Sickle Cell Crisis Question LONG VENT!!

Undecided7 · Jan 19, 2006

Sicke Cell is VERY painful and it sounds like Morphine was not the best option given his BP drop. There are people that seek out drugs and especially Demerol, but it doesn't sound like the case here. In fact, it sounds like the doctor is an A..hole. I would tactfully just inform the pt. and family of their pt. rights at the hospital and right to change doctors if they so desire. You are the patient advocate and without bad mouthing a doctor you can always inform patients of their rights. I don't know if your hospital has a pt. advocate or not, but that might be another resource.

Trauma Columnist · Jan 19, 2006

I am an ER Case manager and for my sickle cell patients, I always push for a pain clinc appt/consult. The reason is - is that yes, these patients do become very tolerant to narcotics. However, since symptom relief is the goal, narcotics are the answer for this particular disease process. Sometimes Toradol also works well. Its very individual. Morphine releases a histamine response and the patients can get very itchy. So, give some Benadryl with the Morphine and usually you get a much better reaction than with Demerol. Our hospital as a whole gives very little Demerol due to the associated nausea.

rjflyn, ASN, RN · Jan 19, 2006

Not to mention the neurotoxic effects of Demerol and that a lot of places are discontinuing the use of it. It is though a fine line between pain control and addiction for these patients. I actually have ran accross a couple that have been treated by the pain specilaists and its amazing the results they get. But the key also seems to be how compliant the patient is with his other treatment for his disease.

RJ

SharonH, RN · Jan 19, 2006

I think that you have your finger on the problem: the doctor is a jerk. I find the sickle cell patients are treated less tolerantly, they are the first to be identified as "drug seeking" and their pain is often undertreated. Overall, there has been much more progress in this area and I now often see sickle cell patients who are pain-controlled when in the past, it used to be a battle. I haven't worked in the hospital in a couple of years, but we used to give them Demerol PCA from the day of admission to the day of discharge and this worked very well, also I noticed that their admissions were shorter because they were treated more agressively. Your doctor sounds like he is from the old school, they need a new doctor pronto but I admire the way you advocated for your patient.

rpv_rn · Jan 19, 2006

Unfortunately, one of the most "abused" patients in our society by health care workers is the person with sickle cell anemia who is in crisis. Their pain is real. When a blood vessel is occluded, that area is deprived of oxygen and nutrients --> very real pain.

When a patient is experiencing chest pain (ie MI) --> what happens? A blood vessel becomes occluded. We treat that person and control his/ her pain.

SCC has a similar pathology. Unfortunately, there is bias in our country due to the race or economics of patients with sickle cell anemia. They have been negatively labeled as drug seekers, etc. I have heard nurses state derogatory remarks when patients with sCC are admitted and do what they can to not have that patient as an assignment. Shame on them.

The MD's response to that young man was unethical. I also agree that the nurse has to speak up about patient's rights and their right to having pain control. He/she needed to assess what the pt's allergic response to morphine was to see if pt truly had allergic reaction.

For the most part, I have seen Morphine via PCA used for patients who are experiencing SCC. Benadryl is given for the histamine effect, as stated in previous posts.

I would assess what s/sx the patient had when given morphine. If his BP dropped that low, his body my have been adjusting to the opiate. The rate could be adjusted (via PCA is better than PRN dosing), evaluate the pt's tolerance and adjust the dose accordingly. The MD could also order PCA bolus for breakthru pain.

I have followed up patients post discharge. When they are not in crisis, for the most part they are productive people doing well in society.

Please give us update on your patient. Thank you.

Aneroo, LPN · Jan 20, 2006

Unfortunately, one of the most "abused" patients in our society by health care workers is the person with sickle cell anemia who is in crisis. Their pain is real. When a blood vessel is occluded, that area is deprived of oxygen and nutrients --> very real pain.
When a patient is experiencing chest pain (ie MI) --> what happens? A blood vessel becomes occluded. We treat that person and control his/ her pain.
.

I have never thought of SCC pain this way, but what an awesome way of putting it!

We don't use demerol anymore at our facility. I have given morphine, then we usually go to dilaudid. Some docs are more understanding and will go straight to dilaudid. I usually don't have them long enough to start a PCA (I'm in the ED).

Trauma Columnist · Jan 20, 2006

Our hospital doesn't use Demerol anymore either.

Tweety, BSN, RN · Jan 20, 2006

Good answers above. We use morphine or dilaudid and demerol if the patient is allergic to morphine. Some of our "frequent fliers" are very narcotic tolerant, but are very sick as well. We have one had to have a leg amputated and now the other leg is infected. I've known him for 14 years and he is a tremendous challenge for pain control and many docs have "fired" him. He's in his late thirties and has nearly died several times and is old for a SC patient that is this sick. Considering he's been on narcotics since he was six years old, it's no wonder he's narc. dependent (he is always on narcs, even at home). Another patient we have just had to have a hip replacement, that got infected, and was just removed, and was a pain control challenge. Another had a stroke. SSC is a dreadful and painful condition to have.

Most of the SSC patients, I see usually report high numbers for their pain, but "appear" to be well controlled, because they aren't crying in pain, and sleep well, and are in good spirits. But to get them there can be a challenge, especially if they have to have surgery.

I've noticed that virtually all of our SSC are now requesting Benadryl IV, has anyone noticed this trend? They virtually all like IV Phenergan as well, which I understand because that helps with the pain.

Trauma Columnist · Jan 20, 2006

The benadryl helps with the histamine release that morphine (especially) gives. So...the patient actually gets more relief with the addition of benadryl than just with narcs alone. Tweety - I agree that these patients are a true challenge. Sometimes the challenge is to change the minds or opinions of the providers!

rpv_rn · Jan 20, 2006

I agree that these patients are a true challenge. Sometimes the challenge is to change the minds or opinions of the providers!

Helping health care providers (HCP) look at patients with sickle cell anemia in a new light is very challenging. I have been privileged to work on a committee whose objective was to improve the care of patients with SCC. The group consisted of black and non-black (which I am) staff MD, RNs, PT/OT, social worker, nutritionist, pharmacist.

One of our objectives was to educate HCP about the disease process of SCC, to behave toward patients with respect and dignity and to improve their pain control during their hospital stay and post discharge.

Another objective was to educate patients about their disease process and lifestyle behaviors that would prevent/ control crises.

One of the most eye-opening situations for me was when we had meetings with our patients and their families. We met their children who also had SCA. These families are like all families. They have concerns for their welfare, health, life for themselves and their family. I can't emphasize enough, that when patients with SCA are not in crises, they are a productive part of our society, as all other human beings.

Unfortunately, our comm disbanded due to the MD retiring and other staff changing / leaving for new positions. I was in staff education but I left for a faculty position in an ADN program.

Now my approach is to educate students about comfort. Included in my lecture is my passionate spiel about patients in SCC and their right to pain control. These students are our future professional nurses. If I can help them to view that all patients have a right to comfort and to feel safe, then I feel I have served a purpose for our profession.

Tweety, BSN, RN · Jan 20, 2006

The benadryl helps with the histamine release that morphine (especially) gives. So...the patient actually gets more relief with the addition of benadryl than just with narcs alone. Tweety - I agree that these patients are a true challenge. Sometimes the challenge is to change the minds or opinions of the providers!

Thanks. I didn't know that and learned something. :)