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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