January 2004

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Pain Clinic Aruba

Pain Clinic Aruba

Organization of a Pain Clinic

Israel A. Posner MD (click to see CV)

Department of Pain Management at the DR Horacio Oduber Hospital, Aruba   Tel. 011-297-5870413 iaposner@hotmail.com

The concept of the Pain Clinic is based on the conviction that the effective management of difficult ?pain? patient is possible only through the well coordinated effort of a group of specialists contributing their knowledge and skills to the diagnosis and solution of these patients ? problems?. Any well-respected modern hospital has a Pain Clinic.

Who is seen in Pain Clinics

Patients seen in Pain Clinics are those for whom the routine health care system has failed.  They therefore demonstrate many iatrogenic problems, both medical and surgical.

Patient with cancer pain. These patients will be investigated and studied to find ways of controlling their pain and improving their quality off life. Most of them will get oral medication. Some of them will need special medication like narcotics to help control their suffering. Other may need more specialized care, where some device will have to be implanted under the skin or some nerves or plexus will have to be burned. This is done with radiofrequency or neurolitic drugs. Other patients have a long standing (more then 3 months) or chronic condition that causes pain. Among others the most common are low back pain, neck and shoulder pain migraine, Fibro Myalgia Syndrome and Pain caused by a diabetic neuropathy. Some patients suffer of severe pain of the face or Trigeminal Neuralgia; these patients are often suicidal because of the pain. The patient is studied extensively, often in a multidisciplinary setting. Research is constantly done, usually in the form of literature search via Medline on the Internet.

Description

Pain Clinic

The Pain Clinic is a place in the hospital where patients visit and or get treatment for their pain. The unit has two employees. One Anesthesiologist and a nurse. The clinic?s director is an anesthesiologist and this Pain Clinic is affiliated to the DR Horacio Oduber Hospital. Most Specialties have use for the Pain Clinic. The specialist will either call the pain specialist in consultation for a clinical pain or they will send the patient to make an appointment to see the Pain Clinic. Especially those specialties that have patients with acute pain like a mother to be who is in labor; patients with cancer pain and patients that have chronic pain.

The difference between acute and chronic pain is that chronic pain has lasted more then 3 months, and the original cause of the pain is not any more. The pain it self, which is usually a warning system, has become the problem. On the other hand, acute pain is usually peri-operative. Perhaps a patient in labor or a patient that has had some noxious stimulus like a heart attack or trauma or a severe burn.

Therapeutic modalities

Since the end off 2004 we have Pulsed Radio Frequency

The various therapeutic modalities offered by the clinic are listed in the order of frequency.

-Intravenous medication, giving medication as an intravenous infusion.

-Trigger points injections, injecting medication in tender spots.

-Lumbar Facet denervation, causing a long lasting block of the little nerves supplying the joints in the lumbar column.

-Cervical Epidurals with steroids, injecting steroid medication in the neck, in the epidural space.

-Epiduroscopy, this fascinating procedure allows us to actually look into the epidural space.

-Nerve blocks, injecting medication to block the pain and feeling of a particular nerve.

-TENS, stands for Trans Cutaneous Electro Nerve Stimulation and it blocks pain without medication.

-Ionthophoresis, giving medication trough the skin, without the use of a needle.

-Reservoir implantation, implanting a device under the skin to give medication.

-Neurostimulation, this is a form of TENS but it is implanted under the skin.

-Rhizotomies, blocking the nerves in a more permanent manner.

-Trigeminal Radio Frequency Lesions, causing a more permanent lesion or block of the nerves of the face, using a computer.

-Percutaneus Lumbar Disectomies and Percutaneous Lumbar Laser Disectomies

-vertebroplasty

Anodyne - monochromatic infrared therapy

Organizational Structure

The Pain Management in the DR Horacio Oduber Hospital is an independently budgeted department integrated in the hospital on the first floor. The clinic counts on one 80 % time Anesthesiologist and a full time medical nurse trained in pain management.

The Anesthesiologist DR Posner heads the clinic and is the specialist responsible for the medical treatment. He is the founder of the department, which started about 8 years ago.  He is a registered cardio-anesthsiologist, intensive care specialist and he has a super specialty in pain management. He is also a Diplomat at the American Academy of Pain Management in the USA.

The Department educates those involved, like other specialists, house doctors, clinic nurses and community nurses and patients on the possibilities of diagnosing, and treating pain syndromes.

Another member of the team is a physician assistant who is a registered nurse trained in the working of a pain clinic. Maritsza Albertsz has been at the Clinic for 3 years now. Before this she has worked for over 10 years at the delivery ward. She has been trained in Aruba and Holland in Pain Management.

As a nurse physician assistant she is qualified to do nursing procedures. And she is also trained in special blocks, working with specialized equipment used at the Pain Clinic. She also does Hospice work. This is the treatment of Terminal patients in their homes.

Equipment used

Besides using needles, electrodes and computers. At the pain clinic we use optic fiber technology, digital cameras, scanners, x-rays equipment. Some patients have to be operated on. And need to get anesthesia, and monitored closely.

Referrals

Patients referrals

Most patients are referred to the Pain Clinic by Colleague specialists. Some patients are referred to the Clinic by their family physicians and a few patients just walk in on their own. Normal the patient gets an appointment. Cancer patients and patients for whom a colleague doctor has called get preference.

The first visit

The first visit for the patient will usually take about one hour. In this the doctor does a complete physical after undergoing extensive questioning. Then the doctor will explain his finding, suggest treatment protocols and attempt to give prognosis. Any questions will also be answered if possible. The patient and the patient?s family are encouraged to make questions.

Then if the patient understands the treatment proposed, and agrees to go ahead, he will be scheduled for an appointment to be treated. 90% of all treatment protocols can be done either policlinically or as an outpatient.

If the patient needs to be treated on the operating room, most of the time he or she will have to be placed on a special bed (x-ray). If it is necessary the patient will have an intravenous access to give medication like antibiotics or sedatives.

The patient is usually asked to be fasting, and they cannot drive after the procedure. After they have been treated they can go home and they get an appointment to return for evaluation.

Some times the patients are treated at the clinic. Usually this is for repeat treatments like getting intravenous medication or trigger points injection trans nasal blocks or ionthophoresis.

Repeat visits

Repeat visits take less time, usually 10 to twenty minutes. Here it is decided together with the doctor and the patient whether the treatment made any difference, whether to continue with the treatment plan or whether the patient has to be returned to the refereeing physician.

Multidisciplinary sessions

Difficult cases

When the patient is considered a difficult case, the patient is reviewed in a multidisciplinary session. In this session present will be the referring physician, DR Posner, the radiologist, neurologist, orthopedic surgeon, some times the physical therapist, the physician assistant the spouse of the patient or others involved. It is not unusual to ask the opinion of the psychiatrist.

The disadvantage we have at the moment is that the clinic is dependent on two key persons. Especially DR Posner is a very important key person. When either of these key persons is on vacation or ill the clinic is almost paralyzed. To remedy this we are recruiting another anesthesiologist and training the neurologist to do most of the procedures. Also we will in the future train more physician assistants.

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Pain Clinic Aruba