Sickle Cell Anemia

[Epi-do]

So, what are you able to do for a patient having a sickle cell crisis?

I had a patient the other day that was having a crisis. He refused analgesics since we were only 5-10 minutes from the ER. I put him on O2 and tried to get an IV. He had absolutely nothing due to years of IVs and blood transfusions, except for alot of scarring. I was finally able to find a single vein in his foot that blew as soon as I stuck it. It was then that he told me that alot of times they have to go to his neck. Since we were getting ready to pull into the ER, I didn't bother with starting the EJ.

I just felt horrible for this guy. He was in obvious pain, primarily in his leg, and I just didn't seem to be able to do a darn thing for him. Had he allowed me to give him some pain meds, I could have at least given him some fentanyl intranasally at least, since I couldn't get a line and get some fluid going.

 

[vquintessence]

But he was appropriately oriented and refused? I wouldn't get upset. Transported many people with injuries that were clearly painful, and they've refused any pain control.

I've refused many times at ED's simply because of the intense nausea and discomfort of being doped up. Who knows what your pts reasoning was; perhaps he may have been a drug addict in the past, and knows the inherent risks of exposure. Too many possibilities, but ultimately your pt knows his own threshold for pain and made the decision. Don't beat yourself up over something you had no say in.

 

[Tincanfireman]

I put him on O2 and tried to get an IV.

Epi, what was the delivery rate of O2? I only ask because we have a number of SCD patients and I normally default to 12 LPM via mask for the really sick ones. Not a lot more that we can do pre-hospital, though our transport times are generally less than 15 minutes except from the hinterlands of the county.

 

[Epi-do]

Epi, what was the delivery rate of O2? I only ask because we have a number of SCD patients and I normally default to 12 LPM via mask for the really sick ones. Not a lot more that we can do pre-hospital, though our transport times are generally less than 15 minutes except from the hinterlands of the county.

It was a NC 4 lpm - he wouldn't tolerate anything more.

 

[Tincanfireman]

Wouldn't accept meds for pain management, nor a mask for O2 therapy... There's only so much you can do sometimes! You did the best you could, dear.

 

[VentMedic]

The patient has probably been stuck for an IV many times and knows it is futile. As well, they may know what meds will and will not work for them and it is doubtful that a Paramedic will have the drugs or be able to give the dosage required to give them any relief. Whatever you as a Paramedic can give may be more of an annoyance for this situation rather than a benefit.

As far as O2, they may also know the pathophysiology of their disease and know which way their oxyhemoglobin dissocitation curve shifts as well as their carrying capacity.

 

[cm4short]

High flow O2, IV, Fluid bolus, and Pain management are the primary hospital concerns.

You main concern lies in perfusion of the patient. Pain management and O2 therapy help the patient cope. Capillary perfusion in decreased in a sickle cell crisis due to; the decreased oxygen carrying capacity and the clumping of RBC's in the capillary veins. This causes decreased perfusion and increased pain to the affected area.

 

[VentMedic]

Epi-do didn't mention the patient's age as that also is a factor in how a person may act as they are approaching the end of their life expectancy. For a man with sickle cell anemia, that age is about 42.

We also do not know the other medical history as to what nerve and organ damage has already been done. That will also determine the effectiveness or complications of pain management.

Hydration is of course a big issue and one of the questions to ask would be what was the patient's fluid intake over that past couple of days.

 

[Epi-do]

Epi-do didn't mention the patient's age as that also is a factor in how a person may act as they are approaching the end of their life expectancy. For a man with sickle cell anemia, that age is about 42.

We also do not know the other medical history as to what nerve and organ damage has already been done. That will also determine the effectiveness or complications of pain management.

Hydration is of course a big issue and one of the questions to ask would be what was the patient's fluid intake over that past couple of days.

I know I didn't include any of that, but it was mainly because I was looking more for what sort of treatments others are allowed to do rather than did I treat this patient appropriately.

This patient was mid-20s, but I don't remember his exact age. I did ask about hydration and he stated he had been drinking plenty of fluids, although again, I can't remember exactly how much he said he had drank that day since it was a few shifts ago. As for any other issues/history, he denied any other diagnosis and didn't disclose to me any additional/chronic issues related to the sickle cell.