Pain Medicine

Acute perioperative/surgical pain service is a rotation with focus on acute postoperative pain management. The fellow will master technical skills acquired previously in residency, tailored to pediatric patients. The fellow will learn about specific issues related to oral and intravenous analgesic administration in pediatric patients. The fellow will be educated in topics related to pain assessment, selection of the appropriate analgesic modality, side effect and complication management, regimen optimization, use of adjuncts and non-pharmacologic means of pain control in various age groups and developmental levels. The fellow will be expected to participate and later on lead the rounds, communicate with and educate patients, families and providers of the referring services and support staff (nurses, nurse practitioners) whenever possible.

The goal of the rotation in the continuity clinic is to gain knowledge of the principles and management of the chronic pediatric pain conditions in an outpatient multidisciplinary setting. The fellow will spend approximately two months (once a week, for total of 44 days per year) at the CCHMC Medical Office Building. The fellow will work under direct faculty supervision, with increasing level of autonomy as the training progresses. The fellow will become skilled in assessment, physical examination, medication management and interventional procedures if indicated as pertinent to the pediatric patients with chronic painful conditions. The fellow will be involved in care coordination, communication with team members and an educational program to meet the rotation objectives.

The main goal of the inpatient medical pain service rotation is to prepare the fellow for the future role of a consultant in the area of chronic pediatric pain medicine. Several facets of this role will be addressed during this rotation and further cultivated throughout the training. 1. In a position of a multidisciplinary team leader, the fellow will be educated about the role of the various team members and their contribution to the treatment. 2. As a member of a multidisciplinary team, the fellow will be taught the proper communication with team members and team leaders, patients and their families. 3. For chronic pediatric patients admitted for inpatient rehabilitation, while the physical medicine and rehabilitation team will be the admitting service, the medical pain team and its fellow will serve as a co-admitting service, working very closely with the PM&R team designing treatment goals. The fellow will learn to select appropriate patients, implement interventional techniques, optimize analgesia and manage complications and side effects to facilitate rehabilitation. 4. The fellow will learn to serve as a consultant during multidisciplinary clinics – such as epidermolysis bullosa (EB).

One of the primary clinical responsibilities of a practicing pain medicine specialist is to serve as a consultant for patients with acute and chronic pain and co-existing neurologic problems. The pain medicine specialist needs to acquire basic knowledge of pediatric neurological disorders and proficiency in evaluating neurological status to determine the best treatment options. Consults may be in regards to primary neurologic diseases, neurologic complications of systemic diseases or the neurologic complications associated with medical and surgical therapies. The goal of spending two weeks with the inpatient neurology consult service is to have a true hand on experience allowing the fellow to become familiar with most common pediatric neurological problems with emphasis on pediatric headache; to develop skills in eliciting a directed neurological history and performing detailed neurological examination to include at least mental status, cranial nerves, motor, sensory, reflex, cerebellum examinations and gait. The fellow will also become familiar with basic neuro-imaging and learn to identify significant findings on CT and/or MRI studies of the brain, cervical, thoracic and lumbar spine. The fellow will have an understanding of the indicators and interpretation of electro-diagnostic studies. Two afternoons will be spent at the Headache Center, observing multidisciplinary evaluations of new and existing patients with headache.

The goal of a two-week rotation with the Physical Medicine & Rehabilitation team is to study a comprehensive musculoskeletal and neuromuscular history and perform detailed examination with emphasis on both structure and function. Detailed assessment is crucial for development of effective rehabilitation programs for our patients. Fellows will gain an understanding of the natural history of various musculoskeletal pain disorders and be able to appropriately integrate therapeutic modalities and surgical intervention in the treatment algorithm.

One of the many clinical responsibilities of a practicing pediatric pain medicine specialist is to serve as a consultant for pediatric and young adult patients with pain related to malignancy or non-malignant chronic illness. Underlying terminal or advanced chronic illness affect the length and quality of life and determine choice of treatment modalities. Untreated pain may impair treatment progression and success. The goal of a 16-day PACT rotation is to familiarize pain fellows with patients with complex medical and social history with special attention to cultural, personal, spiritual and familial values as they relate to pain perception. The fellow will develop an understanding of and ability to implement the principles and techniques of the pharmacologic and non-pharmacologic therapies. The rotation will place significant emphasis on communication with the families, members of the treatment teams, medical and non-medical personnel involved in the care.

Psychiatric comorbidities frequently coexist in pediatric and young adult patients with acute and chronic pain. Presence of a psychiatric illness may impair successful treatment and also affect choices of treatment modalities. The goal of spending 16 consecutive days with the Psychiatry Liaison and Consult service is to familiarize pain fellows with comprehensive psychiatric history with special attention to psychiatric and pain co-morbidities. The fellow shall develop understanding of the principles and techniques of the pharmacologic and psychosocial therapies, with special attention to supportive and cognitive behavioral therapies.

Various radiologic imaging techniques have become essential elements in patient evaluations. Consulting services may request not only medical treatment, but also to offer interventional pain management options. It is of prime importance that a pain medicine specialist has basic knowledge of neurological disorders, the ability to evaluate the radiological findings and their relevance to clinical presentation, and make qualified management decisions. The goal of rotation with the Neuroradiology service is to familiarize fellows with basic neuro-imaging and identify significant findings.

During out-patient pain clinic days, in conjunction with pain faculty, the fellow will be responsible for the management of adult patients with chronic non-cancer and cancer pain, while working at the University Hospital (TUH) clinic as well at the University of Cincinnati Health Pain Management Center (UCHPM center). The setup of these out-patient clinics is such that the fellow gains experience with a tertiary care pain clinic as well as a private practice pain clinic. During the time spent at TUH pain clinic, the fellow will have the primary responsibility for the patient, providing continuity of care. Fellows are supervised by pain faculty, for all evaluations and consultations as well as for procedures performed. Fellows rotating through the UCHPM center work under the direct supervision of the pain faculty. The educational program will consist of both didactic and clinical components. Fellows are expected to learn the principles and practical management of chronic cancer and non-cancer pain. In addition to comprehensive multidisciplinary care of the patient, fellows will also learn and perfect basic and advanced interventional procedures.

Focus of the limited rotation in the interventional pain management is on the diagnosis, therapeutic plan formulation and treatment of adults with chronic painful conditions suitable for procedure in an outpatient office based setting. The offered spectrum of interventional therapies includes diagnostic and therapeutic nerve blocks, facet blocks, radio-frequency ablation, cryotherapy, implantable spinal drug delivery systems, spinal cord stimulation trials, intra discal electro thermal therapy, percutaneous disc procedures and vertebroplasty. The training will embrace all aspects of comprehensive multidisciplinary care which - apart from conservative/medical and/or interventional management - will include assessment of the need for physical restorative and rehabilitative services, pain psychologists, psychiatrists, neurologists, spine surgeons, etc.

The fellow will spend a portion of 24 weeks of the fellowship year caring for adult patients who require regional and neuraxial anesthesia, and pain management for acute, chronic and cancer related pain at University Hospital. The fellow will work under the supervision of a faculty member who specializes in regional anesthesia and pain management, and the activities will be supported by a registered nurse. During this rotation, the fellow will round daily on patients that require pain management (thoracic epidurals, indwelling regional anesthesia catheters and any consults).