By Rose Seibert, RN, BSN and David Lynch, RN, BA
The 21st century has seen American military involvement in wars in Iraq and Afghanistan. Thousands of combat veterans continue to serve on active duty while many others have made the transition to civilian life. Exposure to combat and other deployment stressors has resulted in a myriad of mental health problems, including generalized anxiety, depression, and Post-Traumatic Stress Disorder (PTSD) (McGuire, 2012). The diagnosis of Post-Traumatic Stress Disorder (PTSD) among veterans is increasing, partly due to the changes in the nature of warfare increasing chances for injuries that affect mental health. Additionally, the Operation Enduring Freedom/Operation Iraqi Freedom conflicts are different than previous wars. This combat environment is characterized by roadside bombs, improvised explosive devices, suicide bombers, handling of human remains, high heat, insurgencies that hide among civilians, longer and repeated deployments, and shorter rest periods between deployments. These conditions can have lasting effects on our service members’ mental health.
PTSD can affect all aspects of a veteran’s life, including when they are undergoing surgery. PTSD patients are more likely to experience delirium with general anesthesia. Emergence Delirium (ED) is defined as any occurrence in which the patient awakens in a violent or thrashing manner with attempts to self-extubate, hold breath, displace intravenous line, assault operating room staff, and/or flee. The veteran is also at risk for falling from the narrow operating room table (Wilson & Pokorny, 2012). ED can occur at any time from the end of surgery until discharge from the recovery room. Emergence Delirium is associated with poor outcomes. Statistics show that patients who develop delirium during their hospitalization have higher six month mortality in comparison with patients who do not develop delirium (Ely et al., 2004).
As nurses in the post-anesthesia care unit, we identified that the lack of awareness among surgical staff, especially Operating Room (OR) staff, of a patient’s history of PTSD was a problem. To address the mental health needs of PTSD-prone veterans undergoing surgery, we devised Project Golden Eagle: A Project to Improve Veterans’ Mental Health. The project helps surgical staff and VA Pittsburgh Healthcare System accomplish the high priority performance goal to improve veterans’ mental health. Patients undergoing surgery with a history of PTSD or those exhibiting PTSD behaviors are identified prior to admission and their charts are marked with a “Golden Eagle” sticker to cue the staff to put interventions in place. This action triggers multiple visual cues to alert the staff of the patient’s history of PTSD. These include a golden-yellow chart folder, a golden-yellow OR hat, and an eagle emblem placed on their chart. Subsequent interventions for the project were multidisciplinary, including anesthesia personnel, perioperative surgical staff, and the music therapy department. During the perioperative time period, identified veterans are placed in a quiet room with dimmed lights to promote a calm atmosphere. Warming measures also facilitated a slower, quieter emergence from anesthesia. Patients are also given the unique opportunity to listen to evidence-based music therapy using the Bonny Method, which was provided with the help of our music therapy department. The Bonny Method of Guided Imagery and Music (GIM) is a music-centered depth approach to transformational therapy. The music generally selected for therapy contains selected sequences of classical music, has no words, has a tempo of 60-80 beats/minute, and has a relaxing quality.
References to the healing power of music can be found in the writings of Plato and Aristotle. The earliest known music therapy in the U.S. was in 1789 in an article in the Columbia Magazine titled “Music Physically Considered.” Scientific and anecdotal validation happened in the 19th century when it became a treatment modality in hospitals due to the support of renowned psychiatrists such as Karl Menninger. Interestingly, music therapy was widely used with the veterans of both World Wars at rehabilitation facilities such as Walter Reed Hospital.
Since the start of the Golden Eagle Project, statistical analysis has shown that veterans with PTSD and those exhibiting PTSD-like behaviors have had a much quieter wake-up from anesthesia. Also, the project helped to enhance communication across services proactively for early identification of the PTSD patient. The project has been a great success. The will be expanded throughout the entire VA Pittsburgh Healthcare System in the near future.
Rose Seibert, a former Air Force Reservist, and David Lynch are both front-line nurses at VA Pittsburgh Healthcare System. Seibert has worked at VAPHS for 16 years and Lynch for five. Learn more about health care for Veterans at www.pittsburgh.va.gov.
Ely, E., Shintani, A., Truman, B., Speroff, T., Gordon, S., Harrell, F., et al. (2004, April 14). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA, 291(14), 1753-1762.
McGuire, J. (2012). The incidence of and risk factors for emergence delirium in U.S. military combat Veterans. Journal of Perianesthesia Nursing, 27(4), 236-245.
Wilson, J. T., & Pokorny, M. E. (2012). Experiences of Military CRNAs with Service Personnel Who Are Emerging from General Anesthesia. American Association of Nurse Anesthetists Journal, 80(4), 307-311.