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blackadder

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I'm a med student finishing up my 3rd year and pain medicine is high on my list of possible specialties (probably through PM&R or Anesthesia). However, how feasible is it to practice pain without using fluoro/ct (ie avoiding radiation) for injections/procedures? I know that the use of U/S guided procedures has come along way and continues to grow, but would I be shutting myself out of more invasive spinal procedures and the like if I only used U/S? In your practice, how often do you actually do procedures where the standard of care requires imaging with fluoro? How much would I be hurting/limiting my practice and having to refer patients to other pain docs to have these fluoro-only procedures done?

Thanks in advance for any help/advice.
 

Aether2000

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Agree with DF. Some anesthesiologists practice substandard care blind epidural steroid injections or try to use ultrasound for guidance (cannot determine either vascular uptake or depth due to echogenicity of the lamina).... Do the right thing and get fluoro if you want to do things the proper way.
 
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jsaul

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no flouro, no pain medicine.....

If you do not want to use flouro then don't go into pain
 

knoxdoc

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Without fluoro guided injections, you would be limiting yourself to a practice comprised of Rxing PT and narcotics. Do a fellowship.
 
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I'm a med student finishing up my 3rd year and pain medicine is high on my list of possible specialties (probably through PM&R or Anesthesia). However, how feasible is it to practice pain without using fluoro/ct (ie avoiding radiation) for injections/procedures? I know that the use of U/S guided procedures has come along way and continues to grow, but would I be shutting myself out of more invasive spinal procedures and the like if I only used U/S? In your practice, how often do you actually do procedures where the standard of care requires imaging with fluoro? How much would I be hurting/limiting my practice and having to refer patients to other pain docs to have these fluoro-only procedures done?

Thanks in advance for any help/advice.
If you do PM&R, I think you could could have a successful practice if you become proficient in US and EMG. I agree with the other posters that you want to stay away from injecting the spine and this would be considered a "non-interventional" practice.

But if you do a pain fellowship, you will either get over your fluoro fears quickly or you will drop the fellowship. No such thing as a pain fellowship without fluoro. It's a key component in training no matter what discipline you come from.
 

emd123

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I'm a med student finishing up my 3rd year and pain medicine is high on my list of possible specialties (probably through PM&R or Anesthesia). However, how feasible is it to practice pain without using fluoro/ct (ie avoiding radiation) for injections/procedures? I know that the use of U/S guided procedures has come along way and continues to grow, but would I be shutting myself out of more invasive spinal procedures and the like if I only used U/S? In your practice, how often do you actually do procedures where the standard of care requires imaging with fluoro? How much would I be hurting/limiting my practice and having to refer patients to other pain docs to have these fluoro-only procedures done?

Thanks in advance for any help/advice.

Why the fear of fluoro? Wear lead, lead glasses and rock on. Interventional rads gets exposed, interv cardiology, too. Each specialty has its occupational hazards. Surgeons: needle stick (HIV hepc), psych and ER (assaults by crazy patients), DERM (could be splattered by flying zit juice; seen Animal House?). Live fluoro is what gets you in trouble, ie, interv rads and cards.
 
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Jcm800

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I'm a med student finishing up my 3rd year and pain medicine is high on my list of possible specialties (probably through PM&R or Anesthesia). However, how feasible is it to practice pain without using fluoro/ct (ie avoiding radiation) for injections/procedures? I know that the use of U/S guided procedures has come along way and continues to grow, but would I be shutting myself out of more invasive spinal procedures and the like if I only used U/S? In your practice, how often do you actually do procedures where the standard of care requires imaging with fluoro? How much would I be hurting/limiting my practice and having to refer patients to other pain docs to have these fluoro-only procedures done?

Thanks in advance for any help/advice.

why so scared of fluoro?
 

101N

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I'm a med student finishing up my 3rd year and pain medicine is high on my list of possible specialties (probably through PM&R or Anesthesia). However, how feasible is it to practice pain without using fluoro/ct (ie avoiding radiation) for injections/procedures? I know that the use of U/S guided procedures has come along way and continues to grow, but would I be shutting myself out of more invasive spinal procedures and the like if I only used U/S? In your practice, how often do you actually do procedures where the standard of care requires imaging with fluoro? How much would I be hurting/limiting my practice and having to refer patients to other pain docs to have these fluoro-only procedures done?

Thanks in advance for any help/advice.

When/If you do an externship you will see that most interventional pain procedures are actually spine procedures. Pretty much all spine procedures are based upon bony anatomic landmarks: scotty dog, LAO, RAO, PA, LAT, SAP, IAP, etc. Consequently, we need radiographs - fluoro - to do what we presently do. Conversely, ultrasound is best at imaging soft tissues, not bone. Ergo, we need fluoroscopy.

Down the road it's possible that US will be able to delineate bony spine anatomy as well as fluoro. But right now it cant.
 

blackadder

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First off, thanks so much for all the honest responses--they're very helpful. The pain doc I worked with had given me pretty vague answers when I asked him about this.

Agree with DF. Some anesthesiologists practice substandard care blind epidural steroid injections or try to use ultrasound for guidance (cannot determine either vascular uptake or depth due to echogenicity of the lamina).... Do the right thing and get fluoro if you want to do things the proper way.

When/If you do an externship you will see that most interventional pain procedures are actually spine procedures. Pretty much all spine procedures are based upon bony anatomic landmarks: scotty dog, LAO, RAO, PA, LAT, SAP, IAP, etc. Consequently, we need radiographs - fluoro - to do what we presently do. Conversely, ultrasound is best at imaging soft tissues, not bone. Ergo, we need fluoroscopy.

Down the road it's possible that US will be able to delineate bony spine anatomy as well as fluoro. But right now it cant.

I agree with both of these statements, and I don't want to deliver substandard care (that's why I was asking about this). Sorry if my post suggested otherwise or was unclear.

If you do PM&R, I think you could could have a successful practice if you become proficient in US and EMG. I agree with the other posters that you want to stay away from injecting the spine and this would be considered a "non-interventional" practice.

This is a great suggestion that I'll have to think more about. I worked with a doc who was doing about 10-15 studies/week in his practice and he loved it.

why so scared of fluoro?
Why the fear of fluoro? Wear lead, lead glasses and rock on. Interventional rads gets exposed, interv cardiology, too. Each specialty has its occupational hazards. Surgeons: needle stick (HIV hepc), psych and ER (assaults by crazy patients), DERM (could be splattered by flying zit juice; seen Animal House?). Live fluoro is what gets you in trouble, ie, interv rads and cards.

Hehe, I 100% agree that each practice has it's hazards. I guess it's all about the flavor you're willing to taste.

My concern regarding fluoro stems from some personal/family experiences with cancer. I recognize that lead vests/glasses/etc reduce exposure and I think image-guided procedures are very elegant (I've seen lots this year, especially when on vascular surgery). However, while there is relatively limited data on the issue of long-term physician exposure to rads, the data that is available (after much pub-medding) doesn't placate my apprehension. Here's a link to a recent consensus paper published in Radiology (you can get to the full paper for free through pub med): http://www.ncbi.nlm.nih.gov/pubmed/19188321

Thanks again to everybody for taking the time to respond to my questions--much appreciated.
 

pretenda

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one of my attendings in med school tried doing MBBBs with U/S. very poor imaging in comparison to flouro...youd be doing your patients a disfavor using U/S over flouro in situations where bony landmarks are your best friend in regards to finding anatomy
 

Aether2000

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Plus you won't get paid for it. US codes for spinal procedures are tracking codes- T codes = CPT III codes, that most insurance will not cover.
 

Ducttape

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If you are so afraid of radiation exposure, here are the following professions you probably should avoid:

Radiology (obviously)
Cardiology (even if you dont do interventional, you will have to spend some time during fellowship)
Orthopedic surgery
Vascular surgery

Pain management
Anesthesiology (we are far removed from the radiation of an orthopedic procedure, but its still in the room)
Emergency Medicine

im sure there are others i forgot, but it does limit your options somewhat, and please notice that i put pain medicine way down the list compared to the other professions...
 
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