesthetists who cared for military personnel with TBI and PTSD. Five themes that emerged are as follows: ED rates were encountered more frequently than in the general population; preoperative conversations with suspected
GLOBAL CONNECTIONS
TBI and/or PTSD patients were essential for a smooth anesthesia emergence; the younger military population showed a greater prevalence of ED; ketamine dosing during induction appeared to be linked with less incidence of ED episodes; and total intravenous anesthesia (TIVA) was identified as producing better outcomes for patients thought to have PTSD and/or TBI. Ketamine, showing resurgence in anesthetic care delivery and pain management, reportedly diminished the incidence of ED, with continued research in this area indicated.6 One observational study suggested that morphine administration during acute trauma care (in a predominantly male population) may lower the risk of PTSD development in seriously injured military personnel.7 Another recent study8 showing promise involved the experimental use of ropivacaine during stellate ganglion block to effect the sympathetic nervous system, with a goal of decreasing PTSD symptoms. The military subjects’ PTSD symptoms showed improvement in this limited case series with future expansion of this research indicated. Although use of midazolam in PTSD patients has been purported to increase memories associated with the traumatic event, a study of soldiers diagnosed with PTSD found that no significant difference in memory intensity in those who received midazolam and those who did not.1
Perianesthesia Nursing Implications A great opportunity exists to expand the evidence needed to support best practices in the perianesthesia PTSD patient cohort. The US Department of Veteran Affairs created the National Center for PTSD, which offers excellent educational materials and resources for health care personnel (www.ptsd.va.gov/professional/index.asp).2 The site’s content provides a foundation for nurses lacking experience with PTSD syndrome. In addition to recommended practice standards for the various phases of care, the perianesthesia nurse should incorporate some additional suggested practices in the presence of known or suspected PTSD. ED occurs at a higher degree in the presence of PTSD and is more prevalent in the younger military population. Talking with the patient during the preoperative phase and encouraging interactive communication may decrease the chance of anes-
161
thetic ED. Because the use of TIVA and ketamine appears to lessen the incidence of ED,5 this information would be important to obtain during postoperative anesthesia handoff report. All appropriate postanesthesia care unit safety measures should be in place to prevent injury in the event that a patient becomes restless, agitated, or combative on emergence or experiences a sudden flashback to the trauma experienced. The PTSD patient is susceptible to being startled, so provision of a calm and reasonably quiet environment, plus use of a soft voice with direct communication and frequent orientation is more effective. In cases of severe PTSD, close anesthesia team collaboration should occur at times when resedation measures appear appropriate. Aggressive pain management is recommended because of an association with increased PTSD risk when pain is poorly treated in the early post-trauma period. In addition, the presence of family members and/or those well known to the patient may ease the unfamiliarity with and associated anxiety from treatment in a health care facility environment.1,9
On the Home Front The number of American veterans requiring continuing health care services and surgery because of profound physical injuries incurred while serving on foreign shores has significantly increased, with the incidence of PTSD more prevalent in military personnel than in the general population. These factors will surely impact care delivered by perianesthesia nurses in many facilities across the country. The Mental Health Access to Continued Care and Enhancement of Support Services Act of 2012, introduced in the 112th Congress and referred to the Committee on Veterans’ Affairs, seeks to establish more research and health care provider education and training for the identification and treatment of behavioral health disorders.10 This bill has a long way to go to gain approval as US federal spending cuts proliferate in the current economic climate and the DoD budget is scrutinized for substantial reductions. Months later, my thoughts still return to that Miami flight with hopes that that young marine’s health is improved or restored. As the mother of a son currently fulfilling a 9-month combat deployment to Afghanistan, my concern grows for the health of those who voluntarily defend our nation and for
JONI M. BRADY
162
the future accessibility of veteran health care services. Like other countless families who have sent their loved ones to battle, we do our best to stay positive and patient while waiting for Mike’s return. As a career perianesthesia nurse, I encour-
age every colleague to prepare to care for our globally based military patient population through increased awareness of the challenges they face and generation of evidence-based strategies to use at the point of care.
References 1. Brady JM. Patients with mental health considerations. In: Stannard D, Krenzischek DA, eds. Perianesthesia Nursing Care: A Bedside Guide to Safe Recovery. Sudbury, MA: Jones & Bartlett; 2011. 2. United States Department of Veteran Affairs. National Center for PTSD. Information on trauma and PTSD—Researchers, providers and helpers. Available at: http://www.ptsd.va.gov/ professional/index.asp. Accessed February 24, 2013. 3. Gradus JL. Epidemiology of PTSD. Available at: http:// www.ptsd.va.gov/professional/pages/epidemiological-facts-ptsd .asp. Accessed February 21, 2013. 4. NPR. Those who serve. Available at: http://www.npr.org/ series/137622251/who-serves. Accessed March 4, 2013. 5. McGuire JM. The incidence of and risk factors for emergence delirium in U.S. military combat veterans. J Perianesth Nurs. 2012;27:236-245.
6. Wilson JT, Pokorny ME. Experiences of military CRNAs with service personnel who are emerging from general anesthesia. AANA J. 2012;80:260-265. 7. Holbrook TL, Galameau MR, Dye JL, Quinn K, Dougherty AL. Morphine use after combat injury in Iraq and post-traumatic stress disorder. N Engl J Med. 2010;362:110-117. 8. Mulvaney SW, McLean B, de Leeuw J. The use of stellate ganglion block in the treatment of panic/anxiety symptoms with combat-related post-traumatic stress disorder; preliminary results of long-term follow-up: A case series. Pain Pract. 2010;10:359-365. 9. Mamaril ME. Care of the shock trauma patient. In: OdomForren J, ed. Drain’s Perianesthesia Nursing: A Critical Care Approach, 6th ed. St. Louis, MO: Saunders-Elsevier; 2013. 10. GovTrak.us. S. 3340 (112th): Mental Health ACCESS Act of 2012. Available at: http://www.govtrack.us/congress/bills/ 112/s3340/text. Accessed March 2, 2013.
Post-Traumatic Stress Disorder: A Less Visible Sign of War Joni M. Brady, MSN, RN, CAPA ON A BEAUTIFUL SUNNY MORNING last fall, my family and I boarded a flight at Washington Reagan Airport in the nation’s capital, where we reside. Our destination was Miami for a weeklong vacation with our son, Michael, before his upcoming active duty military deployment to Afghanistan. A departure flight from Washington, DC, commonly includes traveling military service members, some in uniform on official business and others in civilian clothing en route to some other destination. On this early Saturday morning, the flight contained an abundance of both. We settled into our seats and proceeded to an on-time departure. Shortly after reaching the altitude at which the seat belt sign is turned off, a nervous sounding announcement was made over the loudspeaker by a flight attendant asking for a doctor or nurse to please provide medical assistance. Looking back from my seat up front, some commotion was visible in the rear section of the plane. A second nervous call for medical assistance quickly followed. I and another woman stood and identified ourselves as registered nurses and then followed a flight attendant to the person needing assistance. The events that transpired left a permanent vision in my mind. A young physically fit gentleman nicely dressed in slacks and a buttoned-down shirt appeared slumped forward in his seat, unresponsive to verbal or touch stimuli. The other nurse and I quickly formed a team—she watched his breathing and tried to elicit a response while I asked for oxygen, a blood pressure cuff, and Joni M. Brady, MSN, RN, CAPA, is an International Perianesthesia Nursing Consultant and Pain Management Nurse, Nursing Administration, Inova Alexandria Hospital, Alexandria, VA. Conflict of interest: None to report. Address correspondence to Joni M. Brady, Nursing Administration, Inova Alexandria Hospital, 4320 Seminary Road, Alexandria, VA 22304; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.03.009
Journal of PeriAnesthesia Nursing, Vol 28, No 3 (June), 2013: pp 159-162
stethoscope to make further assessments. His airway was patent with a respiratory rate of 22 to 24 per minute, with a palpable and regular radial pulse at 128 beats per minute. Care delivery was quite challenging in the confines of this space, but everyone present was supportive and helpful. I began to interview adjacent passengers and learned that this young man was not personally known to them, appeared ‘‘normal,’’ and identified himself as a military service member while conversant with his seat mate before takeoff. Soon after takeoff, he reportedly began ‘‘shaking violently and then passed out.’’ I asked the flight attendant to check with other passengers to learn if he was traveling with someone else from his unit, in hopes that we could obtain some history. After an initial period of unresponsiveness, his eyes suddenly opened, followed by extremely combative behavior without purposeful responses to verbal interaction or commands. Several uniformed military members came to provide assistance at the request of a flight attendant, while another young man came forward to identify himself as a unit mate and traveling companion of this gentleman. I learned that the young men had previously deployed to Iraq for 9 months and only recently returned from another 6-month combat action assignment in Afghanistan. While there, the combative young man reportedly sustained a head injury currently under medical investigation but, thus far, all neurological tests performed were negative. When asked if his buddy had been diagnosed with post-traumatic stress disorder (PTSD), he replied, ‘‘Yeah, we both have it, but I’ve never seen him do anything like this before.’’ I then asked everyone in the vicinity to refrain from loud verbal interactions and physical restraint and began quietly and directly addressing the affected man by his name to which he responded with some words and a blank stare. He eventually became relaxed and quiet and then became unresponsive for a second time. The pilot sent a flight attendant to ask us what he should
159
160
do. We recommended a return to Washington, DC, for further evaluation and treatment. Soon, the pilot made an announcement, the plane turned around, and we continued to monitor his progress. After a sustained period of minimal responsiveness with stable vital signs, he opened his eyes and appeared dazed on landing, communicated slowly but effectively, and had no recollection of any events that transpired since takeoff. After giving handoff report to emergency medical team (EMT) members who boarded the plane, the gentleman was capable of verbal communication and at his preference slowly shuffled off the plane with the EMT crew.
Behavioral Health and Perianesthesia Practice After returning to my assigned seat, many thoughts ran through my mind, including deep gratitude for the selfless dedication of those who volunteer to serve our country and worry about this young marine and his family. One thought involved some level of surprise that passengers and crew members expressed such admiration for the calm and skilled way in which nurses responded to the situation. As practitioners, we understand all that is required to perform at a high level each day; nurses must continue to educate the lay public on the advanced skill set and consistently important contribution to be made for optimal care outcomes by our profession. My most recurrent thought surrounded over 10 years of war fighting by Americans in Iraq and Afghanistan, and the growing number of redeploying service members diagnosed with traumatic brain injury (TBI) and PTSD. These are the less visible signs of war, and more and more of these patients will enter our work settings across the country. Perianesthesia nurses need to be prepared to deliver the most appropriate care possible to this patient population throughout the perianesthesia continuum. PTSD results from some horrific event involving actual physical harm or the threat of harm, such as assault, disaster, or combat.1,2 The affected person may have witnessed a horrendous situation involving another person or experienced a shocking direct injury. The syndrome is characterized by hyperarousal, avoidance of eventassociated stimuli, emotional numbing, and frequent re-experiencing of the original trauma. Those af-
JONI M. BRADY
fected frequently feel frightened or stressed in the absence of danger and relive the event in a nightmare or in thoughts while awake. PTSD is often accompanied by comorbidities resultant from chronic stress, depression, substance abuse, and additional anxiety disorders. Treatment generally includes psychotherapy and medication management to control symptoms.1
PTSD in the Perianesthesia Setting A recent national survey estimated American adult PTSD prevalence at 6.8%, while the Center for Military Health Policy Research examined PTSD prevalence in Iraq and Afghanistan veterans citing a 13.8% incidence.3 Less than 1% of the US population volunteers to join its military, comprising more than 2 million Americans presently serving in uniform.4 Subsequent to a decade of war fighting in Iraq and Afghanistan, and Department of Defense (DoD) budgets facing deep fiscal cuts, American veterans may increasingly require care inside and outside the military medical system. Therefore, perianesthesia nurses working in all types of health care facilities must understand the unique needs of and be prepared to deliver care to this patient population. Unlike those who sustained disfiguring battlefield blast injuries, the military TBI and PTSD population may have no apparent physical injuries and the presence of PTSD may not be immediately identifiable to a health care worker. For this reason, a thorough preanesthesia assessment should be conducted to identify and document the presence of PTSD. A paucity of studies address behavioral health issues in the perianesthesia practice setting.1 Although some studies are emerging, more perianesthesia research is required to establish best practices for the PTSD patient population. McGuire5 investigated risk factors and incidence of emergence delirium (ED) in military combat veterans and reported an increased incidence of depression, anxiety, PTSD, and ED among service members returning from Iraq and Afghanistan. Wilson and Pokorny6 conducted a phenomenological study on the experiences of military certified registered nurse anesthetists who cared for military personnel with TBI and PTSD. Five themes that emerged are as follows: ED rates were encountered more frequently than in the general population; preoperative conversations with suspected
GLOBAL CONNECTIONS
TBI and/or PTSD patients were essential for a smooth anesthesia emergence; the younger military population showed a greater prevalence of ED; ketamine dosing during induction appeared to be linked with less incidence of ED episodes; and total intravenous anesthesia (TIVA) was identified as producing better outcomes for patients thought to have PTSD and/or TBI. Ketamine, showing resurgence in anesthetic care delivery and pain management, reportedly diminished the incidence of ED, with continued research in this area indicated.6 One observational study suggested that morphine administration during acute trauma care (in a predominantly male population) may lower the risk of PTSD development in seriously injured military personnel.7 Another recent study8 showing promise involved the experimental use of ropivacaine during stellate ganglion block to effect the sympathetic nervous system, with a goal of decreasing PTSD symptoms. The military subjects’ PTSD symptoms showed improvement in this limited case series with future expansion of this research indicated. Although use of midazolam in PTSD patients has been purported to increase memories associated with the traumatic event, a study of soldiers diagnosed with PTSD found that no significant difference in memory intensity in those who received midazolam and those who did not.1
Perianesthesia Nursing Implications A great opportunity exists to expand the evidence needed to support best practices in the perianesthesia PTSD patient cohort. The US Department of Veteran Affairs created the National Center for PTSD, which offers excellent educational materials and resources for health care personnel (www.ptsd.va.gov/professional/index.asp).2 The site’s content provides a foundation for nurses lacking experience with PTSD syndrome. In addition to recommended practice standards for the various phases of care, the perianesthesia nurse should incorporate some additional suggested practices in the presence of known or suspected PTSD. ED occurs at a higher degree in the presence of PTSD and is more prevalent in the younger military population. Talking with the patient during the preoperative phase and encouraging interactive communication may decrease the chance of anes-
161
thetic ED. Because the use of TIVA and ketamine appears to lessen the incidence of ED,5 this information would be important to obtain during postoperative anesthesia handoff report. All appropriate postanesthesia care unit safety measures should be in place to prevent injury in the event that a patient becomes restless, agitated, or combative on emergence or experiences a sudden flashback to the trauma experienced. The PTSD patient is susceptible to being startled, so provision of a calm and reasonably quiet environment, plus use of a soft voice with direct communication and frequent orientation is more effective. In cases of severe PTSD, close anesthesia team collaboration should occur at times when resedation measures appear appropriate. Aggressive pain management is recommended because of an association with increased PTSD risk when pain is poorly treated in the early post-trauma period. In addition, the presence of family members and/or those well known to the patient may ease the unfamiliarity with and associated anxiety from treatment in a health care facility environment.1,9
On the Home Front The number of American veterans requiring continuing health care services and surgery because of profound physical injuries incurred while serving on foreign shores has significantly increased, with the incidence of PTSD more prevalent in military personnel than in the general population. These factors will surely impact care delivered by perianesthesia nurses in many facilities across the country. The Mental Health Access to Continued Care and Enhancement of Support Services Act of 2012, introduced in the 112th Congress and referred to the Committee on Veterans’ Affairs, seeks to establish more research and health care provider education and training for the identification and treatment of behavioral health disorders.10 This bill has a long way to go to gain approval as US federal spending cuts proliferate in the current economic climate and the DoD budget is scrutinized for substantial reductions. Months later, my thoughts still return to that Miami flight with hopes that that young marine’s health is improved or restored. As the mother of a son currently fulfilling a 9-month combat deployment to Afghanistan, my concern grows for the health of those who voluntarily defend our nation and for
JONI M. BRADY
162
the future accessibility of veteran health care services. Like other countless families who have sent their loved ones to battle, we do our best to stay positive and patient while waiting for Mike’s return. As a career perianesthesia nurse, I encour-
age every colleague to prepare to care for our globally based military patient population through increased awareness of the challenges they face and generation of evidence-based strategies to use at the point of care.
References 1. Brady JM. Patients with mental health considerations. In: Stannard D, Krenzischek DA, eds. Perianesthesia Nursing Care: A Bedside Guide to Safe Recovery. Sudbury, MA: Jones & Bartlett; 2011. 2. United States Department of Veteran Affairs. National Center for PTSD. Information on trauma and PTSD—Researchers, providers and helpers. Available at: http://www.ptsd.va.gov/ professional/index.asp. Accessed February 24, 2013. 3. Gradus JL. Epidemiology of PTSD. Available at: http:// www.ptsd.va.gov/professional/pages/epidemiological-facts-ptsd .asp. Accessed February 21, 2013. 4. NPR. Those who serve. Available at: http://www.npr.org/ series/137622251/who-serves. Accessed March 4, 2013. 5. McGuire JM. The incidence of and risk factors for emergence delirium in U.S. military combat veterans. J Perianesth Nurs. 2012;27:236-245.
6. Wilson JT, Pokorny ME. Experiences of military CRNAs with service personnel who are emerging from general anesthesia. AANA J. 2012;80:260-265. 7. Holbrook TL, Galameau MR, Dye JL, Quinn K, Dougherty AL. Morphine use after combat injury in Iraq and post-traumatic stress disorder. N Engl J Med. 2010;362:110-117. 8. Mulvaney SW, McLean B, de Leeuw J. The use of stellate ganglion block in the treatment of panic/anxiety symptoms with combat-related post-traumatic stress disorder; preliminary results of long-term follow-up: A case series. Pain Pract. 2010;10:359-365. 9. Mamaril ME. Care of the shock trauma patient. In: OdomForren J, ed. Drain’s Perianesthesia Nursing: A Critical Care Approach, 6th ed. St. Louis, MO: Saunders-Elsevier; 2013. 10. GovTrak.us. S. 3340 (112th): Mental Health ACCESS Act of 2012. Available at: http://www.govtrack.us/congress/bills/ 112/s3340/text. Accessed March 2, 2013.