Pain medicine: taking it to the streets
IVORY TOWERS AND REAL WORLD REALITIES – DELIVERING PAIN MEDICINE WITHOUT THE FELLOWSHIP
BT Spain
Royal Darwin Hospital, Darwin, NT
Pain Medicine is no different to other medical specialties in that there is a mal-distribution of practitioners relative to the population and service need in rural areas. Whilst there may be no easy access to Fellows of the Faculty of Pain Medicine (FFPM), other Specialists with some training in Pain Medicine can deliver good quality care with the support of FFPM, albeit remotely.
A day in the life of a rural Anaesthesia Specialist may see consultations calling on skills in Anaesthesia, Intensive Care, Pain Medicine, Administration and even Hyperbaric Medicine. Delivery of care at an appropriate level requires commitment to knowledge acquisition, communication with a variety of supportive practitioners in related fields and a dash of courage for some procedural aspects of medical practice.
Darwin is more than 3000km from the next tertiary care centre. It services a population of 150,000 in the TopEnd of Australia, over an area of close to 10% of Australia’s land mass. The population is 25% indigenous and has a younger demographic than Australia’s average. It is one of the last bastions of the true “generalist” in many endeavours of medical practice, including surgery and internal medicine amongst others.
The Culture and politics of the NT have meant that development of multi-disciplinary pain clinics has been delayed until very recently. In conjunction with this, there have been widespread problems with substance abuse and again until recently they have not been well addressed. The margins between chronic pain management and substance abuse have at times been more blurred than in most jurisdictions.
Tasks that have needed to be addressed in the absence of a FFPM have included:
- Reduction of high dose opiates in patients with Chronic non-malignant pain
- Refilling of implanted intrathecal pumps
- Insertion of tunnelled Intrathecal pumps for malignant pain
- Assessment of some new chronic pain patients
- Some procedural tasks in conjunction with other practitioners doing pain medicine consultations eg. Rehabilitation Physicians
Experience has shown that for whatever task a department takes on, there need to be at least 4 staff members who are willing to be involved with the task for it not to be too onerous on any individual.
There need to be clear lines of communication with more experienced practitioners. In our example, the support from the Chronic Pain clinic at the Royal Adelaide Hospital has been invaluable. This has been in both a structured visit approximately quarterly and ongoing telephone support on an as needed basis.
Close liaison with excellent Radiologists has meant that many of the requested procedures can be performed in Radiology when the caseload is insufficient for maintenance of a fully equipped “block session” or the skill of individual practitioners may be higher for some procedures such as those needing radiological guidance.
Overall a good quality of care can be maintained with sporadic visits from a FFPM, with day to day management from a related specialist with some training in Chronic Pain such as Anaesthesia or Rehabilitation Medicine.
Time of Presentation
Saturday 13 May 2006 - 1330-1500
