Pain Medicine

The Perioperative / Surgical Pain Service (APS) rotation focuses on acute pediatric postoperative pain management. Fellows further master technical skills acquired previously in residency tailored to pediatric patients. This includes ultrasound guided peripheral nerve blocks and neuroaxial techniques, pain assessment, utilization of multimodal pain management, side-effect and complication management, and use of adjuncts and non-pharmacologic means of pain control in various age groups and developmental levels. Fellows are expected to participate and lead rounds, communicate with patients, families, referring services, and support staff (nurses, nurse practitioners).

The Medical Pain Service (MPS) is a pediatric chronic pain service that includes several clinical responsibilities assigned throughout the week. Fellows spend a total of 15 weeks throughout the year rotating on this service. The MPS consists of two major clinical areas: the outpatient Pain Management Clinic and the inpatient consultation service.

The main goal of the MPS rotation is to prepare fellows 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 in an outpatient setting, fellows learn about the role of the various team members and their contribution to the treatment.

2. As a member of a multidisciplinary team (inpatient and outpatient), fellows are taught the proper communication with team members, team leaders, patients and their families.

3. Treatment for chronic pediatric patients admitted for inpatient rehabilitation through the Functional Independence Restoration Program. While the rehabilitation medicine team are the admitting service, the medical pain team and its fellow serve as a co-admitting service and work very closely together to design treatment goals. Fellows learn to select appropriate patients, implement interventional techniques, optimize analgesia and manage complications and side-effects to facilitate rehabilitation.

4. Fellows learn to serve as a consultant during multidisciplinary clinics such as epidermolysis bullosa (EB).

Fellows attend outpatient continuity clinic 2-3 days a week while rotating on the Medical Pain Service. The continuity clinic teaches the principles of management of chronic pediatric pain conditions in an outpatient multidisciplinary setting. Fellows spend approximately 40 days throughout the year working alongside faculty with progressively increasing levels of autonomy. Fellows become skilled in assessment, physical examination, medication management, and interventional procedures when pertinent to the pediatric patients with chronic painful conditions. Fellows are involved in care coordination, communication with team members, and an educational program to meet the rotation objectives.

One of the primary clinical responsibilities of a practicing pain medicine specialist is to serve as a consultant for patients with pain and co-existing neurologic problems. The goal of the child neurology rotation is to have a true hands-on experience with the most common pediatric neurological problems such as pediatric headaches. Fellows attend the Headache Center, observing multidisciplinary evaluations of new and existing pediatric patients with headaches. Fellows also become familiar with basic neuro-imaging of the brain, cervical, thoracic, and lumbar spine to develop understanding of the indications and interpretation of electro-diagnostic studies.

The goal of a two-week rotation with the Rehabilitation Medicine team is to obtain a comprehensive musculoskeletal and neuromuscular history and physical examination with emphasis on both structure and function. Fellows gain an understanding of the natural history of various musculoskeletal pain disorders and are able to appropriately integrate therapeutic modalities and surgical intervention in the treatment algorithm.

The goal of a three-week rotation with Palliative and Comfort Care (PACT) is to familiarize pain fellows with patients who have complex medical and social histories with special attention to cultural, personal, spiritual and familial values as they relate to pain perception. Underlying terminal or advanced chronic illness affects the length and quality of life and determines the choice of treatment modalities. Untreated pain may impair treatment progression and its success, and quality of life. Fellows develop an understanding of and the ability to implement the principles and techniques of the pharmacologic and non-pharmacologic therapies. The rotation places significant emphasis on communication with the families, members of the treatment teams, and 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 rotation with the psychiatry liaison and consult service serves to familiarize pain fellows with comprehensive psychiatric history with special attention to psychiatric and pain co-morbidities. Fellows develop an understanding of the principles and techniques of the pharmacologic and psychosocial therapies with special attention to supportive and cognitive behavioral therapies.

Fellows spend a portion of 21 weeks of the fellowship year caring for adult patients at UH who require regional and neuraxial anesthesia and pain management for acute, chronic, and cancer related pain. Fellows work under the supervision of a faculty member who specializes in regional anesthesia and pain management and the activities are supported by a registered nurse. During this rotation fellows round daily on patients that require pain management such as, thoracic epidurals, indwelling regional anesthesia catheters, and consults.

Fellows attend outpatient pain clinic at the University of Cincinnati Medical Center (UH) and the UC Health Pain Management Center (UCHPM). During this time fellows, in conjunction with pain faculty, are responsible for the management of adult patients with chronic non-cancer and cancer pain.  The setup provides experience with a tertiary care pain clinic model, as well as a private practice pain clinic model. While working at UH pain clinic, fellows have the primary responsibility for the patient and providing continuity of care. The educational program consists 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 also learn and perform basic and advanced interventional procedures.

Focus of the limited rotation with 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 spectrums of interventional therapies include: diagnostic and therapeutic nerve blocks, facet blocks, radio-frequency ablation, and cryotherapy. Training in advanced spinal procedures, along with implantable device trials and implants are NOT requirements for graduation from this fellowship, nor affect ABA Pain Medicine certification eligibility. The training embraces all aspects of comprehensive multidisciplinary care.  Apart from conservative, medical, and/or interventional management it includes assessment of the need for physical restorative and rehabilitative services, pain psychologists, psychiatrists, neurologists, spine surgeons, etc.

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 identification of significant findings.