Pain Medicine Service
Pain Medicine (formerly known as Chronic Pain or Interventional Pain) is a specialty with fellows from any of the four core disciplines in pain medicine: Anesthesiology, Physical Medicine and Rehabilitation (PM&R), Neurology or Psychiatry. At the University Hospital you will work with an attending and fellow who are anesthesiologists. There are PM&R staff that you will see on at morning Pain Didactics and Journal Club. During this rotation, a variety of pain conditions are primarily treated using fluoroscopy- and ultrasound-guided injections. These range from familiar peripheral nerve blocks (femoral, popliteal, TAP), familiar neuraxial procedures (epidural steroid injections), to Pain Medicine specific procedures like vertebral facet medial branch blocks, trigger point injections, Botox injections for migraines, spinal cord stimulator implants, and many other things. Time on this rotation is roughly equally divided between performing these procedures and seeing new and follow-up patients in clinic. In clinic you will do H&Ps and get the chance to help manage chronic pain specific medications. This rotation is a definite change of pace from the OR with many back-to-back patients and quick transitions. Overall, this is a fast-paced month with lots of hands-on experience and a chance to brush up on anatomy while learning more advanced procedures and specialized medications.
People
Attendings: Rachael Rzasa-Lynn, MD (pronounced "Razzah"); Narayana Varhabhatla (Var-ha-baht-la; you can also call him Dr. V), MD; Tushar Sharma, MD; Marisa Wiktor, DO
2023-2024 Chronic Pain Fellow: Michael Harlander-Locke, [email protected]
Phone numbers:
- Pain Medicine pager: 303-266-7291
- University Clinic phone: 720-848-1970
Preparation:
Plan on stopping by the UCH plain clinic prior to starting your rotation in order to orient yourself to the new area and get help setting up your new Epic for the month. The pain clinic is located on the first floor of the hospital next to the atrium pharmacy in the inpatient pavilion.
Set your Epic context to "ZZ Pain" for the correct screen layout. You can also use “AMC Pain clinic OP” and “AMC Specialty Proc OP” for contexts. Ask the fellow, or an outgoing resident to help you set up your Epic clinic schedule and receive pertinent shared SmartPhrases. Start reading to become familiar with the field and learn about the unique blocks and medications. Common topics to look up: medial branch blocks; SI joint injections; epidural steroid injections; trigger point injections; lumbar sympathetic blocks and celiac plexus blocks; fibromyalgia, complex regional pain syndrome; back pain, and back physical exam; radiation safety. Faust, M&M and Miller have pain medicine chapters. You will receive material through your email to review as well before starting the month.
Location:
The clinic is at UCH on the first floor near AOP. The easiest way to get there for your first time to clinic would be to enter through the AIP main entrance. You will see the atrium pharmacy right upon entering the rotunda. Make a right, going past the pharmacy and follow the signs to the Interventional Pain Clinic. You will end up in the waiting room/ check-in desk. Tell them you're a resident and they will let you back.
Another option is just to ask your fellow resident who is currently on the rotation for directions straight into the locker room area. The locker room entrance is located on the first floor 1.031 along the hallway that connects AIP and AOP. The conference room used for journal club and didactics is at 1.028 directly across from the locker rooms. If you need to store your lunch or want to eat in the conference room, it is next to the conference room at 1.012.
The clinic space is shared with PM&R, Ortho spine, and Neuro spine. You may need to email someone to get badge access, see emails. There are scrubs and lockers available for use during the rotation just remember to bring your own lock. Green hospital issued scrubs are provided for use, although you can wear your own scrubs for clinic days or wear business casual.
Schedule:
Residents typically arrive for clinic or procedures at 0645 and stay until the last patient is seen, which is usually about 1600. Check next day's schedule for first patient start time and to review what procedures you will be performing. If multiple residents are on rotation, it’s possible you can stagger early and late starts. Plan to go to all normal resident lectures (ITE, Grand Rounds, etc). There is Pain Medicine Didactic Lecture/journal club Wednesdays at 0700. The clinic is closed on weekends and holidays (see call below regarding holiday call).
Call:
The residents and fellow will divide call for the month. It is home pager call, so you do not need to stay within 30 minutes of the hospital. However, you must be in town while carrying the pager and able to return a page within 5-10 minutes if there is a call back number. The fellow will email you the call schedule and pager instructions prior to the rotation. You will need to forward the pain pager (303-266-7291) to your personal cell phone by 7am on the day you start call.
Typically, calls and pages are patients with chronic pain. Almost all outpatient issues can be handled by phone initially. If you are at all concerned, have the patient go to the ED. If you do not think there is an urgent/emergent element to the call, then in addition to handling it over the phone, have the patient call the clinic the following business day to follow-up (720-848-1970). Also mention it to the clinic staff so they can call the patient to check in.
While the clinic is closed on holidays and weekends, you may be assigned call over a holiday (Christmas, New Year’s or Thanksgiving). Holiday call is no different than weekday and weekend call. You must be in town and return the page within the designated time frame. However, for any non-urgent issue the patient will need to follow up in clinic when business resumes after the holiday. If the issue is urgent or you feel concerned, please refer the patient to the ED.
Formal consults must be answered and documented in the patient’s chart. Even if the consult is a phone consult from the ED or a patient’s advice request always remember to check the patient list (Pain Management: Chronic – Initial Consults” list.
Didactics
Each Thursday morning from 7:00-8:00 am, didactics, journal club or board review with residents and attendings is held. The didactics consists of 30-45 minutes presenting on an ACGME topic. It is mandatory to attend. The lectures have mostly been held via zoom but have moved to in person. The lectures will cover fundamental pain medicine keyword topics.
The PM&R fellow oversees the journal club schedule, but the pain fellow is responsible for the topics related to anesthesia. Together with the pain fellow and other residents also on the rotation you will create a PowerPoint presentation on a pain related topic and present at journal club.
Schedule
The pain fellow will make the schedule (which will be emailed to you prior to the start of the rotation). Double check the schedule as it may change day-to-day. This will determine when you arrive each day but try to arrive 15 mins before your first patient. Time slots are typically 15 - 30 minutes per patient for procedures, 1 hour for new patient visit. There are usually 15 - 20+ patients per day. Lunch is from 12 to 1. The last patient is scheduled around 1545. After that you will finish notes then go home. UCH is fast paced but you will adapt quickly.
The day will typically be split between the fluoro suite (procedure) side and the clinic side. On the fluoro suite side you will see the patient briefly in the pre-op area before performing the procedures. On the clinic side you will see new patients and perform some head and face nerve blocks and Botox injections.
Procedures
For procedures, there are five steps:
After the patient has arrived and their dot turns green on EPIC, copy forward their last procedure note, update it accordingly, then share it.
Go see the patient and consent for the procedure and get an update.
Remove appropriate drugs from the Pyxis. If unsure ask your attending. (Attendings usually draw them up anyway.) Ready the procedure room.
Perform the procedure.
Finish the note.
A medication guide near the Pyxis lists what drugs you should pull for a given procedure. Supplies for procedures are in the fluoro room and the ancillary staff will help you set up. For notes, the best way to learn is to have the fellow or a returning resident show you. In brief, for returning patients (vast majority), you will copy forward an old note and update the "Plan" section with the date of the new injection. For new patients receiving their very first injection, make a new note from one of the Amb Pain templates. Learning Epic notes takes practice but is crucial to make the day run smoothly.
When you see the patient in pre-op you should discuss today's procedure with them and have them sign the consent. There is a list of common side effects and complications for each injection located by the procedure computer that you should mention. Then, ask the patient how much and for how long their last injection helped them (you can find out what type of injection they last had from previous pain notes in Epic). Include in your procedure note “Plan” how much benefit they received last time, what you did today, and what injection(s) you plan on doing next time. It is important to actually read through the whole note to make sure it is up to date and accurate, as sometimes the notes have been copied forward incorrectly a few times and therefore contain errors.
For new patients on the clinic side, the MA will bring the patient’s paperwork to the workroom once the patient is checked in. Review any useful notes in Epic from other providers, and any available imaging. It is recommended to start your H&P then fill out parts before and while talking to the patient; it is now possible to “Pre-Chart” on the patient days in advance; if the patient does not present for the visit your documentation with disappear within 30 days. Then, go see the patient and perform a history and appropriate physical exam. Then, report to the attending. You will return to see the patient together. Finally, type/finish a new patient H&P. The fellow or attending will show you the Epic note template plus the instructions will be in your emailed information.
Additional information
Pain clinic is a fun rotation in which you get to experience a side of anesthesia away from the OR. The pain attendings and fellows are great individuals to work with and are a great resource to ask questions and learn more about the procedures performed in clinic. The UC Health Pain clinic is strictly non-opioid management (performs only interventional procedures). If a patient is referred to the clinic and is interested in opioid management, we will refer them to another provider in the community.
All patients seen in clinic or for procedures are adults. However, Dr. Wiktor is a trained pediatric and pain anesthesiologist. Thus, some of her patients are former pediatric patients who have “outgrown” Children’s Hospital and are now seen at University Hospital. As such, they have longer appointment times in clinic (usually 1 hour in length).
There are a handful of spinal cord stimulations (SCS) performed (by Dr. V) a year. However, these procedures are infrequent. The spinal cord stimulator trials are performed in the pain clinic and permanent placement occurs in the general OR under sedation. As the procedures performed in pain clinic are under fluoroscopy always make sure to have lead on including a thyroid shield. I hope this information helps you be well prepared for your pain rotation!