Sickle cell anemia is a horrible, painful disease. Over the years I have gone from viewing sickle cell anemia patients as drug-seekers (here I blame the EMS culture at the time) who I did nothing more than put on the stretcher and take to the hospital to human beings suffering from a painful disease who I aggressively treat with narcotic analgesics and fluid.
Still, I find some of these patients problematic.
Case in point. Patient calls 911. Meets us at corner and requests transport to hospital 30 minutes away. There are at least 5 hospitals closer, including one only two miles away. When asked why she did not get someone to drive her, she says she has no ride. When asked why she doesn’t want to go to the closest hospital, she has no answer. She just doesn’t want to go there. We tell her that we will medicate her, but we really would prefer not to have to take her 30 minutes, and likely more away during rush hour. She relents and agrees to go to the hospital four miles away. She says she has very poor IV access. She says they usually put an EJ in her neck to give her her pain meds. We try a 24 in her wrist with no success. We offer Fentanyl intranasally. 100 mcgs does not touch her pain, she says. We offer 100 more. She declines. It just stuffs up my nose, she says. Your choice, we say. In the hospital, we wait in triage for 20 minutes, and then then put her in the waiting room.
So, let’s analyze this. Her pain is so bad she needs an ambulance, but is willing to travel 30 miles to go to the ED. Why is that? Maybe because she knows she will not get the pain meds she wants at the closer hospital? Maybe her pain is so bad, she is willing to wait that extra length of time to reach the distant hospital for the promise of more lasting treatment. She refuses more Fentanyl IN because it stuffs up her nose. Maybe she knows the Fentanyl won’t work for her? Maybe her pain is so great that she cannot take the added discomfort of a stuffed up nose with little relief in pain?
She never appears to be in pain at any time, but I know that sickle cell patients are so used to pain that they rarely show it.
She is just in her twenties, but she does not look healthy for what should be her prime.
Some will call her a drug seeker. If I call her that I will have to qualify it that she is seeking drugs because she is in pain.
This call causes me to review my stance on sickle cell patient, but not change it. I only wish that we could have gotten an IV in her. As far as doing an EJ or an IO, our guidelines call for their use only in extremis. Is pain extremis? I wasn’t willing to go that far, but will discuss it with some ED doctors I trust for their take.
Next day, we get a man in sickle cell crisis. He is from out of state and calls from the side of the road. He looks like a homeless man. Like the young girl the day before, his arms are pocked with scars. Like the girl, his pain is also a ten and when asked where is the best place to get an IV, he points to his neck. Fortunately, we get an IV this time in his hand and give the pain meds IV along with fluid.
If I were the younger medic of years ago, I might question the older me. What are you doing giving these pain meds to these people?
And now today, as the older medic, I say to my younger self, “It is not your place to judge. If they are in pain, and you have no persuasive reason to doubt their word, you take them at their word.”
But then my stubborn and possibly lazy younger self responds. “Okay, but even if they are not a drug seeker, why medicate them because they have such a high tolerance, all the drugs we carry are unlikley to touch them.”
My older self replies, “Well, fortunately today we carry twice as much as we used to. 20 of morphine and 400 mcg of Fentanyl. And even if that is not enough to take away someone’s pain, as our ED doctors have told us, get them started on the road to being pain-free, you will make it easier for the ED to complete the job.”
“But...”
“No, buts.”
***
We pick up another sickle cell patient, requesting to go to the cross town hospital. No amount of convincing works. The patient had just been discharged from the ED two blocks from the gas station where he is calling from. He says he is still in pain. We just monitor the patient and report the story to the nurse. The patient is put in the waiting room. I don't know how they end up treating him.
Sometimes I don't know what to think. I'm glad I don't have the disease.
