Sickle Cell Crisis Question LONG VENT!!

Nurses General Nursing

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I took care of a 28yo male pt. last night that was in sickle cell crisis. He is what they call at my hospital "a frequent flyer". He was previously hospitalized for 2 weeks and was discharged last Friday. He was readmitted Monday in another crisis. He has c/o pain in chest, lower back, and bilateral hips. On previous admissions, MD had ordered Demerol PCA...can't remember the dose but pretty generous...would change PCA vial out twice a shift. At the beginning of last week, MD swapped Demerol PCA to Morphine PCA 1mg/6min. Had pt. couple of nights last week and Morphine and Phenergan IV worked good to control pt pain...but did bottom out BP 88/43, but asymptomatic. When pt. came in Monday, pt. stated allergy to Morphine so MD ordered Demerol PCA...this was controlling pain well but MD d/c'd the Demerol PCA and Phenergan yesterday...stating that pt. like it way too much. MD ordered Stadol 2mg Q3H PRN and Zofran 4mg Q4H PRN and Ativan 1mg IV Q6H PRN. When in to assess last night at beginning of shift, pt. crying in pain, mother at bedside, asking for pain med. Explained that could not give pain med until 45 mins. later (and that was giving it our allowed 30 minutes early), pt. continues to cry. Go back in and give pain med. Pt. requesting nausea med...explain not time for nausea med. Give Atian 1mg IV 30 minutes later. PT. states Stadol not helping at all. Pt. does drift off to sleep after Ativan. Awaken for VS around 2300. Stadol given @ 2310 and Zofran @ 0000. At 0100, pt. in room moaning and crying out in pain. Has called mother back in to be with him. Not time to give any pain or nausea med. Call MD at 0120, Vistaril 75 MG IM X 1 dose ordered and given. Recheck on pt. @ 0200, pt still crying and moaning. @ 0215, Ativan given again IV. Pt. rests until 0400,when he is again awake and crying. Stadol given again IV. Recheck in 30 minutes, states no relief. Zofran given @ 0545 for c/o nausea/pain without relief. Stadol given again @ 0640 for pain. MD comes into make rounds before I left this a.m. Speak with him about pt. pain and MD is irrate. He says that he told pt. that he could either have the Stadol or Morpine PCA..he is not getting Demerol. I guess it doesn't matter that pt. states allergy to Morphine. Then MD proceeds to say, come with me to room, I guarantee you he will be asleep. I tell MD that I have just given pain med. Go to room with MD, pt. is asleep. MD wakes him up and states "I hear you had a bad night. Is the stadol not helping at all?" pt. states maybe a little. MD states "You can have your Morpine PCA", pt. and mother both say no MD says "Well then Stadol it will be. You are not getting Demerol again...you like it way too much". Not only did this embarrass me but it made me angry b/c how can MD say that the pt. is not in pain....on top of it all MD ordered XRAY of Bilateral hips this a.m. for necrosis of femoral head..but he is not in pain!

What do some of you use at your hospital when pt. come in with Sickle Cell Crisis?

I guess the MD is saying that the pt. is addicted to Demerol. That is not for me to say but MD has always gave Demerol generously to this pt I know for the last year whenever he was in Crisis and now he takes it all away. I am very upset over this situation and I hope when I go into work tonight, there has been some kind of change..but I doubt it, b/c day shift nurse took MDs side.

Thanks for taking the time to read this, looking forward to your responses.

This OP makes me so angry. My first husband had acute intermittent porphyria. It is not in any way related to Sickle Cell except that clinically the two present similar when in crisis. In both cases there is little to do except IV fluids and pain meds.

What makes me so angry is remembering how my husband was treated. He was treated like the OP's patient many many times. Just when a pain med regimen was working, a doctor would stop it so he wouldnt get "addicted".

In ron's case it was ALOT of not only not understanding his disease process but not even bothering to educate themselves about it:angryfire .

I watched him hurt because doctors didnt want to give him proper pain control. We, too, had a doc that stopped Demerol and ordered Stadol NS. Ron went thru one bottle a day @ $70/ bottle! We had home health care and the insurance would have paid for the Stadol IV but the doc refused!

I watched doctors and nurses treat him like a drug seeker. It broke my heart and pissed me off.

I know I am getting off topic here and I'm sorry. Ron had long hair and tattoos. I cant tell you how many times I saw a nurse take one look at him, read his orders of mostly pain meds and IMMEDIATELY label him a drug seeker :angryfire .

I would provide them with information about his disease and they STILL wouldnt try to understand!!

We finally met the most wonderful doctor who didnt understand it but educated herself on the disease process. She was a hematologist and it is she that showed me how porphyria and Sickle cell clinially mimic each other.

She had to fight to treat him. she was at constant odds with the board of doctors at the hospital. They all "in their esteemed wisdom" believed him to be a drug seeker and refused to educate themselves on his disease.

What finally changed all their minds was when he had the most severe crises he'd ever had and ended up in ICU on a vent, fighting for his life.

finally, they started to understand that he really was sick and not just drug seeking. The hospital FINALLY did inservices with the nursing staff on his disease (using information I had given them YEARS BEFORE ).

Having a patient like this is very hard to treat. They need very high doses of pain meds due to the level of pain and the tolerance they develop to the drugs. Ron took morphine every day of his life for the last 5 years. Do I think he was addicted? Yes, I do. but if he didnt take it the pain would kill him. So make him hurt? No, I'd rather have him addicted.

He died this past april while I was on my honeymoon with my new husband. I am still in contact with many of the people that cared for him at the hospital. I can tell you that many of them feel alot of regret for how he was treated early on in his disease.

Part of what angered me in the OP was how the doctor deemed the patient wasnt hurting because he was asleep. You know, when you live in that kind of pain, sometimes sleep is the only way your mind can cope. I saw Ron do that....be in excruciating pain, ask for his meds and fall asleep. That didnt mean he wasnt hurting. Just because your patient is asleep doesnt mean he isnt in pain! When you live in pain 24/7 you learn to cope.

having a patient like this is very hard to treat. they need very high doses of pain meds due to the level of pain and the tolerance they develop to the drugs. ron took morphine every day of his life for the last 5 years. do i think he was addicted? yes, i do. but if he didnt take it the pain would kill him. so make him hurt? no, i'd rather have him addicted.

southern rn brat,

please accept my condolences for your loss.

if i may be so presumptuous, i would like to address a portion of your post.

as long as your 1st husband was taking opiates for pain, he was not “addicted.”

terms that may be more applicable for him are “tolerance” and “physical dependence.”

please read info below from the link: pain.com.

please forgive me for sounding too clinical. i sincerely am passionate about helping patients with pain and the education of health care providers.

http://www.pain.com

[color=#46637b]addiction, physical dependence, and tolerance: precise definitions to help clinicians evaluate and treat chronic pain patients.[color=#333333]

heit ha[color=#333333]

[color=#333333]pain is the most prevalent presenting complaint of patients seeking medical care. opioids have been a valid treatment for moderate to severe chronic pain. addiction, dependence, and tolerance are phenomena not easily understood by the medical community. thus, three healthcare organizations formed the liaison committee on pain and addiction (lcpa) to formulate definitions of addiction, physical dependence, and tolerance. this report discusses the definitions and their application to clinical practice.

[color=#333333]

[color=#333333]addiction[color=#333333] is a primary, chronic, neurological disease with genetic, psychological, and environmental factors influencing its development and manifestations. it is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm and craving.

[color=#333333]physical dependence[color=#333333] is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

[color=#333333]tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

One thing healthcare providers need to keep in mind is that pain is as real as the patient says it is and should be treated as such.

rpv, you are right. I suppose he was dependent and not addicted. I was the addict in that relationship :crying2: .

I know we all know that pain is what the patient says it is but we all also know that isnt the case many times. I saw it so many times. I would see a new nurse come in his room, take one look at him and start treating him as a drug seeker. The nurses that didnt treat him that way would often tell me how the other nurses talked about him. Of course we never ever told him that but he knew it anyway. He would try so hard not to call out for his pain meds because of it. I would always tell him not to let himself get in so much pain that it would be harder to control it, but because of many of the nurses he would wait.

Thank you for all the replies. I worked last night and took care of this pt. again. His pain was somewhat better. The doctor did d/c Zofran yesterday and given Phenergan IV PRN. i think that is what made the pain more tolerable. I also gave hom 2 units of PRBCs last night which he said made him feel better. I am so frustrated with all of this. When I came out of report last night, I discussed this pt. with the day nurse. She totally agreed with the MD. I told her my opinion of it all. I didn't degrade the doctor at all to the pt...in fact, I didn't even mention the MD' name to the pt. but I did talk to him about a Sickle Cell Clinic that treats only sickle cell pt. about 60 miles away from where we live. He didn't know about it but said that he was going to check it out.

Thanks for all the replies!!

Specializes in med/surg, oncology.

I work on a med-surg floor and a large portion of our patients are sickle cell pts. We do use morphine on a few, but mostly dilaudid. On top of that some are also taking oxycontin. We give benedryl and phenergan to all but two that I can think of.

Specializes in Pediatrics.

how sad. i hate caring for sicklers, because they are so difficult to treat. i know they are in pain (i can't imagine just what it feels like), but i get scared that they are going to get too much. i know most of them just want to sleep the pain away, but i'd rather them stay awake, so i know they are alive!!

toradol works good in conjunction with the narcs.

we don't use demerol either.

Found this thread that may help.

https://allnurses.com/forums/f186/sickle-cell-problem-pain-57172.html

how sad. i hate caring for sicklers, because they are so difficult to treat. i know they are in pain (i can't imagine just what it feels like), but i get scared that they are going to get too much. i know most of them just want to sleep the pain away, but i'd rather them stay awake, so i know they are alive!!

toradol works good in conjunction with the narcs.

we don't use demerol either.

you would rather them stay awake to convienience you? i would think you would be thankful for them that they were able to rest. do you have any idea of the pain they are in???

Specializes in Ortho, Case Management, blabla.

I know this is an old thread. And it has been a very interesting read. It opened my eyes to sickle cell patients quite a bit (I don't see them very often).

What if you have a patient that is not in sickle cell crisis; yet has a long hx of sickle cell problems. The pt comes in for something completely unrelated (i.e. an ingrown toenail), and then behaves the same as if they were in the middle of a sickle cell crisis ? (demanding pain medication with benadryl and phenergan IV constantly - and getting snowed out of their minds?). Even if their pain is controlled at home with lorcet/percocet/etc, then suddenly they are in the hospital and none of the pain meds are working? I'm just curious. I hope my question made sense. I'm definitely not one to label someone a "seeker" (I work in ortho, pain meds are my bread and butter and I actually own stock in the makers of dilaudid haha). But is it wrong to try to get them to space their meds out a bit so they can function a bit? Mind you, this is a patient that is not in sickle cell crisis at the time of hospitalization (per the physician). And this is a patient that was getting so snowed I barely managed to keep them on their feet/not fall during trips to the bathroom...Or am I just a bad nurse?

Specializes in Pediatrics.
you would rather them stay awake to convienience you? i would think you would be thankful for them that they were able to rest. do you have any idea of the pain they are in???

wow, must've missed the reply 2 1/2 yrs ago. obviously, i don't know what it feels like, as evidenced by my statement:

i know they are in pain (i can't imagine just what it feels like), but i get scared that they are going to get too much.
. i am extrmeley sensitive to their perception of pain, moreso than many nurses i have worked with, who just write them off as drug seekers. it is not a matter of inconvenience, it is a matter of maintaining respiratory and cns function.

november, your point is very valid. i have personally never experienced anything like this (that i can remember). i don't know if a patient like this can seriously differentiate between the sickle cell pain and any other pain (can this ingrown toenail be as painful as the pain during a crisis?). who knows. i am not suggesting anything here, nor am i passing any judgement (my disclaimer), just throwing it out there :wink2:

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