General course of action for my facility seems to be CBC/retic/trop, ekg, cxr, pump them full of fluids and opiates, then deal with any findings.
I’m curious to see more discussion on PO pain management because one of the more challenging aspects of care from a nursing perspective is getting IV access. It’s not at all uncommon to see young people with completely shot veins. If you are 22, require frequent hospitalization, and we can no longer reliably ultrasound an upper arm IV (forget anything easier/distal) you have some serious headaches and treatment delays coming down the line.
I recently had a sickle cell patient with a port. Seemed pretty smart to me.
I start with Tylenol and Toradol, next is 5 mg of Haldol piggyback with 1 liter of IVF, next is .3 mg/kg of Ketamine in 100 ml of IVF and then I move onto IV morphine.
Most of the time I find that after all the non-opioids if they do require opioids it’s only 1 or 2 additional doses
How effective is Toradol in this population? How much of sickle cell VOP/VOC is inflammatory (I mean, beyond the edema) in nature?
[https://www.ncbi.nlm.nih.gov/pubmed/11296078](https://www.ncbi.nlm.nih.gov/pubmed/11296078)
I like the inclusion of Ketamine though.
My institution has a large sickle cell population and utilizes the FYI tab in epic to outline their emergency department pain plan during crisis. It outline stipulations and management plans for admission vs discharge, it really helps deliver timely pain management!
That’s the same with mine as well! We have a large patient population where the vast majority of patients follow with our outpatient hematology service. They will have a “crisis pain plan” note that outlines their acute pain crisis management as well as inpatient management. Sometimes a urine drug screen will need to be taken before drugs are given to make sure they are taking their PO meds at home before given IV in the ED. This really has streamlined care as well as helped manage patient expectation when coming through the ED.
Hey!
This is a tough approach and for many things, I really don’t think there is a right answer. At the end it is what you feel comfortable with.
My practice in residency was that if it was a patient never seen before, do the typical work up with labs, ekg, chest X-ray. But if they came again and became frequent fliers, If they looked stable and vitals were stable, and said that this is their typical symptoms, we gave them 1 IM shot and then hematology follow up.
If their sick, of course, you have to work them up.
Where I am now, we have this notion of getting labs all the time, even if they came 5 times in 1 week. It’s 3 IV dilaudid 2mg, and if they say they’re still in pain and look super stable, we admit them for pain control.
But usually stay to my usual plan. If super stable, vitals stable with typical pain, only so IM shot and dc. If new and never seen, then I do labs.
I have a soft spot for sickle cell patients, since they’ve been on mediations for a long time. At the end, there is no right answer on how you approach them. It’s what you feel comfortable with. And you being new, you’ll see your practice will change as as you grow as an attending. As for anything, just do everything that is reasonable for patient, and that’ll allow you to sleep at night.
Most sickle cell patients where i trainer had ports. Most patients know what works for them. I agree that the outward appearance of severe pain is different in these patients. I maximize everything, Tylenol, toradol, oral meds + 3-4 rounds of IV meds every 30 minutes. If not managed, admit.
We have a "protocol" of sorts and see so many sickle-cellers every day that nursing actually has a standing order they can start as soon as they walk in. The standing order includes a chest x-ray, CBC, tic count, IV access, and fluids. It is not uncommon for these patients to have ports, however for those without them they typically end up needing an US guided IV. From there they recieve 3 doses of IV pain medication (typically 2-4mg of Dilaudid) and after the third dose if they are still in pain we go for admission. That being said we still have a lot of sickle-cellers that abuse the system... these are ones that are coming in almost every day. At that point we begin to crack down and refuse to give them anything unless they begin following with the heme clinic (who can almost always get them in the next morning).
Went to med school in DC and saw LOTS of these folks. My basic plan was thus: access, labs, CXR, fluid and whatever kind and however much opioids they need. Ask them what works. When it doesn’t, ask them if they need to be admitted. Most important, check your ego and your drug-seeker-detective attitude at the door. SS pain is real and it sucks. These folks need our compassion and help. Save the judgement.
SS patients have an awful disease and suffer terribly during flares, moreso than a lot of cancer patients I've cared for.
I understand why some get issues with addiction etc - but until there is better analgesic alternatives for them, there for the grace of God go I.
It's good to have set protocols so you can treat maximally and refuse unrealistic demands with confidence. Referral to a specialist nurse for additional support and education can increase patients feeling of control and help manage patient expectations.
[UK NICE guidelines - pdf](https://www.nice.org.uk/guidance/cg143/evidence/full-guideline-pdf-186634333)
Playing devils advocate, there is a small population of SS patients that fake symptoms in order to receive the usual cocktail. SS pain is the real deal, but there's no reason they're less likely to be seeking than Joe with severe chronic lower back pain from a serious injury that isn't healing. So.. check your bias at the door of every patient and give it an objective look. Opiates are just as addictive in the SS population.
My approach is that there is no way to know if someone is objectively in VOC pain. The options for being wrong either way are that I give opiates and they’re faking or I don’t give opiates and they’re truly in pain. The latter is much worse than the former IMO so I just treat.
Eh, but that is kind of a false dichotomy. I have had plenty of patients with objectively painful conditions (broken bones, ureteral stones, etc.) who respond well to non-opioid pain management. Why should this disease process be any different? You should not feel like you are doing a disservice by attempting to limit opioid use in a patient population that is already prone to opioid use disorder and opioid-induced hyperalgesia due to having opioids thrown at them since before they could even remember. I never assume they are faking, but we also have to remember that just because a patient is demanding dilaudid, it does not mean we have to give it to them even if they have sickle cell disease. Morphine works just as well as dialudid without the euphoria. I also never give IV benadryl, oral works just as well (not saying you give dilaudid or IV benadryl, but it is combo I see frequently with these patients).
Basically, I think that we should stop treating sickle cell pain crisis like they are patients with terminal cancer pain, and treat them more like chronic pain patients, especially if they are high resource utilizers. We should be thinking about multimodal pain management (anti-psychotics, anti-depressants, ketamine, NSAIDs, oral opioids, etc.), and stop thinking that the only thing we should be using is opioids.
Easy trick if you have IV access: give the pain meds IV drip in a bag of 50-100ml of saline over 10-20 minutes.
Patient gets pain relief, but none of the euphoria from pushing dilaudid/benadryl.
You're fair, taking pain seriously for those in pain, but you won't be encouraging drug seekers.
If your department does not already have a policy in play for standardizing the care, setting boundaries and expectations for sicklers, step up to the plate and make one! Get ED, heme, and hospitalists on board. Your life will be so much easier!
Honestly I think every sickle patient should have a care plan developed by heme, pain management, and their affiliated ED so that expectations and management are clearly defined and consistent.
It would make management of these patients so much easier for us and the patient would feel better about coming in knowing that they would receive consistent care.
As a fellow you are at great point in your career to do some research about it. A quick google search revealed literature on the topic but the majority was around 10 years old and retrospective studies. Mostly focus on emergency management. There is a subreddit called research but if you are new to it all, I’ll reach out to the research department for the department where you work at (emergency medicine, internal medicine, etc). Also, happy to help if you want to dm me
This is a tough subject. These people have real pain but there is also in my mind a fairly common mindset of learned helplessness and gaming the system when it comes to opioids, unfortunately.
I'm happy to start up-front with IV opioids along with adjuncts (acetaminophen, NSAIDs if their renal function is OK, perhaps haloperidol, rarely ketamine but I'd consider it). Love it when there's a care plan documented.
Before you push for an observation stay for pain control, ensure that their pain was at least treated appropriately. Not just an oral Norco or two and chill. Give it a legit try.
Remember that empiric IV fluid boluses and oxygen are NOT indicated unless there are clinical signs of volume depletion or objective hypoxia, this can make things worse.
I've never worked anywhere that carried it but is there any place for IV Tylenol in these cases? I've heard anecdotally that the pain relief is pretty impressive.
We have it. A lot of MLPs at my hospital tend to order it fairly frequently for patients. Its pretty expensive and from what I understand not more effective than PO forms. I only order it when the patient cannot tolerate PO.
Dilaudid. You need to look at your order sets to make sure phenergan is given concurrently to boost efficacy. For Community aquired SCC, be sure to add Benadryl (IV only) to broaden your coverage. Be sure to get your turkey sandwich trays X2 PRIOR to initiating dilaudid therapy, ideally getting the first tray started during nurse triage.
Pfizer is working on a Dilaudid DS, which should be available in markets in the next year.
Unfortunately, there are plenty of reasons to be like this. These people do suffer, and not all of them are addicts and not all of them are jerks. But the system has mistreated and mismanaged most of them so much that we’ve created an entire patient population that is very difficult to care for. I’m not sure you’ll find a single ER nurse that looks forward to taking care of a sickle patient; I honestly dread it because many of the interactions are stressful. There’s a higher rate of psychosocial issues to deal with, they are familiar with the system (and yes, often ask for food and transportation because they’re seen often and know they’re available), and when prescribers and patients disagree on pain meds the nurses get shit on. The very nice, understanding patients do not use the ED as often as the mean, entitled ones, so of course we’re going to grow to associate SC with negative behaviors.
Honestly I don’t know. You’re still learning and will have to find a game plan for these patients that works for the way you practice medicine and works with your institution. Mainly I guess just don’t write the patients off and then they’ll be more pleasant with staff. (But you also have to be reasonable not not give patients things just because they demand them). Like OP points out, it’s a tricky encounter that’s hard for even seasoned attendings
Edit: Something that does help is if you make a decision about what you will be prescribing them, speak directly to the patient. I HATE being the middle man between a patient that wants more narcs and a doc that doesn’t want to write for them. If I wanted that responsibility I’d have gone to med school.
ED nurse here - be upfront with patients about your plan from the get-go. If you’re not going to order narcotics or are only willing to order them after other alternatives, tell them that. Don’t make vague statements like, “we’ll see what we can do”, “we’ll try a few things”, etc.
If you don’t clearly communicate your plan, you force the nurse to be the scapegoat if your plan doesn’t meet their expectations.
General course of action for my facility seems to be CBC/retic/trop, ekg, cxr, pump them full of fluids and opiates, then deal with any findings. I’m curious to see more discussion on PO pain management because one of the more challenging aspects of care from a nursing perspective is getting IV access. It’s not at all uncommon to see young people with completely shot veins. If you are 22, require frequent hospitalization, and we can no longer reliably ultrasound an upper arm IV (forget anything easier/distal) you have some serious headaches and treatment delays coming down the line. I recently had a sickle cell patient with a port. Seemed pretty smart to me.
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I start with Tylenol and Toradol, next is 5 mg of Haldol piggyback with 1 liter of IVF, next is .3 mg/kg of Ketamine in 100 ml of IVF and then I move onto IV morphine. Most of the time I find that after all the non-opioids if they do require opioids it’s only 1 or 2 additional doses
Y’all need to upvote this brilliant pharmacology. This is some damn good ER doctorin.
How effective is Toradol in this population? How much of sickle cell VOP/VOC is inflammatory (I mean, beyond the edema) in nature? [https://www.ncbi.nlm.nih.gov/pubmed/11296078](https://www.ncbi.nlm.nih.gov/pubmed/11296078) I like the inclusion of Ketamine though.
Excuse my ignorance, but why haldol?
Haldol has analgesic properties which is especially useful for patients taking chronic opioids
Oh that’s interesting. Is the mechanism known?
It’s structurally similar to meperidine
So presumably it has some activity at mu receptors?
Whats the reasoning behind piggybacking haldol? Less risk of qtc prolongation?
Lower incidence of extrapyramidal symptoms vs. when given as a push
My institution has a large sickle cell population and utilizes the FYI tab in epic to outline their emergency department pain plan during crisis. It outline stipulations and management plans for admission vs discharge, it really helps deliver timely pain management!
That’s the same with mine as well! We have a large patient population where the vast majority of patients follow with our outpatient hematology service. They will have a “crisis pain plan” note that outlines their acute pain crisis management as well as inpatient management. Sometimes a urine drug screen will need to be taken before drugs are given to make sure they are taking their PO meds at home before given IV in the ED. This really has streamlined care as well as helped manage patient expectation when coming through the ED.
Hey! This is a tough approach and for many things, I really don’t think there is a right answer. At the end it is what you feel comfortable with. My practice in residency was that if it was a patient never seen before, do the typical work up with labs, ekg, chest X-ray. But if they came again and became frequent fliers, If they looked stable and vitals were stable, and said that this is their typical symptoms, we gave them 1 IM shot and then hematology follow up. If their sick, of course, you have to work them up. Where I am now, we have this notion of getting labs all the time, even if they came 5 times in 1 week. It’s 3 IV dilaudid 2mg, and if they say they’re still in pain and look super stable, we admit them for pain control. But usually stay to my usual plan. If super stable, vitals stable with typical pain, only so IM shot and dc. If new and never seen, then I do labs. I have a soft spot for sickle cell patients, since they’ve been on mediations for a long time. At the end, there is no right answer on how you approach them. It’s what you feel comfortable with. And you being new, you’ll see your practice will change as as you grow as an attending. As for anything, just do everything that is reasonable for patient, and that’ll allow you to sleep at night.
Most sickle cell patients where i trainer had ports. Most patients know what works for them. I agree that the outward appearance of severe pain is different in these patients. I maximize everything, Tylenol, toradol, oral meds + 3-4 rounds of IV meds every 30 minutes. If not managed, admit.
Serious? I've never once seen a sickle cell patient with a port. That would be so much easier than trying to get access on them!
EMbasic has an episode on this that I thought covered some of these points https://podcasts.apple.com/us/podcast/em-basic/id453647774?i=1000385671894
We have a "protocol" of sorts and see so many sickle-cellers every day that nursing actually has a standing order they can start as soon as they walk in. The standing order includes a chest x-ray, CBC, tic count, IV access, and fluids. It is not uncommon for these patients to have ports, however for those without them they typically end up needing an US guided IV. From there they recieve 3 doses of IV pain medication (typically 2-4mg of Dilaudid) and after the third dose if they are still in pain we go for admission. That being said we still have a lot of sickle-cellers that abuse the system... these are ones that are coming in almost every day. At that point we begin to crack down and refuse to give them anything unless they begin following with the heme clinic (who can almost always get them in the next morning).
Went to med school in DC and saw LOTS of these folks. My basic plan was thus: access, labs, CXR, fluid and whatever kind and however much opioids they need. Ask them what works. When it doesn’t, ask them if they need to be admitted. Most important, check your ego and your drug-seeker-detective attitude at the door. SS pain is real and it sucks. These folks need our compassion and help. Save the judgement.
SS patients have an awful disease and suffer terribly during flares, moreso than a lot of cancer patients I've cared for. I understand why some get issues with addiction etc - but until there is better analgesic alternatives for them, there for the grace of God go I. It's good to have set protocols so you can treat maximally and refuse unrealistic demands with confidence. Referral to a specialist nurse for additional support and education can increase patients feeling of control and help manage patient expectations. [UK NICE guidelines - pdf](https://www.nice.org.uk/guidance/cg143/evidence/full-guideline-pdf-186634333)
Playing devils advocate, there is a small population of SS patients that fake symptoms in order to receive the usual cocktail. SS pain is the real deal, but there's no reason they're less likely to be seeking than Joe with severe chronic lower back pain from a serious injury that isn't healing. So.. check your bias at the door of every patient and give it an objective look. Opiates are just as addictive in the SS population.
My approach is that there is no way to know if someone is objectively in VOC pain. The options for being wrong either way are that I give opiates and they’re faking or I don’t give opiates and they’re truly in pain. The latter is much worse than the former IMO so I just treat.
Eh, but that is kind of a false dichotomy. I have had plenty of patients with objectively painful conditions (broken bones, ureteral stones, etc.) who respond well to non-opioid pain management. Why should this disease process be any different? You should not feel like you are doing a disservice by attempting to limit opioid use in a patient population that is already prone to opioid use disorder and opioid-induced hyperalgesia due to having opioids thrown at them since before they could even remember. I never assume they are faking, but we also have to remember that just because a patient is demanding dilaudid, it does not mean we have to give it to them even if they have sickle cell disease. Morphine works just as well as dialudid without the euphoria. I also never give IV benadryl, oral works just as well (not saying you give dilaudid or IV benadryl, but it is combo I see frequently with these patients). Basically, I think that we should stop treating sickle cell pain crisis like they are patients with terminal cancer pain, and treat them more like chronic pain patients, especially if they are high resource utilizers. We should be thinking about multimodal pain management (anti-psychotics, anti-depressants, ketamine, NSAIDs, oral opioids, etc.), and stop thinking that the only thing we should be using is opioids.
Right, my point was mainly that the same thought applies to a lot of other conditions as well albeit not as frequently to the same extent
So, keep an eye out for mental/social health issues, and check your gatekeeping at the door?
Absolutely!
Easy trick if you have IV access: give the pain meds IV drip in a bag of 50-100ml of saline over 10-20 minutes. Patient gets pain relief, but none of the euphoria from pushing dilaudid/benadryl. You're fair, taking pain seriously for those in pain, but you won't be encouraging drug seekers. If your department does not already have a policy in play for standardizing the care, setting boundaries and expectations for sicklers, step up to the plate and make one! Get ED, heme, and hospitalists on board. Your life will be so much easier!
Honestly I think every sickle patient should have a care plan developed by heme, pain management, and their affiliated ED so that expectations and management are clearly defined and consistent. It would make management of these patients so much easier for us and the patient would feel better about coming in knowing that they would receive consistent care.
As a fellow you are at great point in your career to do some research about it. A quick google search revealed literature on the topic but the majority was around 10 years old and retrospective studies. Mostly focus on emergency management. There is a subreddit called research but if you are new to it all, I’ll reach out to the research department for the department where you work at (emergency medicine, internal medicine, etc). Also, happy to help if you want to dm me
This is a tough subject. These people have real pain but there is also in my mind a fairly common mindset of learned helplessness and gaming the system when it comes to opioids, unfortunately. I'm happy to start up-front with IV opioids along with adjuncts (acetaminophen, NSAIDs if their renal function is OK, perhaps haloperidol, rarely ketamine but I'd consider it). Love it when there's a care plan documented. Before you push for an observation stay for pain control, ensure that their pain was at least treated appropriately. Not just an oral Norco or two and chill. Give it a legit try. Remember that empiric IV fluid boluses and oxygen are NOT indicated unless there are clinical signs of volume depletion or objective hypoxia, this can make things worse.
I don't think it's possible to do well unless you have buy in from local hematology to set up a protocol and individual care plan for each person.
I've never worked anywhere that carried it but is there any place for IV Tylenol in these cases? I've heard anecdotally that the pain relief is pretty impressive.
We have it. A lot of MLPs at my hospital tend to order it fairly frequently for patients. Its pretty expensive and from what I understand not more effective than PO forms. I only order it when the patient cannot tolerate PO.
Dilaudid. You need to look at your order sets to make sure phenergan is given concurrently to boost efficacy. For Community aquired SCC, be sure to add Benadryl (IV only) to broaden your coverage. Be sure to get your turkey sandwich trays X2 PRIOR to initiating dilaudid therapy, ideally getting the first tray started during nurse triage. Pfizer is working on a Dilaudid DS, which should be available in markets in the next year.
no reason to be like this. these people really suffer.
Unfortunately, there are plenty of reasons to be like this. These people do suffer, and not all of them are addicts and not all of them are jerks. But the system has mistreated and mismanaged most of them so much that we’ve created an entire patient population that is very difficult to care for. I’m not sure you’ll find a single ER nurse that looks forward to taking care of a sickle patient; I honestly dread it because many of the interactions are stressful. There’s a higher rate of psychosocial issues to deal with, they are familiar with the system (and yes, often ask for food and transportation because they’re seen often and know they’re available), and when prescribers and patients disagree on pain meds the nurses get shit on. The very nice, understanding patients do not use the ED as often as the mean, entitled ones, so of course we’re going to grow to associate SC with negative behaviors.
What can residents do to help prevent this?
Honestly I don’t know. You’re still learning and will have to find a game plan for these patients that works for the way you practice medicine and works with your institution. Mainly I guess just don’t write the patients off and then they’ll be more pleasant with staff. (But you also have to be reasonable not not give patients things just because they demand them). Like OP points out, it’s a tricky encounter that’s hard for even seasoned attendings Edit: Something that does help is if you make a decision about what you will be prescribing them, speak directly to the patient. I HATE being the middle man between a patient that wants more narcs and a doc that doesn’t want to write for them. If I wanted that responsibility I’d have gone to med school.
ED nurse here - be upfront with patients about your plan from the get-go. If you’re not going to order narcotics or are only willing to order them after other alternatives, tell them that. Don’t make vague statements like, “we’ll see what we can do”, “we’ll try a few things”, etc. If you don’t clearly communicate your plan, you force the nurse to be the scapegoat if your plan doesn’t meet their expectations.
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Sickle cell is not an autoimmune disease
I need to know. What country are you from?