News: 4th Infantry Division continues ketamine initiative in Afghanistan
Story by Sgt. Antony Lee
KANDAHAR AIRFIELD, Afghanistan – For much of Operation Enduring Freedom, casualties in Afghanistan typically received morphine and fentanyl to help reduce pain suffered from battlefield wounds.
More than two years ago, another drug entered the discussion as a faster, more effective way to help wounded service members: ketamine.
The division surgeon with 82nd Airborne Division, which at the time commanded Regional Command (South), laid the foundation to include ketamine as a pain medicine for medics in Afghanistan to use.
The medical team from 3rd Infantry Division – which replaced the 82nd – took the idea and got it approved through U.S. Central Command to be run as a pilot in RC(S). They also created a way to monitor its use and implement it throughout RC(S) if the pilot proved to be successful.
The 4th Infantry Division began running the pilot after it took command of RC(S) in July 2013, putting the plan into place and delivering ketamine to combat medics to use on missions.
It has proved largely successful. So far, in the six months it has been used in southern Afghanistan, 35 wounded service members – among both coalition and Afghan forces – have received ketamine after suffering wounds on the battlefield.
“In every single instance that we’ve used it, it’s been effective,” said Capt. Seth Mayer, 4th Infantry Division pharmacist.
Mayer adds he is a big proponent of ketamine. It is a drug that can be administered through the nose – making it more efficient than other pain medications.
“Better pain control is the main thing we are concerned about,” Mayer said. “Primary literature supports that this is currently the best primary medication to use on the battlefield. You don’t need intravenous access to use it. It goes right in the nose and it’s sprayed in – it’s quick and it’s effective.”
Lt. Col. Chris Jarvis, 4th Infantry Division surgeon, recently presented the benefits of ketamine to medical advisers across Afghanistan at an International Security Assistance Force Joint Command conference.
“Though ketamine has a storied history in the operating and emergency rooms of the battlefield environment, its use at the point of injury and in the back of a medevac helicopter is entirely new,” Jarvis said. “This evolutionary advancement in the approach to pain control on the battlefield allows for medical providers to rapidly provide pain relief.”
Extensive studies done on ketamine show that pain control is indeed a productive use of ketamine.
“The only reason you can use intranasal ketamine the way we’re going to use it is because it exists in a clinical practice guideline that’s been evaluated by peer-review and is based upon primary literature,” Mayer said, adding that primary literature means that professionals have run studies that led to these conclusions. “If you don’t have clinical data that shows that it’s appropriate, we certainly wouldn’t use it.”
Ketamine is also less likely to cause post traumatic stress disorder in the future and less likely to cause respiratory depression – a risk with both morphine and fentanyl.
Ketamine itself is an old medication that was first developed in the 1960s and was fielded by the military as an anesthetic for conducting trauma surgery. It has since evolved as a medicine; it is now used in Afghanistan for pain control at the point of injury, something that the last three RC(S) division surgeons have worked to make happen.
Intranasal ketamine, particularly, is a unique way to get medication into the body, Mayer said.
“It’s fast,” Mayer said. “In the first 10 minutes, you’ll know if it’s working for the patient.”
According to studies, intranasal ketamine provides more immediate pain relief than IV morphine.
Mayer adds that it is a “superior pain medication” to morphine, dilaudid and fentanyl. Fentanyl has been the primary drug that medics in Afghanistan have used at the point of injury for service members who needed it.
“Ketamine will be another option as a primary use,” Mayer said.
Mayer expects a fragmentary order officially approving ketamine as a pain managing option to soon come down. It will enable combat medics going out on missions across Afghanistan to use ketamine, which can be locally produced by pharmacists in theater, as a primary pain medicine. It will include instructions on properly training the medics who will carry it in their kits.