Sickle cell disease (SCD) patients are at increased risk for a whole slew of life-threatening problems. One of the many reasons they are vulnerable is because people with SCD are functionally asplenic, so they’re more likely to suffer from serious bacterial infections like meningitis, osteomyelitis, and septic arthritis. For a variety of reasons, they’re also more likely than the general population to suffer from cholecystitis, priapism, leg ulcers, avascular necrosis of the hip, acute coronary syndromes, pulmonary embolism, and even sudden exertional death. Many of these diagnoses present with pain similar to a sickle cell crisis and can be challenging because the presentations of some are less typical than usual.
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ACEP Now: Vol 35 – No 11 – November 2016Sickle Cell Pain Crisis Is a Diagnosis of Exclusion
Patients with SCD can sometimes present a challenge when it comes to pain management because it’s often difficult to discern whether they’re malingering. The majority of SCD patients suffer real pain but may not look uncomfortable because they have learned to adapt to a lifetime of chronic pain. In the emergency department, they may appear calm, be preoccupied with their handheld device, or be casually chatting. The rates of true opioid addiction in sickle cell patients are low (less than 5 percent), and the literature suggests that emergency physicians undertreat pain in sickle cell patients. I recommend that unless there is clear evidence the patient does not have SCD, take the patient’s complaint seriously and use analgesics aggressively in the emergency department.
As in all of emergency medicine, physicians need to think of the worst diagnoses first. Therefore, it is imperative not to assume that a patient with SCD who is in pain is suffering from a sickle cell crisis. If the pain is different from previous pain crises, broaden your differential diagnosis to include not only all the painful conditions that should be considered in all emergency patients but also sickle cell–specific conditions such as acute chest syndrome. The diagnosis of a pain crisis is a clinical one; no laboratory test will reliably determine whether the patient is suffering from a pain crisis, and SCD has been described in all races. Do not assume that a patient does not have SCD just because they have a light skin color. Sickle cell patients presenting with an uncomplicated pain crisis will often have normal vital signs. Any abnormal vital signs (especially fever) should raise the suspicion of alternative diagnoses. Examine joints and soft tissues looking for evidence of cellulitis, septic joints, osteomyelitis, and joint avascular necrosis. Perform a careful respiratory exam looking for evidence of an acute chest syndrome. Look for hepatosplenomegaly if you have a concern for splenic sequestration.
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One Response to “Pearls for Treating Patients with Sickle Cell Disease”
September 3, 2019
Sarah akhtarDr. Cifu’s piece published in the Journal of the American Medical Association (JAMA) and aptly titled “Advice for a Student Starting Medical School” does just that. Dr. Cifu’s lessons are a reminder that practicing medicine is a lifelong craft that we must work to perfect by bridging clinical acumen with an aptitude for the human condition.
In the piece Dr. Cifu shows us that his consistent efforts to provide proper care for a patient were not made in vain even though they were consistently denied. As a reader I was reminded that the clinical interaction can only be as effective as the patient is ready and willing to accept. However, the physician can show their support even when the patient is not ready. It can be done with guidance regarding consequences of an action or inaction as well as developing a strong relationship that will provide unwavering support when the patient changes their mind or is forced to come to terms with the extent of their condition.
Like Dr. Cifu, I have learned some important lessons during my third-year clerkships. An unexpected encounter I had during my Ob-Gyn rotation with a G4P3 African American female has forced me to be cognizant of the biases I carry into the encounter and to think about how to best engage with them. The middle-aged female was laying still in bed and moaning when I entered the room. Unfortunately sickle cell disease had left the patient with avascular necrosis of the hip. The patient was given an oral medication and expelled it due to her “nausea” and was insisting on an IV medication for the pain. Prior to this, I had the experience of observing an interaction with her partner who dumped ice water on her due to a small disagreement. He then spat on her and then left running with her cell phone. Between the abusive relationship, chronic pain from avascular necrosis, and the pregnancy I had felt truly conflicted about how to support this patient since the resident I was working informed me that the patient was just malingering prior to my speaking to the patient. To this day, I still wonder if I would have fallen for the “malingering” or if I truly believed that she was malingering. I tried to advocate for the patient, but I know that my experience is limited and that my empathy can blind the clinical acumen. I have also learned that not embracing the biases commonly held is many time strongly discouraged and might get you labeled as naïve.