Veterans, Burns and Pain Management

In Ugly Lies the Bone, Jess's injuries-severe burns sustained from an IED explosion-are indicative of the unique costs of the wars in Iraq and Afghanistan. As of February 2013, these two conflicts had resulted in over 6,500 deaths, nearly half of them from IEDs. IEDs, or Improvised Explosive Devices, are homemade bombs, constructed at a relatively low cost with readily accessible combustive materials (fertilizer, gunpowder, hydrogen peroxide). Occasionally packed with sharp materials (glass, nails, metal) to increase the likelihood of shrapnel-like injuries, the bombs are often buried along the roadside, to be detonated remotely or automatically when troops walk or drive over the sites. When IEDs first appeared in combat zones, in early 2002, the military didn't know how to categorize the deaths that were occurring as a result of seemingly unmanned explosions. The first death immediately (rather than retroactively) classified as resulting from an IED explosion occurred on November 14, 2003. In the following decade, IEDs came to be common knowledge in both the military and the media, and their results have left a lasting legacy-not only in deaths, but also in (far more common, and just as devastating) injuries.

As of March 2014, some 970,000 disability claims from Iraq and Afghanistan veterans had been registered with the US Department of Veterans Affairs. Many of these injuries are what veterans' advocate Paul Sullivan calls "signature wounds," most of them directly linked to IED explosions: traumatic brain injury, post-traumatic stress disorder, amputations, and spinal cord injuries. Of these injuries, the first two are often caused by a soldier being within the "blast radius" of an IED-the area in which the soldier (often in a vehicle) is outside the direct explosion but feels the resultant shock. The latter two injuries, amputations in particular, are more likely the result of being in the "kill zone,"' within the area of the explosion itself. It is within this "kill zone" radius that severe burns, another hallmark injury of the wars in Iraq and Afghanistan, occur.

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Karron Graves, Mamie Gummer, and Caitlin O'Connell in UGLY LIES THE BONE.

Though the number of surviving burn casualties from the wars may not seem very high upon first glance (a 2012 estimate put the total at 900), burn injuries have been hugely impactful-largely because soldiers are surviving wounds that would have previously resulted in death. These increasingly serious injuries pose new problems for postinjury quality of life, and, in turn, have forced medical care to develop new therapies and treatments in order to keep up. Wartime forces a grim but necessary progress in medical advances. And in the case of the wars in Iraq and Afghanistan, the advances have been spectacular.

When a soldier sustains a burn wound in Iraq, they begin a shockingly fast journey back to the United States. The time from injury in Iraq to hospitalization at San Antonio's Brooke Army Medical Center is approximately 36 hours (with a stop at a hospital in Germany). Upon arrival at BAMC, critical wound care begins immediately. The first steps are a shower, cleaning of the burns, and debridement (the removal of blisters and dead skin, to prevent infection). The patient is then immediately transported to an operating room, where any remaining dead tissue is removed. Next, burn victims immediately begin a long series of surgeries to cover exposed tissue with skin grafts.

For a burn victim, the path to recovery is long. On a logistical level, the injuries require extensive treatment: reconstructive surgeries (dozens over months and years), subsequent surgeries to improve scar tissue, constant wound care, and physical therapy. On an individual level, this multi-step process results in a uniquely terrible cocktail of pain.

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Chris Stack and Mamie Gummer in UGLY LIES THE BONE.

Pain is at the forefront of Jess's recovery in Ugly Lies the Bone. At the start of the script, playwright Lindsey Ferrentino notes, "On Jess's physicality: Everything hurts; skin, muscles, heart, bones." Yet in the medical community, pain management, until recent years, has been a largely unexplored frontier. Though soldiers (and civilians) are living through substantially worse injuries than they were centuries and even decades ago, treatment for the acute and chronic pain that comes with survival has remained essentially unchanged since the advent of morphine in 1804.

In large part, the sluggishness of treatment development is due to our understanding of pain itself. For years, pain was only perceived to be a symptom of an underlying physical cause; the cause itself was treated, and pain was abated through the use of drugs. But recently, pain has begun to be understood on its own terms-not only as a result of injury, but as a brain-based condition that must be treated with targeted care. Journalist Jay Kirk, in an article about burn victim and veteran Sam Brown ("Burning Man," GQ), explains that the breakthrough realization for pain experts has been that pain is, as often as it is a physiological adaptation (protecting us from harm), it is also "a pathological adaptation. Not a symptom of something else, but a disease in and of itself."

This understanding of pain-as a neurological state related to, but independent of, physical injury-has led to some surprising discoveries about pain severity and perception. David Linden, a neuroscientist at the Johns Hopkins School of Medicine, shared the findings in a 2015 NPR interview. He explains that pain has two components-a fact-base sensory component (Where is the pain located? What are its qualities?) and an emotional component (How bad is it?). Both of these components are processed in the brain; they are not undiluted responses to nerve endings. And as a result, psychology-specifically, attention-is a major factor in our experience of pain. Linden explains that our brain has the ability to "turn up the volume" on pain when our attention is focused on it, and to "turn down the volume" when we divert focus. Similarly, negative feelings have the ability to amplify pain, while positive feelings have the ability to decrease it. Any parent who has accompanied their child to the doctor's office would instinctually understand the truth of this logic. If someone jokes with the child as they receive a vaccine, the child may barely notice the injection. But if the kid watches the nurse prepare the needle? Cue the tears.

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Mamie Gummer as Jess in UGLY LIES THE BONE.

Our growing understanding of the psychological aspects of pain has led to the development of a transformative type of pain care: virtual reality therapy. We see this therapy in Ugly Lies the Bonethrough Jess's use of a fictionalized version of SnowWorld, an immersive VR system developed by Hunter Hoffman and David Patterson that was the first virtual world designed to reduce pain. Virtual reality therapy draws on our growing understanding of pain's attention requiring qualities, operating on the assumption that if a patient's brain doesn't focus attention on the expectation or the source of pain, the experience of the pain itself can be significantly reduced. Immersive virtual reality is the height of distraction, thanks to the sensory deprivation of 360 degree goggles, highly engaging graphics, and a constant soundtrack. In the case of SnowWorld, the virtual world is a land of ice, snowmen, igloos, mastodons, and penguins. The soundtrack is Paul Simon's "Graceland." And the action is simple-float through a winter wonderland while pelting (through the use of a mouse and head tracking) the various creatures with snowballs.

SnowWorld's initial testing, in the mid-2000s, had some exceptionally positive results that suggested VR might be a more effective tool than opioids in reducing acute pain. Most strikingly, the study participants (burn victims undergoing routine wound care) with the highest standing pain ratings (pain rated at 7 or higher on a 10-point scale) actually reported the greatest reductions in pain while using the VR treatment. Since these initial tests, the body of evidence to support VR therapy as a method of pain control has grown (with brain scans to support patient-reported data), and the list of potential applications for the therapy has begun to swell. Today, the most promising pain-related use for VR therapy is as treatment for acute pain (the pain experienced by a burn victim undergoing treatment, for instance). But in time, as research and technology grow, VR may become a staple in both the broader pain-management field (where treatment for chronic pain is still lacking) and in the wider world, where VR may eventually be commonly used for surgical training, PTSD treatment, and social cognition therapy, among other uses.

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Try virtual reality for yourself and join a discussion about its use in the treatment of pain on Sunday, October 11 following the 1.30pm performance. All tickets to Roundabout Underground are general admission for only $25. For more information and tickets, please visit our website.