Sickle cell

Specialties Emergency

Published

Ok...here's a question that I've asked frequently at work, but I'm not totally satisfied with the answers I get.

We seem to get sickle cell patients (whom many we find are not sickeling at the time) who come in to the ER for pain.

BUT..without fail, everyone of them will ask for dilaudid PLUS benedryl. Why benedryl? I have been told it was so they can get the extra high, but why do only sickle cell patients ask for benedryl with their pain med? Anyone else come across this??

Specializes in ER.

Sickle cell patients are not the only ones who request Benadryl after receiving their pain meds... many people who have chronic pain from certain diseases also request benadryl not just sickle cell. I know it is very hard not to judge people who come in who you think are drug seeking, but that comes with the job of working in the medical field. We need to put our own judgements aside and worry about taking care of the patient, faking pain or not as hard as it is!

And the itching comes from the narcotics... which I consider an allergy if something makes you itch!

"Being a Nurse is about being able to love people when they are at their weakest moments and being able to forgive them for all their wrongs and make a difference in their lives today...No one can make someone a Nurse...You just are"

Specializes in Emergency.

Can't believe no one has mentioned the gastroparesis pts! They are very similar to sicklers with their requirements.

Also, we just do retic counts in our ER to see who is sickling.

Specializes in ED staff.

In my experience sickle cell crisis, those truly in crisis will drop their O2 sat. We do retic counts too. Benadryl is for itch and just as phenergan does may potentiate the dilaudid.

Specializes in ER.
We have a sickle cell protocol at my facility. O2, q30min dilaudid x 4, q1h dilaudid x 2 (iirc) and then see where the pain is at. If their pain is still unmanagable at that point, it decides whether we admit them or not. With those orders are always PRN benadryl and phenegran. I always simply assumed that it was for itching and had a SC patient recently tell me that the dilaudid made him itchy and nauseous. Though, it can definitely appear as though some prefer the snowed effect. Didn't know about the rest - such as the possible adjunct effects! Good to know!

Good topic! Thanks for the discussion! :)

Your welcome! Thanks for posting...Interesting story:

Just recently, I had a "SC" patient come in whom I have taken care of a few times in the past. However, she uses different names each time. Well, I remembered her the other day but I noticed her last name was different. When I asked her about her previous visit, she denied ever being there...BUT she later busted herself by saying she I was the only one who can ever start her IV ( i remember the site and everything)

I happened to remember the name she used during the last visit and I went to get her old chart. Same info, BUT the name was different. On the chart the dr. documented that the pt was "not sickleling according to the peripheral smear and denied any other prior visits using a different name".

Its terrible that someone would be this dishonest....I know this is part of working ER, but we should not let people get away with lying about their identity and med history to get treated. I told her she needed to update her info bc we could possible get her confused with other patients....;)

Specializes in psych nursing/certified Parish Nurse.

My stint on a medical unit (a long time ago) where all the SC-sufferers were admitted, was high-lighted by this gorgeous, young, and amazingly sweet woman... who taught me so much about pain control I was able to convert the knowledge gained to others. I also have had lots of detox nursing experience since... and realize more and more that "drug seekers" are seeking much more than medicine/narcotics... and should these need to be addressed before the self-medicating can stop. Having now also a large inventory of knowledge about nutrition--I know "craving" can be mitigated/relieved through dietary intervention. All medicines deplete the body of nutrients... you simply must know of what one is deficient--and eat the appropriate foods, if you have access. If not, there are supplements... although these, too, can be expensive. Eating "disorders" work the same way... since these "women" (not always, but mostly) tend toward perfectionism or as a response to perfectionism in their significant others... this can be re-directed to careful control of the appropiate foods/nutrients. Of course, careful eating does not relieve the need for satisfying and close relationships/meaningful lives/dignified lives... but it helps. The beautiful woman of whom I spoke originally taught me much, too, about learning to cope with pain; living a dignified life in spite of horrendous affronts, and the need for social support systems--not simply medical treatment groups. She very much has affected how I both treat patients, and how much I expect from myself in the same vein. Incredible woman! (this is a post-death tribute)...

Specializes in Emergency, Trauma, Pediatrics, Cath/EP.

we have multiple "regulars" who visit us d/t sickle cell "crisis." Several of them have their own specific protocols. Most of them hospital hop. They are by far some of the most annoying pts to frequent the ED. Most get Dilaudid. Some have ports because they have no veins left. blah blah blah

Can't believe no one has mentioned the gastroparesis pts! They are very similar to sicklers with their requirements.

Also, we just do retic counts in our ER to see who is sickling.

:werd: on both cases.

we have multiple "regulars" who visit us d/t sickle cell "crisis." Several of them have their own specific protocols. Most of them hospital hop. They are by far some of the most annoying pts to frequent the ED. Most get Dilaudid. Some have ports because they have no veins left. blah blah blah
I find it to be quite disheartening to hear a nurse speak of a SC patient this way (or any patient for that matter). As a nursing student with Sickle cell disease, I assure you that wouldn't be able to withstand the frequency nor the severity of the pain we withstand everyday. Not to mention numerous other complications throughout our lifetime. As a nurse it is your duty to be compassionate and without discrimination towards ALL of your patients. But then again, I suppose a lot of us are capable of obtaining a nursing degree, but far less of us are capable of being NURSES. Here's some advice, if you are tired of trying to draw IV's on us "regulars", maybe it's time for you find a new profession.
1 Votes
Specializes in ER.

My last ER drew retic counts prior to administering narcotics to most sicklers. Fluids and o2 are better treatments for sickle cell crisis anyway!!

We had several sicklers that we knew well enough and were managed in a local sickle clinic that would come by when in crisis and we would administer narcotics before their labs came back. Otherwise, I can't tell you how many times I have had patients swear they were in crisis only to have a completely negative lab work up. Its unfortunate but true. These patients should be followed in sickle clinic and should be treated by MDs that know them better. In the ER, we can not possibly justify administering huge numbers of narcotics to them without knowing their past.

Don't even get me started on the smoking sicklers and those that generally just don't take good care of themselves. At some point, even if you sickle, aren't you an addict for kind of invoking the sickle crisis itself by smoking and refusing to take care of yourself?

Specializes in Emergency.

Aside from prophylactic treatment of opiate-induced pruritis, the addition of an antihistamine to an opiate helps potentiate the opiates effect. Besides a dilaudid/benadryl combo, I've seen morphine/vistaril ordered as well. While pruritis is a SE for which many people develop a tolerance, many don't. Regardless, when a patient asks me to "push 'em fast", I can't help but wonder if itching is really why they requested the benadryl in the first place.

Specializes in Urgent Care NP, Emergency Nursing, Camp Nursing.
But then again, I suppose a lot of us are capable of obtaining a nursing degree, but far less of us are capable of being NURSES. Here's some advice, if you are tired of trying to draw IV's on us "regulars", maybe it's time for you find a new profession.

First, you're a nursing student, not a nurse. You will likely never have an ED rotation during your education. You don't see the things we see from behind a nurse's badge. You don't get to use that tone with us,and in the meanwhile you can get off your high horse.

Second, there are sicklers in crisis and sicklers in "crisis." If I know your name and your regular doses, you're probably in "crisis," and I'll get to you after dealing with my ESI 1s, 2s, 3s, AND 4s. I'd put you after my 5s too, but by definition they don't need anything from me. Does it suck for you when you're actually having an honest-to-goodness crisis? Yes, but you're the one who cried wolf one too many times.

First, you're a nursing student, not a nurse. You will likely never have an ED rotation during your education. You don't see the things we see from behind a nurse's badge. You don't get to use that tone with us,and in the meanwhile you can get off your high horse.

Second, there are sicklers in crisis and sicklers in "crisis." If I know your name and your regular doses, you're probably in "crisis," and I'll get to you after dealing with my ESI 1s, 2s, 3s, AND 4s. I'd put you after my 5s too, but by definition they don't need anything from me. Does it suck for you when you're actually having an honest-to-goodness crisis? Yes, but you're the one who cried wolf one too many times.

Well I did not intend for my "tone" to seem condescending in any way, however I feel from the aspect of an SC patient and a nursing student who looks up to nurses like all of you, it hurts my heart to know that you have put all SC patients into a generalized category. I understand how clinically our pain can be overlooked because we don't always "look" sick. But as I stated before, you have NO idea what it's like to be in excruciating pain every single day of your life, leaving you with no choice but to be opioid tolerant. I wish there were other ways to help regulate the frequency of our crisis, but I cannot tell you how many times I have heard "your labs look fine". Just to sit there writhing in pain wondering if I should ask for something to help because I don't want to face judgement of those I know will never understand. All I'm asking is that you please do not see all of us as being the same because we aren't, and sometimes, a kind word or someone simply believing we feel how we say we do helps so much (the nurse BEING a nurse). -Krystal

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