Guest Editorial

This edition of the British Journal of Pain looks at the pain suffered when people are pushed to the extremes of their endurance. The articles lead us from the impact of a roadside bomb to the emergency department via ambulance or helicopter, through the treatment of acute traumatic pain and on to the long-term pain management of the consequences of injury. This horizontal journey in time is matched by a vertical ascent into a discussion of the symptoms and suggested pathology behind acute high-altitude illness, in which pain in the form of headache is the core symptom of acute mountain sickness and may herald the onset of high-altitude cerebral oedema. The number of people travelling to high altitudes is increasing; currently there are 35 million visitors each year to destinations over 3000 metres. Or, as Ranulph Fiennes pointed out just before leading the first team on foot across Antarctica during the southern winter, a trip he described as one of the last great challenges, ‘now that everyone’s grandmother goes up Everest at the weekend’.¹

Well-publicised charity treks by military amputees across the Arctic or up mountains may give an overly positive view of the long-term consequences of military trauma and increase feelings of inadequacy in other trauma survivors. Similarly unhelpful are negative assumptions that all veterans have post-traumatic stress disorder or are likely to be violent offenders.

Temporal associations of pain are important. While high-altitude headache may portend worse things to come, pain from a phantom limb may trigger unpleasant memories and psychological associations in a blast victim. Indeed, the current experience of pain in a torture victim may powerfully transport them back to the terror of their captivity and abuse; equally, memories of past torture can elicit present pain.

Understanding the culture and context of pain for these patients is particularly important if we are to provide worthwhile management of that pain. Feelings of depression, anxiety, survivor guilt or shame may be found in both civilian and military survivors of major trauma, but may not be elucidated in a pain clinic because of limited time or by a reluctance of disclosure by the patient. Furthermore, a torture victim may not reveal his or her history because of a deep distrust of those in authority, which may result in their experiences never being recognised.

As announced in April last year, trauma services are becoming more concentrated across the country, with the development of major trauma networks and designated major trauma centres to have ‘all the expertise, experience and equipment in one place’.² The intended model of good trauma care involves a seamless progression from initial contact to pre-hospital assessment to acute trauma care, then on to acute or specialist rehabilitation followed by community or general rehabilitation. The NHS can learn much from the established military model of providing high-quality analgesia at each stage and it is only by engaging all disciplines involved along this patient pathway that we can achieve this. In this issue of the British Journal of Pain, it is encouraging to see that this multidisciplinary approach has already started.