PAIN MODULE HANDBOOK
Practicalities since COVID/How to get the most out of your module in the covid climate:
- Plan and email ahead; virtual clinics are-new normal; – mostly telephone but exceptionally face to face or video consults.
- A number of consultants are doing pain clinics remotely. Please email Dr Love-Jones, Dr Murli Krishna, Dr Kat Ng and Dr Shelley Barnes well ahead in time to join them in their remote sessions.
- Your rostered sessions in the pain clinic should be visible on CLW (starting 8th March 2021). A detailed rota of all activity is displayed outside the nurse’s office and the secretaries office as well. This information is also there on page 8 of this handbook. Please join the consultant session marked in bold on the rota.
- A good mix of clinics and interventional work takes place at NBT pain clinics during the week.
- Please check your CLW or template rota displayed in the pain clinic and join in with the allocated session /session of your choice. If for some reason you are unable to attend your rostered session (for example consultant away) please join an alternate session in pain clinic/with the pain management team
- If you wish to partake in any of the additional activities such as psychology or acupuncture your best bet is to email the psychologists/pain nurses and seek guidance, then let the consultant (whom you were originally allocated to) know of your plan.
- All aspects of our pain management service are currently remote. This includes Selfmanagement programmes, Pain management programmes, Back-pack programme, individual psychology and physiotherapy sessions, compassion and exercise group. The team uses attend anywhere software but gets better connection with Zoom. Telephone consults are also a regular feature depending on patient preference.
- It may also be worth emailing/contacting the nurses (Ext: 47379), physiotherapists, psychologists as they may be working remotely or be present in Gloucester house– in which case you could ask to sit with them whilst learning.
- The Pain Management team, after getting permission from patient, may ask you to join the conference call while they assess the patient virtually.
- Patients are risk assessed for COVID and for any medium/high- risk patients- Nurses discuss with consultants and take appropriate decisions for alternate managements if possible and use of steroids in interventions.
- For core and intermediate modules, you may be asked to do e-Pain module (This is only required in scenarios such as an upsurge in Covid cases leading to suspension of all pain clinic activity). In addition to a logbook, intermediate CUT sign off requirements are 1 each of ACEX/CBD/DOPS. A minimum of 20 sessions with a mixture of acute, chronic and cancer pain are required. In addition to a logbook, essential requirements are 1 each of ACEX/CBD/DOPS for a CUT sign off
- Higher pain trainees require 20 sessions with a good mix of acute, chronic and cancer pain cases along with 1 each of ACEX/CBD/DOPS and an ALMAT in addition to the logbook for a CUT sign off.
- Higher and Advanced pain trainees should register with The Faculty of Pain Medicine for recognition of their training time.
General information (For all stages of Pain training)
The pain clinic at North Bristol NHS trust is in Gloucester House marked on site map page 1 of this Document. Entrance to this site is by obtaining a visitor access card from the A& W reception desk.
The clinic can be accessed through the main entrance via Gloucester house car park on Dorian way.
The visitor pass MUST be returned after your week’s placement. The doors to Gloucester house may not be open until 08:30 at the earliest and leads straight to the AWP reception desk from where a visitor pass can be obtained for accessing Gloucester house. The pain clinic reception is on the other side of AWP reception desk. Annie at reception is extremely helpful and will let you in should there be issues with obtaining an access card. Morning clinics start at 9.00 and afternoon clinics start at 13.30.
Please dress smartly and do not wear scrubs to the clinic.
The pain clinic activity is quite varied and includes general pain clinics, joint pain-neurosurgery clinics, Neuromodulation MDT, Monthly complex pain MDT, Craniofacial pain clinics/MDT, Pelvic pain MDT, Spine MDT and Palliative care MDT. In addition, there is a busy pain management team of physiotherapists, psychologists, and occupational therapists. Our specialist nurses run TENS clinics, provide acupuncture treatment and Qutenza (Capsaicin 8% patch) clinics. We also provide various fluoroscopy guided pain interventions in the fluoroscopy suite situated on level 1, gate 18 and some of the commonly performed procedures have been detailed below. Spinal cord stimulation work and cervical interventions take place in Brunel theatres. At Gloucester House, we do Botox treatments for chronic migraine and perform ultrasound guided interventions such as peripheral nerve blocks and caudals. We rarely manage patients with cancer pain as these are mostly dealt with by palliative care. Arrangements can be made with the palliative care team to attend complex palliative pain MDT. The team prefers if they are made aware of this well in advance as they receive a lot of shadowing requests.
Please touch base with the Advanced Pain Trainee (if there is one) on arrival or the week before if you are keen. Alternatively, I would hope this document is comprehensive enough to help you with your week’s placement. In case of any doubts, please do not hesitate to email Elaine.Musgrove@nbt.nhs.uk or ring the nurses’ office (47379) for any clarifications.
Please refer to 2010 curriculum for obtaining the required competencies. A link to the curriculum at the appropriate stage of training has been provided on page 14 of this handbook. Intermediate trainees are not expected to see patients or perform procedures unsupervised but if you are interested and enthusiastic about pain, please discuss this with Dr Chhabra. You are required to keep a logbook on LLP. The WPBA’s should be taken from a good mix of consultants and the CUT form submitted promptly once competencies are done.
Self-rostering trainees should check on clwrota or with Anaesthetic secretaries/ Anaesthetic rota coordinators to ensure they do not overlap with other trainees rostered for clinic that week.
Specific Information more relevant to Advanced Pain Trainees (but useful for everyone to know!)
- Please email Dr Chhabra well in advance so a meeting can be organised within the first 2 weeks of your start of APT year.
- On arrival, contact Kate.Roche@nbt.nhs.uk to obtain permissions for pain clinic shared folder (for access to letters, guidelines, audit data etc), winscribe author login for dictating letters, mail tray in pain clinic office for mail and letters to sign and Gloucester house access.
- Please ensure you have a working smart card for access to Lorenzo, Synapse, Bluespier
- Please refer to the FPM website for an in detail read of competencies expected for a CUT sign off. In summary this includes 4 ACEX (1/ Quarter), 4- CBD (1/Quarter), 6 DOPS and a satisfactory MSF within the first 6 months of APT year. MSF may need to be repeated only if the first one has highlighted concerns / areas requiring improvement. Quarterly assessments with the faculty tutor are an essential aspect of APT year.
General pain clinics
- Most clinics include new and follow ups patients.
- Once your confidence has increased in initially assessing patients and later devising a provisional management plan, you may be able to assess a patient.
- Please dictate letters at the end of session/ day so you do not miss out on clinic activity such as assessing or observing more patients during the same session. Letters are typed by respective pain consultant’s secretaries. Typed letters would need to be checked on Lorenzo before dispatch/ sign off. Please confirm with individual consultants that they are happy for letters to be dispatched (This is of relevance when starting out your APT year).
Joint Pain and Neurosurgery (JPNS) clinics/ Quarterly MDT
JPNS clinics (Alternate Monday mornings 08:00 am) are jointly run by Dr Love- Jones and Mr Adam Williams, consultant neurosurgeon. Pain patients referred for SCS work are assessed jointly and decisions made. There is quarterly neuromodulation MDT’s on a Tuesday morning from 08:00 to 10:00 am when all neuromodulation aspects of pain service are discussed. Neuromodulation nurses Rose and Nicki are a regular feature on these sessions/ MDT’s.
Procedure/intervention lists
Interventions that require fluoroscopy take place in Fluoroscopy suite, level 1, gate 18. Spinal cord stimulator trials are in level 2 or level 3 theatres. Please check with neuromodulation nurses beforehand the location of theatre activity as it can vary with availability of theatre space.
ICE X-ray requests must be submitted for all fluoroscopies. Copies of the theatre lists can be found in the nurses’ office. There are other procedures including ultrasound guided injections, Botox, intrathecal pump refills and IV infusions which are usually done at Gloucester House treatment rooms. These lists are printed weekly and displayed in treatment room 2.
How procedure lists run
- Occasionally, symptoms may have changed, and it is important to re-assess this as a different procedure may become more appropriate. Take informed consent.
- Mark the side/site if applicable.
- Team brief approximately at 0815 (or 13:15)
- 1st patient 0830 /13:30 (after radiographer presence)
- WHO checklist is mandatory.
- Patients need cannulas for cervical procedures, and we do not offer sedation for any of our procedures.
- Certain procedures require a wheelchair/ trolley to leave the procedure room as leg weakness can occur with e.g., root sleeve injection.
- Document as per consultant directions and preference.
- Resuscitation trolley is on corridor outside theatres level 2/3 and in the reception area of fluoroscopy suite. Anaphylaxis drugs and intralipid® are kept and regularly checked by pain nurses.
TENS/Acupuncture/Qutenza
These clinics are nurse led. These currently take place periodically in the group room or therapy room of Gloucester house. 6 sessions of acupuncture therapy are provided on the NHS and if there is good/reasonable benefit, patients are advised to continue this privately if this is something they wish to consider. Top up Acupuncture treatment is no longer provided.
Qutenza (Capsaicin 8% patch) applications are done by nurses but patients are assessed before they proceed with treatment. If there is sufficient benefit, this can be repeated at 6 monthly intervals.
Pain Management Team
We are blessed to have an extensive Pain management team working with us – to provide the patients with the practical tools towards becoming more functional in their daily lives.
Patients referred to the pain management team for a pain management programme (10-week course) are initially invited to an introductory information session (currently remote). At the end of this session, patients decide whether they wish to proceed or not and then attend an assessment appointment with one of our pain psychologists. The group programme is run at Southmead and Cossham. There are separate local arrangements for patients referred from Weston-Super-Mare. Some of the pain management work involves pain education/ pain pathways, exercises, Tai Chi, Pacing, self-compassion, sleep hygiene, relaxation/breathing exercises.
Psychology
Please email our Lead psychologist Dr Hazel O’Dowd (Hazel.O’Dowd@nbt.nhs.uk) if you wish to arrange to sit in with her for a session. Hazel also has a specialist interest in assessing patients for neuromodulation in addition to general assessments.
There are other Pain psychologists working within the team, who would be happy to accommodate requests for observing sessions should you be interested.
Physiotherapy/Occupational Therapy
We usually advise patients that mobility and strengthening are one of the most important aspects of self-management, and that performing an injection is not a cure but to help give them a ‘kick start’ to engage with their exercises.
Pain physiotherapy is extremely important in giving the patient confidence with how far to push themselves (most will tell you physio makes their pain worse, so they stopped it!).
These sessions are run by specialists’ physios and OT who are all a part of the pain management team. Melanie Berry is the lead for back-pack programme which is specifically geared for helping patients with axial pain.
Other specialty outpatient clinics
Please contact the team and consultants directly to attend sessions. This is especially important for advanced pain trainees, so they are able to cover the broad aspects of the curriculum.
Craniofacial Pain Clinics/MDT- Mr Nik Patel (Nik.Patel@nbt.nhs.uk Neurosurgeon), Gaurav Chhabra (Pain Consultant) and Luke Bennetto (Luke.Bennetto@nbt.nhs.uk, Neurologist) are a team of clinicians having joint monthly MDT for complex head and face pain. This is organised over MS teams or face to face in Oldbury room, neurology office. Dr Bennetto runs clinics in BRI Monday mornings, BEH Thursday afternoons (IIH) and Brunel Gate 36 Friday afternoon. Mr Patel does complex functional craniofacial pain interventions usually on a Monday in theatre 7
Neurology (peripheral nerve) - James Stevens (James.Stevens@nbt.nhs.uk ) Neurology with interest in Peripheral Nerve disease, Peripheral Nerve clinic Friday morning Gate 36.
Rheumatology – Contact Dr Samir Patel, Consultant Rheumatologist, (Samir.Patel@nbt.nhs.uk) for sitting in clinics usually on a Friday afternoon at Gate 5
Rehabilitation medicine – Dr Angus Graham (Angus.Graham@nbt.nhs.uk), Rehab consultant has clinics on alternate weeks on Monday afternoon. He also runs an Intrathecal baclofen refill pump service which is supported by neuromodulation nurses on Thursday mornings.
Palliative care –We rarely have patients with cancer pain as these are mostly dealt with by palliative care. Palliative care – ward rounds in UHB and Wednesday at St Peter’s Hospice with Dr Nilesh Chauhan (nilesh.chauhan@uhbristol.nhs.uk).
NBT hospital Palliative care Team
They are able to support trainees shadowing although usually arrange this for 1-2 days/ week at a time (depending on staffing). As they receive a lot of shadowing requests from different specialities the earlier you contact them, the better. Currently shadowing is being co-ordinated by Kerri Knapp (keri.knapp@nbt.nhs.uk), one of their clinical nurse specialists and I would suggest you contact her directly with your requirements and dates.
St Peter’s Hospice Please contact Dr Anjali Mullick directly with your request.
Anjali.Mullick@stpetershospice.org
In addition, there is a monthly complex pain MDT (1st Wednesday of every month 08:30 AM) rotating between St Peters Hospice and the BRI which you may find helpful/informative to attend. This is led/organised by Dr Bethany Wright
Bethany.Wright@stpetershospice.org and Dr Nilesh Chauhan Nilesh.Chauhan@UHBristol.nhs.uk
Inpatient pain programme – Run nationally at Royal Mineral Hospital, Bath and will require time away to attend (2 weeks for CRPS programme, 4 weeks for residential PMP). Please contact Cath Brown (Specialist Physio, Catherine.brown26@nhs.net) to organise. Honorary contract is a requirement.
Gynae pelvic pain – Dr Kat Ng, Pain Consultant and Gynaecologists Dr Jessica Preshaw
(Jessica.Preshaw@nbt.nhs.uk) / Dr Tracy-Louise Appleyard (tracy-louise.appleyard@nbt.nhs.uk) have an interest in pelvic pain. Please liaise with Dr Ng/ Dr Preshaw early on should you be interested in pelvic pain as a subject. There are Endometriosis clinics on alternate Monday afternoons, Tuesday mornings and pelvic pain clinic on Thursday morning. There is work going on with the pain psychologists and pelvic health physiotherapy on developing a dedicated pelvic pain management programme. This would be linked to the pelvic pain MDT as one of the avenues for patients.
Audits and Quality improvements projects: Please discuss with Dr Love-Jones, Clinical governance and pain clinic lead, should you be interested. There are several research projects running in the department on spinal cord stimulation.
Formal teaching
APT study days organised by London Pain Training Advisory Group (LPTAG) – monthly which can be attended in person or via GoToMeeting website/app.
https://www.rcoa.ac.uk/faculty-of-pain-medicine/events/events-calendar
APT Study days organised by North East – accessible via GoToMeeting
FFPMRCA Exam Tutorials at RCOA and FFPMRCA viva courses – Organised by Leicester
Upon registration with the faculty, the Pain trainee rep is made aware of you and hopefully would add you to the trainee WhatsApp group and their mailing list.
Pain clinic Staff
1.Dr. Sarah Love-Jones, Lead for Pain clinic and Neuromodulation sarah.love-jones@nbt.nhs.uk
Secretary: Sue Harvey (Susan.Harvey@nbt.nhs.uk # 47364)
2. Dr. Murli Krishna Murli.Krishna@nbt.nhs.uk
Secretary: Jo Creedy ( Jo.Creedy@nbt.nhs.uk # 47363)
3. Dr. Gaurav Chhabra (Regional Advisor and Faculty tutor/ CUT sign off)
Gaurav.chhabra@nbt.nhs.uk
Secretary: Elaine Musgrove( Elaine.Musgrove@nbt.nhs.uk #47351)
4. Dr. Kat Ng Kat.Ng@nbt.nhs.uk
Secretary: Karen Durrell ( Karen.Durell@nbt.nhs.uk #47360)
5. Dr. Shelley Barnes Shelley.Barnes@nbt.nhs.uk
Secretary: Irene Burdock ( Irene.Burdock@nbt.nhs.uk # 47362)
Pain clinic Manager: Kate Roche ( Kate.Roche@nbt.nhs.uk #47361)
Pain clinic Reception: Elizabeth Davis ‘ Annie’ ( Elizabeth.Davis@nbt.nhs.uk #47369)
Pain clinic Nurses: # 47379, 47380
Rose Marriott, Senior Sister, Rose.Marriott@nbt.nhs.uk
Nicola Wade, Sister, Nicola.Wade@nbt.nhs.uk
Pain Management team
Marie Goodman (Admin 47357 ) Marie.Goodman@nbt.nhs.uk
Psychologists
Hazel O’Dowd, Lead Psychologist, Hazel.O’dowd@nbt.nhs.uk
Physiotherapists
Peter Gladwell, Lead- Senior Physiotherapist Peter.Gladwell@nbt.nhs.uk
tables here
Pain procedures at NBT Pain clinic
Acupuncture—Done by pain clinic nurses specialised in this technique
TENS machine trial- Nurse led clinics
Qutenza treatment- Nurse led clinics
Botox for chronic Migraine
Ultrasound and Fluoroscopy guided Caudal epidural.
Fluoroscopy guided Cervical epidural.
Cryotherapy to suprascapular nerve and lumbar area
Facet joint injections- Cervical/Thoracic
Radiofrequency denervation ( RFL) at cervical and Lumbar levels
Fluoroscopy guided cervical and lumbar nerve root blocks/ Transforaminal Epidurals
Fluoroscopy guided Cervical and lumbar nerve root Pulsed RF
Fluoroscopy guided Interlaminar epidurals
Ultrasound guided Femoral inguinal nerve block/ Pulsed RF
Ultrasound guided Transversus abdominis Plane Block/ Pulsed RF
Ultrasound guided Rectus sheath Block/Pulsed RF
Ultrasound guided ilioinguinal and ilio hypogastric Block/ Pulsed RF
Ultrasound guided Greater Occipital nerve block/ Pulsed RF
PENS treatment to Greater occipital nerve/ Suprascapular nerve/ scar tissue
Ultrasound guided Suprascapular nerve block/ Pulsed RF
Ultrasound and fluoroscopy guided genicular nerve block/Pulsed RF
Ultrasound/Fluoroscopy guided Genicular nerve block/ Pulsed RF
Ultrasound guided intercostal nerve blocks
Ultrasound guided Joint/Bursa Injection
Ultrasound guided Trigger point injections
Ultrasound guided Refill of Intrathecal pump
Fluoroscopy guided Insertion of Spinal cord stimulator/ Removal of SCS in Gloucester house
Books
- Oxford Handbook of Pain Management
- Oxford Pain Management Library
Acute Pain Cancer-related breakthrough pain Chronic Pain Back pain Opioids in
Cancer Pain Opioids in Non-Cancer Pain Pain in Older People Migraine and other
Primary Headaches Neuropathic Pain
- Key Topics in Chronic Pain
- Case studies in Pain Management by Alan David Kaye, Rinoo V. Shah
- Case studies in Neurological Pain by Claudia Sommer & Douglas W Zochodne
- Spinal Interventions in In Pain Management by Karen Simpson, Ganesan Baranidharan, Sanjeeva Gupta