Hamilton anaesthesiologists have been at the forefront of pain management in Canada for over 25 years, with a substantial commitment to pain management in a variety of clinical settings. The first multi-disciplinary pain clinic in Ontario and possibly Canada, (with Dr J.B. Forrest, Anaesthesia and Dr. Eldon Tunks, Psychiatry along with other medical specialists, physiotherapy and occupational therapy) was started at the McMaster Medical Center in 1972, and the first Acute Post-operative Pain service in Canada was formed in 1988 by Dr. Kari Smedstad, Dr. Norm Buckley and members of the McMaster Medical Center Department of Anaesthesia. McMaster University and its associated teaching hospitals are recognized internationally for their excellence in pain management.
Anesthesia Residency Program Pain Rotation
Anesthesia residents rotate for a period of one month at the Pain Management Centre at the General site of Hamilton health Sciences Corporation. There is an opportunity to see significant numbers of chronic pain patients and perform both initial consultations and follow-up assessments. Residents are expected to become comfortable with the basic interventions including stellate ganglion block and epidural steroid injection particularly for acute disc prolapse, as well as become familiar with the pharmacological management of chronic pain problems.
Residents will be responsible for some of the management of acute post-operative pain problems through their regular Operating Room and on-call rotations. In addition while at St. Joseph’s Hospital they are responsible for assisting in the coverage of the Acute Pain Service while on obstetric rotations.
Acute Pain Management
All Hamilton hospitals have an Acute Pain management Service (APS), focused primarily on post-operative pain management and offering PCA, epidural and regional techniques. These services operate within the Hamilton Health Sciences at the General, Henderson and McMaster sites, and at the St. Joseph’s Health Care Charlton Avenue site. Anaesthesia staff physicians working with nurses drawn from the Post Anaesthesia Care Units at the MUMC and Henderson sites provide APS coverage; at the General site an Advance Practice Nurse Clinician provides daytime Mon to Fri coverage with physician support. An Advance Practice Nurse Clinician with physician support runs the St. Joseph’s Health Care APS.
Chronic Pain Management
Hamilton Health Sciences (HHS)
The merger of Chedoke-McMaster Hospitals with the Hamilton Civic Hospitals in 1996 created the largest full service hospital corporation in Canada. As part of the merger of the previously separate anaesthesia departments, the anaesthesia based chronic pain clinics that had been provided as individual clinic operations by the physicians involved were combined into a single location at the General Hospital site, The Pain Management Centre, as of spring 2002.
This site permits all of the anaesthesia-based providers to work out of a single location to facilitate referrals from the community, and also facilitate training of residents and fellows. Hamilton Health Sciences is supporting this consolidation in the spirit of its commitment to supporting academic as well as clinical activities, and improving the services that can be offered by the clinical Department of Anaesthesia. The consolidated clinics have patient visits in excess of 12,000 per year, with approximately 3,500 new referrals and the remainder follow-up visits. There are facilities for interventional pain management with a procedure room, radiology support 9 hours per week and an appropriate recovery space.
Ten members of the anaesthesia department currently offer chronic pain management services ranging from office type consultation and minor nerve block, through a whole range of major nerve block procedures including implantation of intrathecal devices for cancer pain management; acupuncture is also offered, and a course in acupuncture for pain management is taught by members of the Department. Dr. Ammar Gilani, a member of the Neurology Department, joined the clinic in 2005 to practice pain management in addition to his neurology practice. His particular interest is headache, and he offers Botox treatment.
Behavioural Medicine Centre
With the recruitment of Dr. Arthur (Arnie) Cott to the Department of Anaesthesia several years ago, the Behavioural Medicine Centre has added a new dimension to the range of services and educational possibilities available to anaesthesia trainees. This long-standing (25 years) clinical organization focuses on interdisciplinary management of complex clinical cases; frequently a major component of the problem is pain management, but in all cases the problems have extended into many aspects of the patient’s life. The theoretical basis of the approach to management involves consideration of not just medical but psychological, psychiatric, employment and interpersonal issues; the goal of treatment is to bring all aspects of the problem under control through the use of extensive education and field-based interventions with the patient.
St. Joseph’s Health Care
Drs Larry Kahn and Jim McChesney provide pain management services through clinics at the East End Health Centre of St. Joseph’s Hospital Hamilton. They offer consultation, peripheral nerve blocks and interventional treatments also. Dr. Kahn in particular has expertise in the insertion of epidural stimulators and Intrathecal Drug Delivery Systems. Presently these latter services are only available through the support of third party payers (e.g. WSIB and Insurance coverage).
The Pain Management Centre (PMC), with the support of unrestricted educational grants from a variety of interested pharmaceutical companies, offers monthly pain management seminars at the PMC. A mixture of local and guest speakers, including pain fellows and graduate students, present these seminars. These seminars take place on the fourth Thursday of the month. Click here to access the Archived Educational Presentations.
A pain management fellowship is offered, usually for two fellows each year although occasionally a third position may be available. The fellowship is usually for a period of one year. Fellows work 2-3 days per week on average in the regular operating rooms and 2-3 days in the Pain management Centre. There is an extensive experience of clinical opportunity available. In addition it is expected that fellows will complete some academic activity of significance during their fellowship, such as designing and carrying out a clinical study. Because of the time required for initial development of such studies it is often best to correspond in advance to develop an outline and begin the process of obtaining Research Ethics Board approval etc in advance of the start of the fellowship.
The consolidation of a large volume of pain management services into a single site, and the addition of a unique approach to managing complex cases, is intended to provide a clinical `critical mass’ as the basis for further education and research in the field of pain management. There have now been pain fellows consistently for the past several years, and a core curriculum based on that developed by the International Association for the Study of Pain (IASP) is being developed.
The DeGroote Centre for Research and Care in Central and Thalamic Pain was created in 2005. This centre is contributing to the development of research activity in pain particularly basic science in pain mechanisms, and also clinical research in the particular problem of central post-stroke pain. Discussions are presently underway also towards developing a strategic plan for pain services in the region with Hamilton Health Sciences playing a significant role on the clinical service side with pain declared as a part of the strategic plan for the organization.