Clinical time is spent in the following rotations:
|Block Area & Operating Room (Duke North)||20 weeks|
|Block Area & Operating Room (Ambulatory Surgery Center)||20 weeks|
|Inpatient Pain Service||10 weeks|
|Chronic Pain||2 weeks|
Block Area & Operating Room (Duke North and Ambulatory Surgery Center)
Fellows are assigned 2-3 clinical days per week in the operating room supervised by a faculty member from the RAAPM fellowship. The fellow will perform his/her own peripheral and/or neuraxial blocks under supervision, in addition to managing the case throughout the perioperative period. Elective orthopedic surgery cases (i.e. joint replacement, hand surgery, sports medicine) make up a large proportion of these assignments, but there is a wide variety of other rooms to provide fellows an excellent regional anesthesia experience, such as vascular, breast, plastics, trauma, and general surgery.
The remaining clinical days per week are spent in the preoperative block area. Fellows perform a variety of peripheral and neuraxial blocks for a diverse array of clinical services under the supervision of RAAPM faculty. A typical day for a fellow in the block area would involve performing 10-15 blocks for upper extremity, lower extremity and truncal procedures. Fellows regularly act as consultants for other anesthesiology attendings who are staffed to rooms requiring pre-operative or post-operative block procedures (e.g. TAP, QL, PECS, erector spinae, paravertebral, etc.) Fellows are also called upon to perform rescue blocks in the Emergency Department and Postoperative Care Unit under the supervision of a RAAPM faculty member.
This rotation is split between the main hospital (Duke North) and the Ambulatory Surgery Center. This is designed to expose fellows to the complete breadth and depth of regional anesthesiology clinical practice. Whether caring for elite athletes in the fast-paced ambulatory sports medicine rooms, placing multiple catheters for lower limb amputation, or choosing just the right combination of blocks for a patient undergoing mastectomy and reconstruction, one of the foundational goals of our fellowship is to ensure that there is no clinical scenario, technique or judgment call relating to acute pain medicine and regional anesthesiology that our fellows have not faced as they prepare for their roles as leaders in the field.
Skill in the use of ultrasonography is acquired throughout the academic year. In addition to the techniques related to regional nerve blocks, fellows receive instruction in Point of Care Ultrasonography (POCUS), including trans-thoracic echocardiography, gastric, lung and IVC ultrasound, airway ultrasound and abdominal/FAST exam.
Inpatient Pain Service (IPS)
Fellows spend a total of 10-12 weeks on the IPS where they assume the leadership role on a team of other trainees and mid-level providers, all under the guidance of RAAPM faculty. On this service, the fellow learns to manage acute postoperative pain using a variety of pharmacologic, non-pharmacologic, and nerve block-based techniques and tools. Rounds are conducted daily on a patient population primarily consisting of those with peripheral and neuraxial catheters in situ and those on ketamine or lidocaine infusions. This includes patients on the surgical floors, the critical care units and the pediatric floors. The management of new acute pain consults and the placement of peripheral nerve or neuraxial blocks is a substantial part of the IPS experience.
Chronic Pain Rotation
Pain doesn’t respect the strict boundaries of “acute” and “chronic” and there is a lot to be gained by managing patients who have longstanding pain needs. Fellows spend two weeks seeing new consults for chronic nonmalignant and cancer pain and using many of the tools learned in the care of acute pain management to help ease the suffering of these patients. This inpatient rotation is done at Duke North.
Structured Educational Program
Much of the learning in regional anesthesiology and acute pain medicine occurs through observation, hands-on instruction and mentored practice at the bedside. However, the RAAPM fellowship at Duke prides itself on a strong foundation of structured learning opportunities. These include:
- Simulation: Duke’s state-of-the-art Human Simulation and Patient Safety Center is internationally recognized for its educational innovation. Fellows participate in multiple high-fidelity simulation courses throughout the year with a particular emphasis on anesthesia crisis resource management of rare, critical scenarios. One simulation course focuses on regional anesthesia and acute pain management, including the diagnosis and management of complications. Another course is a joint simulation course with other anesthesia subspecialty fellows to consolidate both technical and non-technical skills.
- Tuesday Afternoon Seminar Series: Every Tuesday afternoon from 4:30-5:30 pm is protected time for the fellows to take part in a seminar, lecture, or problem-based learning discussion. These sessions are always led by a RAAPM faculty member and tend to focus on topics that are best suited to a discussion or classroom type environment. Examples include:
- Regional anesthesiology and outcomes
- Peripheral nerve injury: etiology and prevention
- Setting up a regional anesthesia and acute pain service
- Regional anesthesia and trauma
- Local anesthetic systemic toxicity
- Management of neurologic deficits
- Pharmacogenomics and acute pain medicine
- Sonoanatomy Scanning Sessions: These hour-long hands-on sessions run throughout the first half of the fellowship year and are designed to familiarize the fellow with the sonoanatomy of the entire body, with particular emphasis on neurologic, vascular and musculoskeletal structures. Each of the ten sessions tackles a separate region of the body and focuses on identification of relevant structures to safely perform various peripheral and neuraxial blocks, vascular access procedures, and musculoskeletal diagnostic and interventional procedures.
- Journal Club: Every four weeks one of the fellows presents a recently published article that is of interest to him/her. The goal of this series is both to acquire skills in critical appraisal of the literature, and also to educate the group about new and interesting studies; fellows often select articles that highlight novel or controversial topics and are assigned a faculty mentor to help guide them through the process of evaluating the study methodology. Fellows also participate in a joint journal club with fellows from outside fellowships (Mayo Clinic Jacksonville, University of Florida Gainesville, and Penn St.)
- Departmental Fellowship Seminar Series: Every Monday afternoon the fellows attend an educational lecture series that focuses on more general topics, such as leadership, statistics, or quality improvement. This affords the fellows an opportunity to learn and discuss these topics with fellows from other anesthesiology subspecialties.
Scholarship and inquiry are part of the foundation of the fellowship. Fellows are trained in research methodology including the generation of a hypothesis, statistics and the creation of study design. Fellows receive formal training in the use of tools such as the REDCap (Research Electronic Data Capture) survey and database application, the Duke electronic IRB system, and the DEDUCE (Duke Enterprise Data Unified Content Explorer) database query tool, which allows users to generate research questions and electronically search through millions of Duke patient records to obtain data. By the end of the fellowship year, fellows are expected to have presented their work at national meetings as well as the Duke Academic Evening and to have submitted at least one paper for publication in a scientific journal.