The 9th Annual Pain Care Skills Training taking place at SOUTHCOM Conference Center of the Americas in Miami, Florida, brings colleagues and subject matter experts together to learn more about optimizing care and integrative approaches to pain management within the Department of Defense (DoD). The focus will be in sharing best practices, conducting hands on training and learning integrative approaches. The overall goal of the Pain Care Skills Training will be to promote readiness, restoration of function and relief of pain while decreasing the use of opioids.

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Transcript

Okay, welcome back everybody. We’ll get started with our next two lectures of the morning. If you will all take your seats. All right, keeping on time, a couple of other announcements. Want to make sure that you all remember that this week Pain Skills Training is really only the beginning through Walter Reed and National Capitol Region Medical Director, we offer multiple trainings. And if you can go to our second, yes, so we were off our quarterly buprenorphine waiver training, battle field actor, our case-based webinars, the first Tuesday, Wednesday, Thursday of the month. Also we offer an addiction case-based webinar, acupuncture, pain, functional medicine. We offer our monthly pain grand rounds, our monthly pain journal clubs, our annual Substance Use Disorders Symposium, which is coming up September 11th. And on the next slide you’ll see some of our resources. Remember these lectures for today are all on the milSuite and on the next slide here are our pain and neuroscience distinguished professor lecture series for this upcoming academic year and we have a lot of our colleagues, a lot of our friends are willing to give us talks, we’re offering all of those via Adobe Connect also. So feel free to call in for any of those. And we’ll go back to our introductory slide. Remember one of the most important things about this week is building the community of practice. Remember that it’s really making our connections, talking to people that maybe you know, don’t know, and really expanding your access to resources, bringing us all together. And we’re bringing together pain specialists, very young in training to pain specialists such as myself that are very old and have been around a long time. The interdisciplinary nature of this training is really phenomenal. We have everything from nursing, pharmacists, social worker and many, many others, primary care, specialty care and the like. So again, the ability to have workshops, to do our workshops. Everybody there, everybody really bringing in their ideas, really making it very powerful and really strengthening our training. So again, building our community of practice, I really emphasize. Wear your name tags. Reach out and just talk to people and that will really help you in bringing back skills when you go back to the exam room on Tuesday morning I believe since Monday will be Labor Day. So with that, we have two more sessions this morning. Our first is we have, we’re very, very fortunate in having a patient talk to us today. And this is Lieutenant Commander Patrick Millam. And I encourage you to read the bios. We can read Lieutenant Commander Millam’s bio. I don’t want to embarrass myself because there are so many acronyms with the awards and his outstanding accomplishments in the bio. But I want to really welcome you, Commander Millam. Again, we’re very fortunate to have you, who’s been dealing with pain for the past several years and we wanna really appreciate our patients’ experience in battle with coping and overcoming and helping all of our patients as we return back to our clinics. And with that Commander Millam, I’m gonna turn it over to you. And then I have my colleague, Dr. Harold Wayne from Walter Reed where we’re going to ask you maybe a few questions.

[Patrick] Absolutely.

And I will get for you the microphone.

It’s really an honor to be here with you guys today. I’m not hiding behind this trident today. I’m totally coming clean with everything’s that’s happened to me.

Excuse me sir, because of the live stream, okay.

So again, I’m Lieutenant Commander Pat Millam. BUD/S class 196. Class started with 16 people and I’m sorry, graduates 16 people, started with about 120. Basic Underwater Demolition School or BUD/S is three phases. The third phase is the land warfare phase. And BUD/S is a good place to talk about pain management and cold, and wet and tired and just being miserable. So third phase, I’ll just call it two months. You do your first month in Coronado and then the class flies out to San Clemente Island for about a month and start doing land warfare, shoot, move, communicate all those kind of things. As soon as we landed in San Clemente, all we had to do is just one month and we’re gonna graduate. As soon as we landed the aircraft in San Clemente on the runway, we were unloading the aircraft full of ammo, full of weapons. So I’m picking up one part of this heavy weapon case and I’m walking backward off the ramp. I trip over something and catch myself with my left wrist. Turns out I broke my left wrist but I didn’t tell anybody ’cause I was gonna graduate. I was not going back. So I can do pull-ups with a broken wrist. I ended up doing push-ups knuckle-wise with a broken wrist. And I was still able to shoot, move, communicate with a broken wrist. I did a 3-1/2 mile swim with a broken wrist. I didn’t really care. I was going to graduate. So about a week into, before we head back to the island, the corpsman, SEAL instructor, Instructor Blah, he goes Millam, get over here. I go, “Yes Instructor Blah.” He goes, “What’s going on with your wrist”? “What are you talking about?” “How come you’re not doing push-ups “with your hands like this?” I was like, all right, I guess I gotta come clean. “I think I broke it when we came off the aircraft.” He was like, “Oh, man. “Okay, if you graduate”, we got a week to go, of course I’m gonna graduate. “Don’t go to a ceremony with a cast.” And I was like, deal. Go to the ceremony without a cast. After the ceremony, go see the docs and get a cast. I was like, too easy, definitely. That’s when my pain management started. (audience laughs) Want me to set this here? Okay, so the worst kicked off. In my platoon was the maritime option in the Mediterranean, take down ships, those kind of things. It’s called VBSS. I’m not gonna bore you with the, what it really means. So we were training constantly, constantly had to take down ships. So our boats come up at night, we hook it. We climb it, we take down the bridge. We take down the steering, we control the ship, blah, blah, blah. Well the war kicked off and we were getting ready to take down a ship. We come up on the ship, hook it. The number one man climbs up. I’m the number two man. I climb up and we hit a wave or something and it shot me over the rail. So I landed like really awkwardly and I was like, wow that hurt, but continue mission and let’s go. So the next day my back is just spasming. My back, and I can’t breathe. My platoon chief comes up to me and is trying to do direct pressure when it’s happening. Then I finally go to see the medic of the ship that we were stationed on. And without an x-ray he begins back manipulation with no x-ray. We (muffled speaking) maybe a month later I went to the doc at (muffled speaking). X-ray, I had two compression fractures, T4, T6. So the doc was manipulating my back when I had two compression fractures. Probably about six, no four weeks later, I got an offer to go to breachers school. Breachers school is, the breacher in the platoon is the guy who opens the door, whether it’s explosives, a shotgun, manual tools. You know, it’s a good school to have. So with a compression fracture, two of ’em, I was like yeah, I’m going to breacher school. Yeah, absolutely. So there’s kind of like this internal drive that guys like myself and other guys like myself have. I was lead breacher on the FTX, the final training exercise and gas masks, dark, no light. Came up to the first door, lay a charge on it, blow it, no problem. Go inside to the second door. I run into a residential door, which is just basically any kind of door. In fact I’ll use this thing as an example. So I come up to the door and I’m banging on it, banging on it and I finally get the chainsaw out. Get the chainsaw out, start it up. (imitates motor and explosion) It had a New York lock on the other side, which is basically a steel bar on the other side. So I take a manual tool, it’s called a hooligan tool. And all I have on are flight gloves, real basic gloves. Take the hooligan tool, bam, try and hook the door down ’cause now a steel Westminster of your door when you cut it with a chainsaw, the metal becomes like a razor blade. That’s all a steel Westminster door is is just tin and that foam inside and we use a chainsaw and it becomes a razor blade. So I hit the door again, bam, trying to pull it down. It works back up. I hit the door again, bam, it comes back and meanwhile I got the assault team on either side of the door. You know, they’re anxious and ready to get inside. Finally I grab the door with my flight gloves, pull the door down, get on my hands and knees so the assault team can hop over the New York lock, with two compression fractures. So I’m holding the door and the number one guy, probably the biggest guy in the platoon, he decides to use my left hand as a launchpad. So basically I’m holding the door like this and he step on it and I said a few nasty words at that point. I can see the instructors with a flashlight. Everything we did was videotaped. Come over and my hand is just sitting there, I got a gas mask on, can’t feel my fingers. I took my shotgun, took off my gas mask, immediately went down to the Portsmouth Naval Hospital that night and for a day and a half or two days, they sewed me back up. I had severed a tendon and two nerves in this hand. Luckily physical therapy and good surgery by you guys, I’m able to make a fist, which is good stuff. In Iraq we were guarding the Iraqi, this is all open source. We were guarding the Iraqi prime minister. We were basically his secret service. We were coming back from a meet somewhere in the red zone and he had two really nice limos. And my team had the Suburban and was shift lead in the back which means I’m kinda like the secondary guy in charge. I had this bad black Ford Expedition. This thing was massive. It can take 762 round and it was fast. Long story short, we’re coming back into the green zone, we’re on a bridge, a four-lane bridge, night. My point vehicle is somewhere out lost in the HESCO Barriers that are out there at night. It took the wrong turn, got lights in his face or whatever. So the limos kept on going. We followed the limos and then we would eventually take lead and my point would take rear, pretty simple. Well the limos took off on the bridge. They were flying. So I told my driver, Wagdog, I go, well let’s go take point. So right now we’re probably doing 80 on this bridge and I tell Wagdog to pull in in front of the limos, in front of Ajil al-Yawer. Wagdog, he pulls in, starts to lose it to the right, comes back to the left. (muffled speaking) saying get it Wags. He didn’t get it. We did a 180, hit a curve, took out a telephone pole, left 10 feet of the telephone pole and did our rolls and all that. I didn’t have my seatbelt on. I ended up in the floor where it’d be your feet in the passenger side. And I just remember my com guy and Wagdog saying, “everybody all right, everybody all right”. I was dangling like a sock and I was like, “Ow, that f’ing hurt.” Anyway, got taken to the CSH, jacked up my head, jacked up my right shoulder and I was off the detail for a couple weeks. But got back into it right away. Last story I’ll tell is went up to Mosul. We were gonna do a counter-sniper mission. Apparently some bad guy was killing army guys so our guys, somewhere up in Mosul, Tal Afar area. So we got sent up there to hunt this guy down. On our way to our insert point, we were inserting in four strikers. Everybody familiar with a striker vehicle is? A big vehicle with big tires. We hit an IED hole. We were probably doing about 40, 45. We hit an IED hole. We were the lead vehicle and a couple guys broke their arms. Nobody got seriously hurt. But we continue the mission, just reconsolidate. Had to change out gear or whatever. And we ended up killing the sniper. We found him, shot him, verified it through the grapevine so we saved American lives, paying a price for it though. That kinda sends me, I did my last deployment in ’17 to East Africa. I was doing a third world country meet and I’m a cat one collector as well so I can technically recruit people. And this is kinda, this part here kinda goes into the mental health piece of it. So I got all this physical stuff going on. I got chronic lower back pain. I got two torn tendons in my right shoulder. I have severed tendons. I’ve not cartilage on the inside of my right knee. I got a blind spot in my right eye. So that’s the physical piece. And I’ve had these things for probably about 10 years. I go to Africa, do that mission, come back in September of ’17. November, what holiday is in November? Veteran’s Day. Prior to that I had five friends that I used to go out and drink with and shoot with and operate with, commit suicide. And I think at that point it kinda makes you wonder if you’re vulnerable to it. Honestly, today I’ve never thought about it but when your friends were doing it, it’s kinda like when’s my turn? When’s that demon gonna hit me. So Veteran’s Day, I’m looking through YouTube and I like this band called Five Fingered Death Punch. Don’t laugh at me. That’s a new band. It’s not the Eagles. (audience laughs) I’m teasing. They got this video called Gone Away. I don’t know if you guys saw it. But (imitates explosion). You know, the demon came to see uncle Pat and it wasn’t good. I think the thing is that you don’t know what is going on. So I go to work and see the psych. And she’s like oh yeah, you’re going to NICoE, like as soon as possible. NICoE was in March of ’18. I didn’t know what I had probably for, honestly for like two months before I went to go see the psych. I just wanted to go see the psych about physical ailments. Then within five minutes, she’s got me crying on the couch. I’m like, what is going on? And so for two months I thought I was going schizophrenic. That’s not a good place to be. So before I went to NICoE, I made what was called a caustic cocktail. Basically every day I came home from work I’d take eight shots of whiskey like fast. Like pour, drink, pour, drink, pour, drink, no chaser. And then I would fire up Ambien. But that wasn’t good enough so we had had to add Valium. So I did that for about two to three months. Anxiety was off the hook. I’d have to pull over going to work and have an episode. I don’t know what you’d call it. Have an episode. The day I left for NICoE, I was partying with, I don’t know, like four good buddies of mine, drinking tequila at a Mexican restaurant. I probably had eight shots, right up my alley. Once you break down in front of team guys, (whistles) you’re in a bad spot. So I went to NICoE. You guys probably know the routine. Day one you gotta go tell about yourself in front of all your doctors. And told them that for the last two, three months I’ve been doing this caustic cocktail and they all got their notebooks out. It was hilarious. What helped me I think, because I was all in, the art, the psychiatry, gave ’em the mask, the music. I was all in. ‘Cause honestly I couldn’t go another two or three months. When the headaches become a nine, you just kinda want it to go away. And it does. When the headaches are like a five or six, they just linger for days, for days. And you can’t shake it. So I would try to get it to a nine. So I would watch that video of Five Fingered Death Punch and I would start drinking and I would try to get it to a nine. ‘Cause once it got to a nine, I knew it would be okay. I sat in my kitchen many times at night crying uncontrollably. It was really weird. I call it the demon. So you got all this physical stuff going on. Now you’ve got all this mental stuff going on. You got buddies committing suicide. I can compartmentalize big time. But they got full. They got full and I couldn’t compartmentalize anymore. Been to funerals that just crush team guys, operation Red Wings and Extortion 17 are just two examples. When Danny Dietz’s wife got up there and spoke, (whistles) I don’t care how tough you are. Good news is that I’m getting better. I don’t know if I’ll ever be myself. But day two of my program, day two at NICoE they gave me the stellate ganglion block and 225 grams of Effexor and that ganglion block made me numb. I was just walking around like, whoa. And I’m still at NICoE at this point. I’ve taken the ganglion block maybe once a quarter and it’s not having the same effect like it did at NICoE. I dropped down from 225 Effexor to 150. It makes me a little edgy. I can kinda feel the demon behind me and he’s knocking on the door. But I think with the help of what you guys have done, obviously the folks at NICoE, I’m the average team guy. I’m not extremely tough. I don’t consider myself to be a badass. I’m just a dude who does a job. You know what, I’d do it all again, no regrets. That’s all I got, thank you. (audience applauding)

So I wanna again thank you for that absolutely outstanding insight and degree of honesty that you shared with us. I think that that’s really going to help us as we take a look inwards at ourself and how we can benefit from your experience, from listening to you, going beyond the diagnosis. And we do have a couple of minutes and Dr. Wayne and I would like to ask you a few questions if that’s helpful.

Absolutely.

If that’d be possible. And really, and I’d like to start off and I’d like to know from you what are the characteristics of the physicians and the people that have treated you just throughout your whole course that you have found most helpful. What are those?

I think before you can really put it, before you can have a real relationship with you and your physician, you gotta come clean with yourself. You gotta be totally honest with the physician. You’ve got to, he’s gotta be in receive mode, I think it’s critical. The characteristics that I’ve had with mine are absolutely professional. It’s gotten better obviously, you know before the war began. You know I give everybody a nine or 10 with their wanting to help, knowing how to help, following up and collaborating. I’ve heard a couple guys mention here collaboration. Collaboration with the physical piece, the mental health piece, the physical therapy piece. I mean it’s all connected. I mean you guys know how to fix a bone in the arm. It’s, sick’s a lot more complicated than that, and I think you guys have an idea of what it’s like. So did I answer the question?

I think so. I think that that’s very helpful for us because there, identified multiple characteristics that you brought out, that willingness, the openness to listen to you, the knowledge, the collaboration and making sure that all of those things come together, that those are the ingredients of that successful healthcare team. I appreciate that. And Dr. Wayne, I’m gonna let you ask our last question for the morning.

I’m just gonna make a comment. I had a long oration prepared to talk about the biopsychosocial aspects of integrating that with patient care. Your ability to describe it did much better than any of could have done because you integrated all those factors together. You’ve done this very beautifully, how the physical, the emotional, the psychiatric and the cognitive aspects going back to our earlier speakers as well, were all integrated together. Also the way you took charge. He came in. We had something else planned. He walked in and he says this is what I’m going to do. You presented yourself beautifully. And it’s very impressive how you did but I would suggest to all of us, think about a patient reacting to their pain in a manner that we have to facilitate them taking control. That’s exactly what you did. He also demonstrated something else one of our speakers talked about, the need for a purpose. You have purpose while you served us in the military. You have a purpose now in educating others what is important in patient care, what you need and how you integrate all these phenomenons together. And this brings up one other question for you. Dr. Spivak asked you what were the positive aspects. But all of us face these complex patients. We gotta ask ourselves what would we do under those circumstances? What did Commander Millam’s discussion do to remove some of our biases with regard to these patients? How do we maintain that therapeutic alliance so we can facilitate and utilize us as placebo factors and not suffer the narcissistic injury that many of us have in dealing with chronic pain patients. But along with this Commander, what would you say were the deleterious impact that providers had for you? What derailed you in terms of trying to overcome?

Well obviously doing manipulation on the back with two compression fractures and no x-ray. We can start with that. I think lately though, I think we need to really learn from maybe a guy like me because I’m just one of hundreds, maybe thousands out there that are kinda going through this. I still have chronic pain in my lower back. I’m not too worried about the right knee. I’m not too worried about the shoulder. Chiropractic, a chiropractor got me through BUD/S. I don’t think anybody’s mentioned that yet. They bring us home with our last dive in dive face, we got all our gear on and the instructors ran us for four miles after the dive in soft sand wearing our mask, our drager, which has a neck strap and a back strap, fins out like this. You know, typical BUD/S, right? Well the next day we clashed up in the third phase and I couldn’t pass a run. I could not pass a run because I would slow down, I would get dizzy. My legs became numb. My back became numb. So I failed a bunch of runs in third phase. Buddy of mine said go see a chiropractor. I’m in, so I’m cracked, smoked all the runs. Smoked all the swims. It’s all related. It’s all related. Nobody has told me to go see a chiropractor. Nobody has told me to get, just get stretched, maybe to release some pressure on the nerves. I haven’t heard one, go see a chiropractor in many years and one got me through BUD/S. So I would tie it all in together. It’s all synced up some way or another.

Thank you, thank you, sir. We really, again, we so much appreciate your generosity in coming here and talking with us. And we have a chance, if you don’t mind for just one question and if you would be so kind as maybe to stay afterwards for questions.

[Mr. Motz] Lieutenant Commander Millam, this is Mr. Motz. I’m the Army Comprehensive Pain Management Program Manager. Don’t hold that against me. We’re brother in arms. I just got a comment for you. In behalf of the Military Health System, you are the reason why we exist. So I just wanna convey that with you. And I want to take the occasion for the people here to acknowledge Lieutenant Commander Millam. Stand up and give him a round of applause if you don’t mind people. So please stand up. – Thank you for that Mr. Moss. (audience applauding)

Thank you.

Thank you again, sir, thank you.