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CORE ROTATION
INFORMATION
The Anesthesiology department’s residency rotation for chronic pain management and the ACGME Pain Medicine Fellowship Program is sponsored through the University of Florida and is based at the Malcom Randal VA Medical Center (MR-VAMC), specifically in association with the Pain Management Clinic. Rotations for Fellows to Gulf Coast Pain Specialists, P.A. in Pensacola will commence in July 2005, providing Fellows with additional opportunities in their comprehensive education and training program.
Residents in the core anesthesiology program gain experience by managing patients with acute perioperative pain primarily while rotating on the Regional Anesthesia rotation, the preoperative evaluation clinic, and the recovery room. Chronic pain management experience is obtained at the Pain Management Clinic at the VA Medical Center. This clinic is also staffed by our pain management specialist. Working together with the faculty members at the VA, a plan is developed and treatment initiated. Approximately 1800 patients are seen at this clinic each year, and of these, 800 are new patients. Common pain problems treated are: upper and lower back pain, cancer pain, complex regional pain syndrome, postherpetic neuralgia, pancreatic pain, phantom limb pain, diabetic neuropathies, and central and neuropathic pain of all origins. Residents will be exposed to multiple procedures including among others: stellate ganglion blocks, thoracic and lumbar sympathetic blocks, celiac plexus blocks, continuous interscalene and axillary blocks, and epidural and spinal blocks. Residents will also become proficient in the use of pharmacologic pain control methods including narcotic analgesics, non-steroidal analgesics, antidepressants, anticonvulsants, hypnotics, and other relevant pain medications.
Advanced level elective rotations in pain management are available at the VA. The advanced level resident can receive exposure to more difficult management problems and treatment modalities including invasive pain management modalities such as RACZ catheters and radiofrequency ablations.
Pain Management Contacts
@ MR-VAMC:
Andrea Trescot, MD, Pain Clinic Medical Director & Pain Medicine Fellowship
Program Director
Vance Elshire, MD, Pain Clinic Staff Anesthesiologist
Emilio B. Lobato, MD, Acting Chief, Anesthesiology Service
Henry Richard, Program Support Assistant
Luann M. Cox, Pain Medicine Fellowship Program Coordinator
Timothy Steinberg, MD (Shands, Jacksonville)General Goals
This rotation will help the anesthesia resident develop
the skills to ameliorate suffering caused by chronic pain problems. The
resident will learn to use many indicated pain treatment modalities. The
resident will learn to perform an initial assessment of the patient with chronic
pain, decide on appropriate diagnostic testing, develop skills in performing
diagnostic and therapeutic procedures, and learn the appropriate use of
pharmacotherapy. In addition, the resident will develop communication
skills helpful in developing a professional, therapeutic relationship with
chronic pain patients and their families. Using a multidisciplinary
approach, the resident will learn to develop management strategies, tailoring
pain management and treatment modalities to the patient's individual needs. The resident completing the first rotation in pain management should be able to
diagnose and treat the following common syndromes:
- Trigeminal neuralgia
- Post-herpetic neuralgia
- Phantom limb pain
- Diabetic neuropathy
- Sympathetically mediated pain
- Low back pain
- Myofascial pain
- Inflammatory mediated pain such as bursitis, carpal
tunnel syndrome, arthritis related pain
SPECIFIC COMPETENCIES:
(General
Competencies also apply)
Patient Care Skills
- Assessment skills:
- Performance of a thorough, goal-directed patient
history with emphasis on historical information relevant to the patient's
chronic pain problem. Because the etiology of a chronic pain problem
is often complex, the resident must be able to perform a complete,
thorough history of the pain problem as well as a comprehensive review of
all systems.
- Performance of a thorough, goal-directed
physical examination with emphasis on the neurologic system. Because
the etiology of a chronic pain problem is often complex, the resident must
be able to perform a complete, comprehensive physical examination of all
systems.
- Appropriately order laboratory tests, radiologic
studies, and psychological testing in order to assist in determining the
nature / etiology of the patient's chronic pain problems.
- Based on information obtained from the history,
physical examination, and testing, develop a complete differential
diagnosis of the patient's chronic pain problem.
- Be able to differentiate among the different
common chronic disease states including, but not limited to, neuropathic
pain, sympathetically mediated pain and myofascial pain syndromes
- Management skills
- Be aware of the various available modalities
for treatment of the patient with chronic pain and appropriately utilize
a multidisciplinary approach to designing a treatment plan
- Pharmacotherapy
- Appropriately use the different classes of
drugs available for the treatment of chronic pain syndromes (including
opiates, nonsteroidal antiinflammatory drugs, anxiolytics,
anticonvulsants, antidepressants, local anesthetics, and others)
- Diagnostic and Therapeutic blocks
- Perform appropriate pre-procedure evaluation
- Obtain informed consent
- Be able to perform common blocks including
- Trigger point injections (myofascial pain)
- Cervical, thoracic and lumbar epidural
blocks (both diagnostic and therapeutic) and steroid injections
- Sympathetic blocks (diagnostic and
therapeutic)
- Stellate ganglion (cervical)
- Lumbar sympathetic block
- Celiac plexus block
- Facet joint injections
- Other blocks as available each month
including radiofrequency lesions, neurolytic blocks and others -
these are mainly fellow-level procedures, but may be done by
residents if patient volume is available
- Know when it is appropriate to
refer patients to different specialists for definitive or adjunctive
therapy, for example, neurosurgery, orthopedic surgery, neurology
- Provide appropriate
post-procedural follow up and continuing care
- Provide appropriate continuing
care for patients receiving non-procedural treatment
Medical Knowledge
- Know current theories regarding the
pathophysiology of chronic pain syndromes
- Based on an understanding of the
pathophysiology of each syndrome, know which syndromes are best
handled by pharmacotherapy, physical or occupational therapy,
therapeutic interventional procedures, or alternative pain
management methods such as massage therapy or acupuncture. Know which pain syndromes are best treated with more invasive
modalities such as dorsal column stimulation, implantable
morphine pumps to provide intrathecal morphine, or ablative
procedures such as dorsal root entry zone lesions or
radiofrequency lesions.
- Neuroanatomy relevant to the performance
of diagnostic and therapeutic blocks
- Learn the anatomy of the
sympathetic and somatic nervous systems, specifically, the
anatomy of the epidural and subarachnoid spaces and the location
of sympathetic and parasympathetic ganglia
- Know the cutaneous dermatomal
mappings
- Medical conditions that may cause
chronic pain (e.g. herpes zoster)
- Know the types of drugs that
relieve pain and their efficacy, indications, doses, side
effects, interactions, and contraindications - specifically:
- opiates
- non-steroidal
antiinflammatory drugs
- anticonvulsants
- local anesthetics
- antidepressant medications
- sedatives
- anxiolytics
- How
doses and dosing intervals may have to be adjusted in patients
with chronic pain
- Know the different
modalities of physical therapy that may relieve both acute and
chronic pain and learn how to obtain such therapy
- Know the indications and efficacy of
each of the above described blocks for common chronic pain
syndromes.
- Know the complications associated
with each of the above described blocks
INTERPERSONAL AND COMMUNICATION SKILLS,
PROFESSIONALISM
- See general
competencies section
- Learn interpersonal skills that enable the
anesthesiologist to communicate effectively with the difficult, hostile or
needy chronic pain patient
- Gain skills to be able to prevent being
manipulated by patients with chronic pain and to maintain control of the
therapeutic relationship
- Learn to accept the slow pace of improvement
often seen in this patient population
- Learn to effectively communicate with other
professionals who have skills helpful to the patient with chronic pain
- Learn to communicate effectively with the
patient's primary care physician to gain information needed for your
evaluation of the patient and to provide ideal continuing longer term care
for the patient.
PRACTICE-BASED LEARNING AND
IMPROVEMENT
- See general competencies section
- Learn to efficiently manage a pain clinic that
must (and often simultaneously):
- Evaluate new patients
- See return / follow-up patients
- Perform invasive procedures
- Deal with multiple phone calls from patients
SYSTEMS-BASED PRACTICE
- Appropriately utilize consultants and
laboratory testing to correctly diagnose and develop treatment plans for
patients with chronic pain
- Anticipate the impact of each patient's pain
pathology and planned procedure(s) on the level of
subsequent care and follow-up required.
- Integrate the care of the pain management
specialist with the patient's primary care physician to best manage the
overall patient.
- Practice cost-effective, safe pain management
Evaluation to Determine Goal Achievement:
- At the end of the rotation,
you will take a short oral examination designed to specifically test ability
to diagnose common pain syndromes and knowledge of commonly applied treatments
for these syndromes. The answers will be reviewed at the time of the examination.
- Knowledge and skills in the
management of acute pain will be tested by an oral examination in which
you discuss a case scenario and your approach to the case
- You are evaluated online
weekly by all attendings who worked with you. The attending
physicians complete a Departmental Resident Evaluation Form,
which are reviewed quarterly by the Clinical Competence
Committee and continuously by the program director. Your advisor informs you of any problems identified, and
serious problems will be discussed with you immediately
after they occur.
- You will complete a Departmental
Rotation Evaluation Form.
- The Resident Education
Director will evaluate the results of the In-Training
Examination for the American Board of Anesthesiologists
(ABA) in general and for areas of departmental weakness.
Consistent weaknesses will result in adjustment of the above
goals.
Teaching Resources to Accomplish
the Objectives
- Veterans Administration
Medical Center: 6241 total patients undergoing 4229
procedures as follows:
- Trigger point
injections: 1001
- Acupuncture therapy: 1518
- Facet injections: 225
- Sacroiliac
injections: 9
- Epidural steroid
injections: 139
- Racz catheter
insertions: 6
- Radiofrequency
lesions: 156
- Selective nerve root
injections: 26
- Lumbar sympathetic
blocks: 3
- Stellate ganglion
blocks : 2
- Massage therapy: 809
- Peripheral nerve
block: 308
- Discography: 2
- Text books:
- Waldman SD.
Interventional Pain Management, 2nd Edition. W.B. Saunders Co, New York, 2001
- Raj PP.
Practical Management of Pain, 3rd Edition. Mosby, 2000.
- Benzon et al.
Essentials of Pain Medicine and Regional
Anesthesia, Churchill Livingstone, 1999.
- Abram SE, Haddox
JD. The Pain Clinic Manual., 2nd Edition. Williams and Wilkins, Philadelphia, 2000.
- Netter FH. Atlas
of Human Anatomy., 2nd Edition. ICON
Learning Systems, New Jersey, 1997
- Cousins MJ,
Bridenbaugh PO. Neural Blockade in Clinical
Anesthesia and the Management of Pain, 3rd
Edition. Lippincott-Raven, Philadelphia, 1998.
- Faculty:
- Jerry J. Berger,
M.D.
- Segudina Saga-Rumley, MD
- Timothy Steinberg, MD
- Lori Dangler, MD (Acute Pain)
- Dr. Saga-Rumley is the faculty
member responsible for the primary rotations in the CA-2 year and CA-3
level electives done at the VA.
CA3
ADVANCED CLINICAL TRACK ROTATION IN PAIN MANAGEMENT
CA3 rotations in Chronic Pain Management are available at
the VA Medical Center, and Shands, Jacksonville. Goals and
Competencies are the same for all locations, but the types of patients
seen are different at each location. For residents rotating in pain
management rotations for 4-6 months, a clinical research project must be
designed, initiated, and preferably completed with the assistant of a pain
management faculty member. These residents will also be directly
instructed in the management and administration of a pain clinic.
- VA Medical Center - same as described above -
primarily elderly male veteran patients
- Shands Jacksonville: This rotation will take place at
the comprehensive pain center located in Jacksonville. The patient population will be primarily those patients with chronic pain
disorders relating to congenital, acquired, and degenerative diseases of the
spine. Residents rotating here will be exposed to spinal cord
stimulation and morphine pump placement (only location where this is currently
done)
PATIENT CARE
SKILLS:
- Be able to independently evaluate and develop a
treatment plan for patients with common pain syndromes including:
- Trigeminal neuralgia
- Post-herpetic neuralgia
- Phantom limb pain
- Diabetic neuropathy
- Sympathetically mediated pain
- Low back pain
- Myofascial pain
- Inflammatory mediated pain such as bursitis,
carpal tunnel syndrome, arthritis related pain
- Visceral pain
- Evaluate and prepare patients for more invasive
pain management modalities including
- Facet injections
- Racz catheter insertion
- Radiofrequency lesions
- Selective nerve root injections
- Dorsal column stimulation and stimulator
implantation
- Morphine pump implantation
- Deep Brain Stimulation (theoretical knowledge
only)
- Celiac plexus block
- Vertebroplasty
- Intradiscal Electrothermal Therapy (IDET)
- Participate in the following pain procedures
- Facet injections
- Racz catheter insertion
- Radiofrequency lesions
- Selective nerve root injections
- Dorsal column stimulation and stimulator
implantation
- Morphine pump implantation
- Deep Brain Stimulation (theoretical knowledge
only)
- Celiac plexus block
- Vertebroplasty
- IDET
- All procedures listed above for the primary
rotation
MEDICAL KNOWLEDGE
- Know indications, efficacy, contraindications,
and complications of the following pain procedures:
- Facet injections
- Racz catheter insertion
- Radiofrequency lesions
- Selective nerve root injections
- Dorsal column stimulation
- Morphine pump implantation
- Deep Brain Stimulation (theoretical knowledge
only)
- Celiac Plexus block
- Vertebroplasty
- Intradiscal Electrothermal Therapy (IDET)
- Know supportive neuroanatomy to facilitate
performance of these more invasive blocks:
- Facet injections
- Racz catheter insertion
- Radiofrequency lesions
- Selective nerve root injections
- Dorsal column stimulation
- Morphine pump implantation
- Celiac Plexus Block
- IDET
- Vertebroplasty
- Deep Brain Stimulation (theoretical knowledge
only)
- Organization and administration of a Pain Clinic
RETURN
TO INDEX FOR GOALS AND OBJECTIVES
Revised 3/2007
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