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PED-EM-L  January 2009

PED-EM-L January 2009

Subject:

Re: Triage guidlines for sickle cell disease

From:

"Martin Herman, M.D." <[log in to unmask]>

Reply-To:

Martin Herman, M.D.

Date:

Thu, 8 Jan 2009 17:44:59 -0600

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (358 lines)

I agree chronic pain may have different responses. I wonder if anyone wants
to do a multicenter study looking for some marker that would help
differentiate those drug seekers, faker sfrom the really distressed. I have
read papers that have proposed that a Substance P level might be helpful.
Other levels that come to mind are cortisone, catecholamine levels, IL-6,
and TNF.  Perhaps we can actually find a substance that reliably
differentiates these patients.

In out city the Heme people have been very concerned about their SSA
patients becoming addicts. Believe me they are not shy about prescribing
pain meds like MS contin, even dilaudid. ALmost all of the kids have beeen
on either apap with codein or hydrocdone their entire life. Still some do
not seem to need as much pain medication as others. Hydroxyurea does seem to
be a big help.

I think the point is if you think the patient is in moderate to severe pain
you caninitiate care in triage. We have standingorders for our SSA pts in
pain. They are to get Toradol 0.5 mg/kg IV ( max 30), followed by MS 0.1-0.2
mg/kg IV. Benadryl if needed is to be given po because we have experienced
kids getting high on the IV form. Meds can be started long before a doc sees
the kid. If the pats pain is subjectively mild or in the opinion of the
parents or triage nurse then there is no reason to bump them to a high
triage level. BTW, we have a very large population of SSA pats since St Jude
has alarge Hem division and if we made all the SSA pts Level 2, we might use
5 rooms or at any given time. We only have 25 beds in our ED and handle
about 50K pts a year. DO the math if every SSA was brought back, we would
have about 20 beds to see everyone else. So it just isn't feasible in a busy
ED with a high volume of these pts.


MArty


On Thu, Jan 8, 2009 at 12:38 PM, Asselta, Robert <
[log in to unmask]> wrote:

> It is difficult in emergency medicine/nursing to categorize "all
> patients with a history of....." should be assigned a level "2" and
> brought immediately into the treatment area. Where do we draw the line?
> Should all abdominal pains be brought right in because of the potential
> of end organ failure related to possible GI bleed, perforation,
> obstruction, pancreatitis, liver failure etc? There are, at times, a
> limited amount of beds as well as medical and nursing caregivers.
>  Again, each patient is assessed according to their complaint, and their
> potential for instability, also taking into account their hx and risk
> factors.
>
> In general, MOST sickle cell patients who have pain WILL NOT be left in
> the waiting area. Severe pain is a criterion for a level 2 anyway. In
> addition, because of the reasons you state, they will/should not wait
> long.
>
> In the ED today we have no choice but to prioritize.
>
> We empathize with our patients who suffer with chronic pain. ED staff
> utilizes their utmost in expediting relief and comfort for our patients.
> The frustrations we feel when treatment is delayed or when facing angry
> patients, families, or friends is not something we become accustomed to.
> We expedite treatment as best as we can, even if, as Marty says,
> initiating care in the waiting area.
>
> The challenges that we face in the ED (overcrowding, boarding, staff
> shortages) are processes that we work on everyday to improve upon.
>
> Respectfully,
> Robert
>
> Below is an answer to your guideline question:
>
>
> According to ESI triage guidelines and Emergency Nurses Assn. triage
> guidelines, there are NO specific criteria for SSD or any other disease
> process for that matter. Triage levels are assigned according to patient
> presentation. The triage level given will depend on the patient's level
> of distress. Example: if a SSD patient presents to the ED c/o SOB, chest
> pain (we would worry about chest pain syndrome) or a pain scale > 5 with
> stable vitals, they should be triaged as a level 2. If there is NO SOB,
> CP,  and a pain scale <4 or 5,  they can be triaged as a 3.
>
> Robert
>
> Robert Asselta, RN, CEN
> Education Specialist, ED
> Dept.of Nursing Education
> Office: 212-241-4910
>  Pager # 8053
>
> -----Original Message-----
> From: Pediatric Emergency Medicine Discussion List
> [mailto:[log in to unmask]] On Behalf Of William Zempsky
> Sent: Thursday, January 08, 2009 9:44 AM
> To: [log in to unmask]
> Subject: Re: Triage guidlines for sickle cell disease
>
> Marty
>
> I don't want to single you out for my comments because I think many if
> not the majority of physicians feel the way you do regarding sickle cell
> patients in the ED.  I have heard comments like yours many times.  "Hey
> ...they say they are an 9 out of 10 but they don't look like it to me.
> I think their faking, or drug seeking. "
>
> I have spent the last 3 years heavily involved in this issue.   I have
> spent time with children, parents and adults with sickle cell disease.
> They recount the horrors of their emergency department visits.  No one
> believes them, they are treated like drug addicts.   I ve heard them
> describe their pain like "  being hit with a board with nails in it",
> or "like a million little heart attacks  all over my body".   They ask.
> "Why on earth would I go to the emergency department, a place where I am
> treated like a subhuman if I didn't need to go?,  Don't you think I have
> something better to do with my Saturday night?".
>
> So getting back to your point regarding their lack of vital sign
> changes, their relatively comfortable appearance.  What explains this
> phenomenon?  When you fall down and break your leg, how do you respond?
> You sweat, you get tachycardic, hypertensive.  What if this happened
> every day, or every week?  Your physiologic response becomes muted,
> controlled. i have a clinic full of patients  (mostly not sickle cell
> disease) who report pain that is 10/10 constantly yet look better than
> you or I.  This is chronic pain.   Sickle cell pain is this type of
> pain.  The patient may have had pain for hours, days or weeks when they
> come to the ED. Thus the blunted response.
>
> I truly believe based on medical indications alone  (severe pain, end
> organ damage), patients with sickle cell disease should be treated with
> expedience in the ED.  But clearly there is an incredible bias against
> this group of patients.  If affirmative action is needed to reduce this
> bias (ie,. make them all level 2 because that's the only way they will
> get the care they deserve) I am all for it.  This is not an issue of
> compassion, its medical necessity.  Its allowing these patients to be
> treated with dignity and respect, they deserve nothing less.
>
> Bill
>
> William T. Zempsky, MD
> Associate Director, Pain Relief Program
> Medical Director, Clinical Trials
> Connnecticut Children's Medical Center
> 282 Washington Street
> Hartford, CT 06106
> 860-545-9041
> Fax 860-545-9969
> [log in to unmask]
>
>
> >>> "Martin Herman, M.D." <[log in to unmask]> 1/7/2009 5:32 PM
> >>>
> I am all for compasion. Some of our patients do not have opioids at
> home.
> Some haven't given anything at all and I have a few patients that get
> nearly
> pain free with NSAIDS. Especially if they are not on hydroxyurea ( more
> severe sicklers) . Our hematologists want us to try NSAIDS before we
> give
> morphine. So our protocol for the HgbSS, SC, and S-Thal pts is to give
> motrin or Toradol first.
>
> Actually this discussion though interesting is a little off point. Bill
> had
> asked if the sickle cell pts should be Level II or not. I posited that a
> triage intervention may obviate the need to Level them a II. If you want
> to
> have a policy of giving Lortab or VIcodin in the triage or starting and
> IV
> and giving IV MS before being seen, I guess you can do that. Questionis,
> does the pt with sickle cell pain who rates the pain as a 8 or 9/10 but
> whoose bp, pulse and resp are nml. WHo is talking normally on their cell
> phone or necking with their girlfreiend really need to be brought back
> before a baby with a fever? or a kid with an earache?
>
> Marty
>
>
> On Wed, Jan 7, 2009 at 2:02 PM, Amy Baxter <[log in to unmask]>
> wrote:
>
> > Hmmmm    Motrin?
> >
> > A pediatrician I worked with happened to have HgbSS and two children.
> We
> > were discussing pain control for labor -- she had delivered both kids
> > naturally.  When I expressed the respect women give other women who
> have
> > "gone natural", she taught me more about sickle cell pain than I'd
> learned
> > in residency and two fellowships:
> >
> >        "Labor?!?  Compared to a sickle cell crisis, labor is nothing.
> >  Sickle
> > cell pain is like having your bone crushed, like your whole world is
> > focused on something that takes your breath away.  Over time you
> realize
> > that crying doesn't help, sucking up to doctors for pain medicine
> doesn't
> > help, only trying to put your mind somewhere else can help a little.
> > Believe me, after dealing with SS all my life, labor was nothing."
> >
> > So when children whose parents almost always have oral opioids at home
> > bring them to the ED for relief, having them wait or offering Motrin
> just
> > really isn't fair.  We can't always fix what's wrong with people, but
> with
> > the subset of humans who were dealt a definitively crappy hand, let's
> err
> > on the side of believing them and on the side of compassion.
> >
> > Morphine for everyone!!!!
> >
> > -Amy
> >
> > William Zempsky <[log in to unmask]> writes:
> > >Because especially in adult EDs sickle cell patients (adolescents and
> > >adults) can languish in the waiting room for hours.  Early and
> agressive
> > >managment of sickle cell pain is an effective method to prevent
> > >hospitalization, and there is an emerging body of evidence that
> > >coinciding with pain episodes is end organ damage from sickling.
> > >Agressive treatment may diminish this as well (not yet proven)
> > >
> > >Bill
> > >
> > >
> > >William T. Zempsky, MD
> > >Associate Director, Pain Relief Program
> > >Connnecticut Children's Medical Center
> > >282 Washington Street
> > >Hartford, CT 06106
> > >860-545-9041
> > >Fax 860-545-9969
> > >[log in to unmask]
> > >>>> "Martin Herman, M.D." <[log in to unmask]> 01/07/09 12:20
> PM
> > >>>
> > >WHy a triage level 2 . I think some patients can be handled as triage
> > >3,especially if you allow the triage nurses to administer motrin in
> the
> > >WR.
> > >
> > >Marty
> > >
> > >
> > >On Wed, Jan 7, 2009 at 9:09 AM, William Zempsky
> > ><[log in to unmask]>wrote:
> > >
> > >> My colleagues and I in connecticut are tryng to develop statewide
> > >> guidelines for triage of patients with sickle cell disease.  These
> > >guidlines
> > >> will target both adult and pedatric facilities.
> > >>
> > >> There appears to be a wide range of approaches to this issue
> especially
> > >in
> > >> adult EDS
> > >>
> > >> As a first step I would like to get all EDs in our state assgning
> all
> > >> sickle cell patients who present with pain to level 2 triage
> status.  I
> > >am
> > >> looking for published triage guidelines from national/international
> > >> organizations which list sickle cell pain as a level 2 triage
> criteria.
> > >>  Please contact me if you know of any.  Thanks.
> > >>
> > >> Bill
> > >>
> > >> William T. Zempsky, MD
> > >> Associate Director, Pain Relief Program
> > >> Connnecticut Children's Medical Center
> > >> 282 Washington Street
> > >> Hartford, CT 06106
> > >> 860-545-9041
> > >> Fax 860-545-9969
> > >> [log in to unmask]
> > >>
> > >> For more information, send mail to [log in to unmask] with
> the
> > >> message: info PED-EM-L
> > >> The URL for the PED-EM-L Web Page is:
> > >>                 http://listserv.brown.edu/ped-em-l.html
> > >>
> > >
> > >
> > >
> > >--
> > >Marty
> > >Martin Herman, M.D.
> > >Pediatric Emergency Specialists, P.C.
> > >Lebonheur Children's Medical Center
> > >Memphis Tn 38103
> > >
> > >901 287 5986 ( ED office)
> > >901 287 6226 ( ED fax)
> > >
> > >For more information, send mail to [log in to unmask] with
> the
> > >message: info PED-EM-L
> > >The URL for the PED-EM-L Web Page is:
> > >                 http://listserv.brown.edu/ped-em-l.html
> >
> >
> >
> > Amy Baxter MD
> > Pediatric Emergency Medicine Associates
> > 404 371-1190
> >
> >
> > For more information, send mail to [log in to unmask] with
> the
> > message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> >                 http://listserv.brown.edu/ped-em-l.html
> >
>
>
>
> --
> Marty
> Martin Herman, M.D.
> Pediatric Emergency Specialists, P.C.
> Lebonheur Children's Medical Center
> Memphis Tn 38103
>
> 901 287 5986 ( ED office)
> 901 287 6226 ( ED fax)
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>



-- 
Marty
Martin Herman, M.D.
Pediatric Emergency Specialists, P.C.
Lebonheur Children's Medical Center
Memphis Tn 38103

901 287 5986 ( ED office)
901 287 6226 ( ED fax)

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html

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