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ED patients often deal with frightening symptoms, noisy waiting rooms, and long delays. However, patients with sickle cell disease have a unique problem: Although they are in excruciating pain, they often are viewed as drug seekers.
"Patients tell us that they are not believed by ED staff and they feel like they have to act out to get attention," says Allan Platt, PA-C, program coordinator for the Atlanta-based Georgia Comprehensive Sickle Cell Center at Grady Health System, which has a nine-bed dedicated ED for sickle cell patients. "The level of pain stated by the patient should be believed and treated accordingly."
He gives the following as an example: A 25-year-old auto mechanic with sickle cell disease hemoglobin type SC reports excruciating back and hip pain. The patient came to the ED twice in the previous week and was given a meperidine shot and some meperidine pills upon discharge. You overhear the ED physician comment, "He’s back — he’s just drug seeking."
As the ED nurse, you must advocate for appropriate pain management for this sickle cell patient, urges Sylvia Ann Rainey, RN, the facility’s research nurse. "A nurse can remind a doctor that patients have the right not to be labeled," she says. "It is not for us to judge who should receive pain medications and who should not." Sickle cell patients may present to the ED with high levels of pain and need rapid pain treatment, she emphasizes. (See chart with specific interventions to take.)
Ask the patient, "Is this pain typical for your pain crisis?" advises Platt. "This is a great question to determine if the pain is routine for the patient or a complication causing atypical pain."
Use a visual analog scale to assess pain in sickle cell patients, says Platt. He points to a recent study which found that visual analog scale scores reflect the pain levels of patients accurately.1 Researchers found that pain score rating by physician and parents is consistently lower than by patients, and that visual analog scores and categorical scale (ranging from "none" to "very severe") scores are strongly correlated. The results emphasize the importance of patient self-reporting with a visual analog scale, says Platt.
In the above case, ED nurses made sure that an ED attending physician with sickle cell experience evaluated the patient, says Platt. The attending suspected that the patient had pain crisis and avascular necrosis of the right hip, and the following steps were taken:
1. The physician ordered X-rays, intravenous fluids D5W at 250 cc per hour, ketorolac (a nonsteroidal anti-inflammatory drug) 30 mg intravenously (IV) every six hours, and morphine 10 mg IV every three hours.
2. ED nurses ensured that basic lab work was ordered, including a complete blood count with reticulocyte count, chemistry profile, and urinalysis.
3. Once the patient’s pain level was down to a level 5 on a numerical pain scale of 1-10, ED nurses escorted him to X-ray for hip films. This confirmed avascular necrosis of the right hip, a condition common in sickle cell disease patients, Platt adds.
4. The attending reviewed the findings with the patient, arranged a hematology-sickle cell clinic follow-up, and started the patient on a daily long-acting nonsteroidal anti-inflammatory drug. The patient was informed that orthopedic consultation would be needed in the near future and that he would need physical therapy and vocational rehabilitation to help with the hip pain and his job. He was given a 48-hour supply of hydrocodone/acetaminophen for breakthrough pain and told to return to the ED if the pain increased.
At this time, the patient’s pain had decreased to a level 4, and he thanked ED nurses for believing his level of pain. "He stated that this was the best ED visit he has ever had," says Platt.
1. Weiner DL, Stark PC, Hibberd PL. Pain assessment: A comparison of patient, physician, and parent ratings and of rating scales. Acad Emerg Med 2003; 10:441.
For more information on sickle cell patients, contact:
• Allan Platt, PA-C, Program Coordinator, The Georgia Comprehensive Sickle Cell Center at Grady Health System, 80 Jesse Hill Jr. Drive, P.O. Box 109, Atlanta, GA 30303. Telephone: (404) 616-5994. Fax: (404) 616-5998. E-mail: firstname.lastname@example.org. Web: www.SCInfo.org.
• Sylvia Ann Rainey, RN, Sickle Cell Research Nurse, The Georgia Comprehensive Sickle Cell Center at Grady Health System, 80 Jesse Hill Jr. Drive, P.O. Box 109, Atlanta, GA 30303. Telephone: (404) 616-7808. Fax: (404) 577-9107. E-mail: email@example.com.