LISTSERV mailing list manager LISTSERV 16.5

Help for PED-EM-L Archives


PED-EM-L Archives

PED-EM-L Archives


PED-EM-L@LISTSERV.BROWN.EDU


View:

Message:

[

First

|

Previous

|

Next

|

Last

]

By Topic:

[

First

|

Previous

|

Next

|

Last

]

By Author:

[

First

|

Previous

|

Next

|

Last

]

Font:

Proportional Font

LISTSERV Archives

LISTSERV Archives

PED-EM-L Home

PED-EM-L Home

PED-EM-L  January 2009

PED-EM-L January 2009

Subject:

Re: Triage guidlines for sickle cell disease

From:

"Asselta, Robert" <[log in to unmask]>

Reply-To:

Asselta, Robert

Date:

Thu, 8 Jan 2009 13:38:56 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (304 lines)

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

Top of Message | Previous Page | Permalink

Advanced Options


Options

Log In

Log In

Get Password

Get Password


Search Archives

Search Archives


Subscribe or Unsubscribe

Subscribe or Unsubscribe


Archives

May 2019
April 2019
March 2019
February 2019
January 2019
December 2018
November 2018
October 2018
September 2018
August 2018
July 2018
June 2018
May 2018
April 2018
March 2018
February 2018
January 2018
December 2017
November 2017
October 2017
September 2017
August 2017
July 2017
June 2017
May 2017
April 2017
March 2017
February 2017
January 2017
December 2016
November 2016
October 2016
September 2016
August 2016
July 2016
June 2016
May 2016
April 2016
March 2016
February 2016
January 2016
December 2015
November 2015
October 2015
September 2015
August 2015
July 2015
June 2015
May 2015
April 2015
March 2015
February 2015
January 2015
December 2014
November 2014
October 2014
September 2014
August 2014
July 2014
June 2014
May 2014
April 2014
March 2014
February 2014
January 2014
December 2013
November 2013
October 2013
September 2013
August 2013
July 2013
June 2013
May 2013
April 2013
March 2013
February 2013
January 2013
December 2012
November 2012
October 2012
September 2012
August 2012
July 2012
June 2012
May 2012
April 2012
March 2012
February 2012
January 2012
December 2011
November 2011
October 2011
September 2011
August 2011
July 2011
June 2011
May 2011
April 2011
March 2011
February 2011
January 2011
December 2010
November 2010
October 2010
September 2010
August 2010
July 2010
June 2010
May 2010
April 2010
March 2010
February 2010
January 2010
December 2009
November 2009
October 2009
September 2009
August 2009
July 2009
June 2009
May 2009
April 2009
March 2009
February 2009
January 2009
December 2008
November 2008
October 2008
September 2008
August 2008
July 2008
June 2008
May 2008
April 2008
March 2008
February 2008
January 2008
December 2007
November 2007
October 2007
September 2007
August 2007
July 2007
June 2007
May 2007
April 2007
March 2007
February 2007
January 2007
December 2006
November 2006
October 2006
September 2006
August 2006
July 2006
June 2006
May 2006
April 2006
March 2006
February 2006
January 2006
December 2005
November 2005
October 2005
September 2005
August 2005
July 2005
June 2005
May 2005
April 2005
March 2005
February 2005
January 2005
December 2004
November 2004
October 2004
September 2004
August 2004
July 2004
June 2004
May 2004
April 2004
March 2004
February 2004
January 2004
December 2003
November 2003
October 2003
September 2003
August 2003
July 2003
June 2003
May 2003
April 2003
March 2003
February 2003
January 2003
December 2002
November 2002
October 2002
September 2002
August 2002
July 2002
June 2002
May 2002
April 2002
March 2002
February 2002
January 2002
December 2001
November 2001
October 2001
September 2001
August 2001
July 2001
June 2001
May 2001
April 2001
March 2001
February 2001
January 2001
December 2000
November 2000
October 2000
September 2000
August 2000
July 2000
June 2000
May 2000
April 2000
March 2000
February 2000
January 2000
December 1999
November 1999
October 1999
September 1999
August 1999
July 1999
June 1999
May 1999
April 1999
March 1999
February 1999
January 1999
December 1998
November 1998
October 1998
September 1998
August 1998
July 1998
June 1998
May 1998
April 1998
March 1998
February 1998
January 1998
December 1997
November 1997
October 1997
September 1997
August 1997
July 1997
June 1997
May 1997
April 1997
March 1997
February 1997
January 1997
December 1996
November 1996
October 1996
September 1996
August 1996
July 1996
June 1996
May 1996
April 1996
March 1996
February 1996
January 1996
December 1995
November 1995
October 1995
September 1995
August 1995
July 1995
June 1995
May 1995
April 1995
March 1995
February 1995
January 1995
December 1994
November 1994
October 1994
September 1994

ATOM RSS1 RSS2



LISTSERV.BROWN.EDU

CataList Email List Search Powered by the LISTSERV Email List Manager