EFIC

The fellowship started on January 11, 2010. On the first day, after I was instructed by the people at the personnel department about the rules and regulations at the hospital, about my status as a “hospitant” – guest physician and after I signed the necessary confidentiality form, I was introduced to the ZISOP administrative assistant. She took me around the department and introduced me to Prof. Rudolf Likar. Prof. Likar introduced me to the staff physicians working at the moment and explained the daily routines and tasks in the unit.

My stay at the clinic is very well organized. I start each morning at 7.15 and work until 14.00. Every morning there is a staff meeting of the physicians to discuss the daily program and the patients expected. Thus I get informed about forthcoming interesting cases and manipulations during the day so I know where to be at a given time. The work day ends with another meeting discussing the patients examined, their treatment plans and the need for additional diagnostic work up and follow up. Thus I have the chance to gain even more experience in how the pain clinic works, as well as to get ideas about how to treat more difficult cases or how to arrive at a diagnosis, as this is a collective discussion.

Every day I am attached to an attending physician and I take part in the interviews and examinations of patients. It is possible for me to review and discuss with the physician the previous treatments, their efficacy, the possibility for and expected results from a change in the treatment plan. We discuss also the results of relevant laboratory or image tests and their interpretation in connection to the given patient’s condition and treatment. Professor Likar, all of the physicians in the department and the nurses too are very supportive, they always answer my questions (although most of the time they are very busy), they go through the documentation together with me and explain why something was done, what is the practice in the clinic about a given disease or a manipulation, or how a decision about a specific procedure was reached. I am allowed also to examine the patients, so to see and feel the signs of specific conditions as well as to ask the patients additional questions about different symptoms, effects or side effects of various drugs or interventional procedures.

The learning opportunities at the pain clinic at LKH Klagenfurt to my mind are enormous. On the one hand there are a lot of patients carrying the full spectrum of possible painful conditions, and on the other, the center offers a great variety of treatment options as it is a truly multidisciplinary one. This gives me the opportunity to learn and to see a lot over a comparatively short period of time. First I get more information about the combinations of different medications, their synergy in a given disease entity and how to create suitable combinations avoiding possible side effects or how to monitor them. Second I am able to follow the path of each individual patient carrying a specific painful condition through conservative treatment, physiotherapy, education, psychological counseling and invasive procedures, how each subsequent step is planned and implemented. Last but not least I learn about the arrangement of suitable follow up periods, reevaluation of treatment results and switching to different strategies, how to be patient about the outcome, to explain and to look constantly for new possibilities to alleviate pain.

As I have pointed out in my application form, in my country – Bulgaria, currently there is no such well-structured pain unit so, especially from a practical point of view, there is not a single place where I can learn procedures which are so important in the comprehensive pain management today. I think that this is one of the most important tasks for me during my stay at LKH Klagenfurt. I try to witness most of the manipulations that are done every day at the department, to ask questions on practical issues so that I can understand better the techniques used.

As I have passed a basic course in musculoskeletal ultrasound diagnosis and as I plan to take an intermediate one I am particularly interested in the procedures done under ultrasound control. One that I am sure I will start to do after I am back in Bulgaria is the block of the median brunch of the dorsal ramus (facet block). As at the moment I am working also in a Rheumatology Clinic I can use this technique both for diagnostic and therapeutic purposes to the numerous patients with lumbar osteoarthritis. The ultrasound guided block to the sacroiliac joint is another procedure I think I will master during the time of the fellowship, as there are several such blocks performed every week. This knowledge will also be of great use in treating pain originating from these joints in my rheumatological patients. Another procedure which I will start to perform in my practice is the block of the supraspinatus nerve. I think (and I have already seen it work several times) it will be very useful in refractory shoulder pain, especially if combined with subacromial or intra-joint infiltration, as well as for restoring the range of motions in the frozen shoulder. To name just one more procedure which I think will be of much use for my patients with low back, sacral or coccyx pain and which I will learn to practice during my stay – the caudal block.

One big challenge in my everyday practice are patients with soft tissue pain like myofacial syndrome, various regional painful disorders or fibromyalgia. In Bulgaria I think these patients are somewhat neglected while they are in real pain. Now I have the chance to compare my experience and to learn more about the trigger point injections and other infiltration techniques, as well as about conservative treatment modalities, which I think will be of great use in my future practice. As I have already pointed out, these patients constitute a big part of all patients attending a rheumatology practice and improving their treatment and alleviating their pain and restoring their normal everyday life will improve considerably the quality of my work. That is why I try to be around and gather experience asking, looking and palpating whenever such a patient comes in the pain clinic.

I have also learned in the pain ambulatory some other small but useful practical procedures such as regional subcutaneous infiltration for postherpatic neuralgia or scar pain.

In general I have been deeply interested in how to treat pain especially musculoskeletal and neuropathic one and now I have the chance to test my knowledge – both theoretical and practical. I have the opportunity to compare my practice and to learn a lot and hopefully bring back many new methods to treat my patients and to share with my colleagues in Bulgaria.

AGENDA

15-18/09/2010 IX CONGRESSO NAZIONALE AIUC

22-25/09/2010 VIII Congresso Internacional de dolor - VIII Congreso Peruano del Dolor

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