Photo by Jill Schramm/MDN Heading the Heart of America Pain Management Clinic team are physician’s assistant Nicole Lemieux, Dr. Ted Fogarty and nurse anesthetist Chelsey Wyatt, who stand next to a CT scanner. The scanner has been added to the clinic’s tools for guided pain intervention.

RUGBY – In an era when specialized medical treatment is gravitating toward major centers, Heart of America Medical Center in Rugby is bucking the trend with its investment into a scope of pain management services that’s rarely found in rural areas.

Having opened in late 2016, the pain clinic has been slowly building its practice, evolving into a full-service practice for the Rugby and surrounding areas, said Chelsey Wyatt, certified registered nurse anesthetist, who helped found and lead the program.

Heart of America carved out a clinic area for pain management in its specialty services wing by converting space previously used as a board room. It invested in new fluoroscopy equipment, training and the expertise of an interventional radiologist.

“We want to offer individualized care for each patient through multiple modalities. We don’t limit them to medication or to a therapy or to an injection. We want to assist patients in a non-narcotic, interventional, multimodal pain treatment plan that gives them the very best improvement in their quality of life,” Wyatt said.

The clinic recently added the services of Dr. Ted Fogarty, chairman of radiology at the University of North Dakota School of Medicine. Fogarty, who comes to Rugby about three days a week, has been building a rural interventional radiology practice.

“What I bring in is something that we’ve lost on the Northern Plains. We’ve lost general radiologists with hands-on skills to do interventional procedures, and that’s been occurring over the last 10 years in a fairly rapid fashion,” Fogarty said. “We’re getting into this really troubling consolidation situation in medicine, and in part, it has really come through my specialty, first and foremost – through teleradiology. So it kind of opened the genie’s bottle, so to speak about 10 years ago in the Dakotas, with more and more of our advanced imaging being interpreted by non-North Dakotans through teleradiology services.”

If a Rugby surgeon wants to talk to the radiologist who read the mammogram on his patient, that person may be in California or Florida, he said.

“That’s where we have lost the human element in rural American medicine,” he said. “We’re kind of trying to do a little barnstorming revival of patient care and bringing the high-tech stuff back home to the small town.”

In working with the Rugby pain clinic, Fogarty can augment Wyatt’s ability to deliver treatment by providing CT and ultrasound guidance. He has experience in ultrasound-guided injections of the joints of the hand, which few physicians do because it is a complicated procedure due to the numbers of nerves and tendons.

“There are a lot of procedures that really require ultrasound and/or CT guidance for the safest care,” Fogarty said.

Part of his role will be to teach the use of advanced imaging processes, giving Wyatt the ability to best approach the more complicated pain management cases, he said. Having that ability means area patients can get that high-level of care locally.

From a rural medicine standpoint, there are both safety issues and feasibility issues in transporting someone or requiring someone to travel to a larger center to receive pain management services, Fogarty added.

“Those travel issues become a second-layer hazard for a lot of folks in rural America,” he said. “That’s where I feel like this mission is very important for a state that has a lot of rural, hard-working folks and a big need – almost a crisis need for interventionalists, proceduralists, who can help with the pain of daily life.”

Wyatt said the majority of her clinic practice is chronic pain management.

“Often we see people that are elderly who are in a lot of pain. It’s an issue with quality of life. They may not have transportation or family available to get them to outside facilities. And more importantly, now they don’t need to,” Wyatt said. “We can really get patients good relief. With the recent attention to opioid narcotic issues throughout America, this is one more level of care that helps people to avoid some of those medications that cause long-term problems for them. Our goal is to continue to bring more services directly.”

Wyatt, who also works in Rugby’s surgical center, has been spending a day a week on pain clinic services. Hours of the pain clinic will be restructured as services expand. Currently, the clinic is booked out for weeks with patients, so expanding the hours is necessary, Wyatt said.

The pain clinic has been able to work with a Heart of America family-care physician, but in May, the clinic will be adding Nicole Lemieux, a physician’s assistant to provide its primary care. Having that primary-care component means any medication adjustments, imaging or referrals can take place in one appointment, streamlining the process for pain patients.

“They’re really getting a whole circle of care,” said Lemieux, whose presence also will increase the opportunity for patient education.

There are discussions regarding working with an accredited compounding pharmacy in Dickinson to customize medications for patients at the pain clinic. The clinic also coordinates non-medicated treatments through physical and occupational therapy.

Wyatt called it a team approach. The immediate team includes two nurses and a radiology tech as well as Wyatt, Fogarty and Lemieux.

“Within our team, we work to coordinate this patient’s physical therapy needs, their medication needs, their education needs, their procedures. We do a lot of follow up with our patients,” Wyatt said. “We revisit what works for them and what didn’t, and I think that is really a benefit to the patient to have a whole team of people within their own specialties just working to improve their care.”

Wyatt said credit goes to the hospital leadership for its support for a pain management program in Rugby.

“Our hospital here has made it a priority in seeing the need for pain services in the community and surrounding areas,” she said. “Not a lot of rural hospitals have the ability to prioritize. They’re barely keeping their doors open, so we’re very fortunate here to have a hospital board and executive team that have prioritized this service for our community.”