sickle cell crisis...when enough is enough....

  1. Yesterday at work, I was really worked up with one of my patients who has a sickle cell anemia..She's 24 years old and had been dealing with it since she was about 4 years old...According to the other nurses at my work, she's a frequent flyer and a non compliant with her care management...she comes to the hospital almost evey other month...she's been almost in all the med-surg floor in the hosptial and almost all nurses and doctors has dealt with her in the past...Yesterday was my first time to care for her...Anyhoo, this poor lady is in so much pain (mostly joints and back) that she's been asking for her pain medicine every 2 hours on the dot (Dilaudid 6 mg IVP every 2 hours, together with benadryl 50 mg IVP)...She complain that 6 mg is not giving her enough comfort that she's wanting more...Her reticulocyte is at 6 (indicative of crisis)..So, I placed a call to the admitting Doctor and stated 6 mg is more than enough, instead he gave her Norco 1 tab PO for breakthrough pain...but still she was not satisfied and was still in pain...She's also on IVF and refused oxygen...she sats 96% on RA...During the shift another Doctor came and assesed her and discontinued her Dilaudid IVP to VICODIN ES itab q 4 hours PRN and discontinued her IVF as well...I asked the Doctor and said that this patient is taking advantage and knows how to use the system and that the patient is noncompliant..so they are not going to tolerate it anymore and will nol onger give her any IV pain meds. He also stated that if the patient is not happy about how they manage her care, she can leave the hospital AMA and look for another provider. I was in shock and in dismay...The patient is in pain for crying out loud! I've learned from school that if someone's in pain, you don't question them...you have to acknowldege it..sure this patient might have been a frequent flyer but with this sickling disease that no cure hasn't been found..how can you just stand there and say enough is enough...
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  2. 14 Comments

  3. by   NurseyBaby'05
    Here's the thing: there are some patients who abuse the pain assessment/control guidelines. She's refusing something that can help control her pain with out getting her high. (O2) Also, patients can't be sent home on IV pain meds. She has to have her pain controlled while still in the hospital on something she can (but probably will not) follow at home. How bad would it be for her if she's given IV drugs until the last minute and the docs and hospital staff have no idea if she'll be controlled @ home? That would be cruel. Also, if you give a shot right before she leaves and slips, falls and cracks her head in the parking lot, guess who can be held responsible?
    Last edit by NurseyBaby'05 on Aug 18, '06
  4. by   traumaRUs
    Sickle cell patients live with chronic pain and many are opiate tolerant. When someone receives 700mg of morphine in an out-patient setting (ie home), then giving them Dilaudid 6mg q2 hours is nothing. I would most certainly bet this patient was not "out of it", confused or exhibiting an unsteady gait.

    Sickle cell patients do best seeing specialists that truly want to see sickle cell patients. (IMHO). They need consistent care. Sickle cell patients die at a young age, they have many sequelae from their disease process and they are often looked on as being noncompliant.
  5. by   RGN1
    Quote from traumaRUs
    Sickle cell patients live with chronic pain and many are opiate tolerant. When someone receives 700mg of morphine in an out-patient setting (ie home), then giving them Dilaudid 6mg q2 hours is nothing. I would most certainly bet this patient was not "out of it", confused or exhibiting an unsteady gait.

    Sickle cell patients do best seeing specialists that truly want to see sickle cell patients. (IMHO). They need consistent care. Sickle cell patients die at a young age, they have many sequelae from their disease process and they are often looked on as being noncompliant.
    :yeahthat: Never underestimate the pain of a patient in sickle cell crisis. They need O2, hydration & plenty of pain relief Period!!!
  6. by   FreshRN05
    Quote from traumaRUs
    Sickle cell patients live with chronic pain and many are opiate tolerant. When someone receives 700mg of morphine in an out-patient setting (ie home), then giving them Dilaudid 6mg q2 hours is nothing. I would most certainly bet this patient was not "out of it", confused or exhibiting an unsteady gait.

    Sickle cell patients do best seeing specialists that truly want to see sickle cell patients. (IMHO). They need consistent care. Sickle cell patients die at a young age, they have many sequelae from their disease process and they are often looked on as being noncompliant.
    this is exactly what I don't understand.....my patient was very much alert and oriented...she knows what's going on and even her vitals signs revealed that she's in pain...the doctor even said it himself that she's experiencing tolerance with her pain meds...sometimes I wanted to think that these doctors are not treating her fairly well because of the fact that she's on Medi-caid.....Why do they have to see it as patient abusing meds if indeed these doctors knew what kind of pain sickle cell can give you...
  7. by   traumaRUs
    She needs to seek a different care provider.
  8. by   sunnyjohn
    Quote from traumaRUs
    Sickle cell patients live with chronic pain and many are opiate tolerant. When someone receives 700mg of morphine in an out-patient setting (ie home), then giving them Dilaudid 6mg q2 hours is nothing. I would most certainly bet this patient was not "out of it", confused or exhibiting an unsteady gait.

    Sickle cell patients do best seeing specialists that truly want to see sickle cell patients. (IMHO). They need consistent care. Sickle cell patients die at a young age, they have many sequelae from their disease process and they are often looked on as being noncompliant.
    :yeahthat:
  9. by   PANurseRN1
    Quote from NurseyBaby'05
    Here's the thing: there are some patients who abuse the pain assessment/control guidelines. She's refusing something that can help control her pain with out getting her high. (O2) Also, patients can't be sent home on IV pain meds. She has to have her pain controlled while still in the hospital on something she can (but probably will not) follow at home. How bad would it be for her if she's given IV drugs until the last minute and the docs and hospital staff have no idea if she'll be controlled @ home? That would be cruel. Also, if you give a shot right before she leaves and slips, falls and cracks her head in the parking lot, guess who can be held responsible?
    Ever heard of a CADD-PCA/other home PCA device? Pts. can indeed go home on IV pain meds.

    These docs are causing this pt. needless suffering. I have zero tolerance for healthcare workers who automatically assume someone is a "seeker" just because he/she needs pain meds.
  10. by   Daytonite
    There is a difference between the acute pain of a sickle cell crisis and the long term pain of the residual effects of the many crises. I think the doctor might have been harsh in switching her to the PO medication, but he did give her a large dose. I assume you are in a teaching facility. These kinds of decisions are not done without being discussed by the entire medical team which, I am sure, know her case quite well. I would be content that this was not the action of some maverick doctor.

    I am not implying in any way that this patient fits the same profile, but we had a number of sickle cell patients who were just the same. Many of them would disappear for a couple of hours and come back loaded (drugged up) or go out AMA because, they would tell us, they could get better stuff on the street. I think that often they come into the hospital because they don't have enough financial means to buy the stuff on the street. All they are left with is MediAid or MediCare to depend on. Acting out that dramatically is due to straight out addiction and craving for a lot more than they are going to get in the hospital. However, they still try, hoping, they'll run into one sympathetic person they will feed their need. I wonder why the docs aren't also giving her chasers of Ativan to help take the edge off?

    Feel sorry for her condition, but she is a hardened addict and that has complicated her condition and put the doctors in a compromising position.
  11. by   NRSKarenRN
    Quote from daytonite
    feel sorry for her condition, but she is a hardened addict and that has complicated her condition and put the doctors in a compromising position.
    not having cared for this patient, don't see how one can judge this patient.
    it is attitudes like this from nurses and physicians that often has the patient reluctant to seek help early until they can't stand the pain any longer; meanwhile much harder to control the pain. organ damage often sequela of disorder that patients have minimal control over.

    having cared for patients with this disorder for 20 years, most are just trying to live their lives. iv pain management at home is possible with the use of cadd pumps. education and effective pain management, preplanning for next crisis is crucial for helping these patients gain control over their lives and pain. tolerance to narcotics does occur...doesn't mean you don't treat the pain. :angryfire pulse oximetry is skewed if anemia is present...often case with these patients.

    patients managed by a hematologist specialising in this disorder usually can lead fairly longer, less pain filled lives.



    sickle cell crisis
    a severe attack, known as sickle cell crisis, can cause pain because blood vessels can become blocked or the defective red blood cells can damage organs in the body.
    nursing care plan:sickle cell crisis

    nursing assessment and management for children (summer 2006 ...

    teenagers with sickle cell disease

    sickle cell disease (scd)
    Last edit by NRSKarenRN on Aug 21, '06
  12. by   traumaRUs
    Karen - I totally agree with you. In the nephrology practice where I now work, we have several dialysis patients who have sickled off their kidneys resulting in end-stage renal disease. They are also not able to get transplants since the chance of this happening again is high. These patients can be some of our most challenging. However, those that do resort to street drugs do so only when their pain has been so uncontrolled for such a long time that they feel they are out of options. I say this with 10 years of ER experience caring for this chronic population.

    For the most part, these patients just want a life like you and I have and they will unfortunately die much earlier than us.
  13. by   babynurselsa
    Is it possible that the physician group is frustrated also with the fact that it might appear that the patient is picking and choosing the parts of the treatment that she wishes to comply with.
    I do know that this is a horrible, tough disease. I also know when I see these same patients over and over and over again presenting in the ER because they are not compliant with treatment plans or even bothering to follow up at all with their pcp it can be frustrating.
  14. by   leslie :-D
    living w/sickle cell is a horrible way to exist.
    what we perceive as non-compliant is often the pts' way of knowing what works and what doesn't.
    and the treaters don't listen.

    one time yrs ago, i had a very minor injury.
    for awhile, there was an ischemic process that caused me alot of pain.
    i couldn't believe that something so minor could be so painful.

    i just can't even pretend to imagine the pain of a sickle cell crisis.
    i say, whatever it takes.
    and to get this population ongoing,effective and reliable treatment.

    leslie

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