Podcast: Optimizing care for patients experiencing sickle cell crises
Transcript
Mojola Omole: Hi, I'm Mojola Omole.
Blair Bigham: And I'm Blair Bigham.
Mojola Omole: This is a CMAJ Podcast.
Blair Bigham: So Jola, we've had sickle cell disease on our minds probably since we started the podcast but a recent paper in the spring re-sparked this conversation amongst us and it's a case of a sickle cell patient who actually got extremely sick. They had sickle cell SC, so a single allele gene, and ended up in the ICU with E. coli bacteremia, with renal failure, with quite a significant amount of red blood cell transfusions. They got extremely sick.
CMAJ has talked about sickle cell a couple of times in the last few years from the basics of how to manage sickle cell crisis and how to determine if there is a more dangerous vaso-occlusive crisis going on to having some conversations with patients over the years about how many times they don't receive a high standard of care. Often, there are thoughts that there's a lot of bias from providers involved in this around drug seeking behavior and other more systemic racism problems that prevent appropriate care from being given.
Mojola Omole: In the pediatric population, it's much different, mainly because they're treated as sick kids or another children's hospital and they are less viewed as drug seeking because they have a caregiver or a parent who is accompanying them. Whereas with adults, it's a different kettle of fish and having family members and having close friends who have sickle cell as adults, it's really impacts where they can live because they want to live near a hospital that they know is going to take care of them when they're in crisis and not turn them away that they have to start going to different hospitals to try and get care.
Blair Bigham:So we had this story meeting and one of our senior editors brought up this example of a well known emergency physician who people go to specifically when they're on shift for good sickle cell care and it turns out that he's not the only one. There's a number of centers that are known for being particularly adept at providing really good care to people having a sickle cell crisis. We found one of those experts and we're going to speak to Dr. Jennifer Bryan shortly. After that, we'll be talking to a patient with sickle cell disease who has had, well, some good interactions but also some not so good interactions with Ontario's healthcare system.
Dr. Jennifer. Bryan is a founding member of the UHN Emergency Department Sickle Cell Working Group and an emergency physician at UHN. She's also the co-chair of the 2022 Sickle Cell Summit being organized by the Sickle Cell Awareness Group in Ontario. Hi Jennifer, Thanks for joining us.
Dr. Jennifer Bryan: Hi, Blair. Hi, Mojola. Thanks for having me.
Blair Bigham: It's nice to go emerge doc to emerge doc on the podcast today. Jola and I mentioned off the top that people with sickle cell disease report that their treatment as children in pediatric centers is very different from the treatment they experience as adults. Does that resonate with you?
Dr. Jennifer Bryan: It does. It does. Yeah.
Blair Bigham: So what do your patients tell you about that experience of turning 18, as some people say they get kicked out of SickKids. What do they tell you about what that experience is like when they have a sickle cell crisis?
Dr. Jennifer Bryan: So what I've heard patients talk about is that switch in needing to advocate for themselves as patients and how that's a quite different experience from going in with caregivers, with parents. And so when patients are coming in as adults, now they're more often dealing one on one with their healthcare providers, they're encountering the realities of adult emergency medicine where we are very aware of issues around the opioid crisis and that certainly can impact people's care. I've heard from adults that the issues that they've encountered in terms of stigma, lack of understanding about sickle cell, and facing anti-Black racism is much more pronounced in adulthood than when they were children.
Blair Bigham: And so, it goes beyond just having to now be solo and advocating for yourself. Despite being alone, it's more that the need for advocacy is even greater because do you think it's just that there's a lesser understanding of sickle cell in the community or in "adult hospitals" or does this really get down to the more nastier topic of racism and anti-Black tendencies in medicine and this fear that emergency doctors have of drug seeking behavior?
Dr. Jennifer Bryan: I think it's all mixed in together, right? So for our adults who are living with sickle cell, when they come to the emergency department, and there is a number of different complications related to sickle cell that can bring people to an emergency department, but most common would be vaso-occlusive episodes. And so, these are incredibly painful episodes that people describe as being worse than having a broken bone, worse than labor pains, but these episodes are often invisible.
So the person is telling you, "I'm having 12 out of 10 pain," but their vital signs may well be normal. There's nothing to find on physical exams so it's an invisible cause of excruciating pain. And so, that certainly is a complicating factor. It is a lack of education around sickle cell and about the presentation of pain in people who have lived with this disease and had symptoms, often since infancy. That presentation of pain is quite different than someone who's experiencing pain for the first time maybe with renal colic, right?
Blair Bigham: By that, do you mean people are more stoic, they don't show the pain as much as they experience it? Is that what you're... I just want to cut right to it because I think a lot of emergency doctors are probably sitting there thinking, "Well, there is no tests. There's no confirmatory way for me to know what's going on here." So how can we better attend to that suffering and not be as suspicious of it?
Dr. Jennifer Bryan: So I would say let's keep it simple, right? It doesn't have to be complicated. If someone tells you they're in pain, they're in pain. One of the things that I've seen happen with people who are living with sickle cell is the coping strategies that they've developed over a lifetime of living with pain get misinterpreted as signs that they're not actually in pain and that's one of the things that we need to get past.
Blair Bigham: Give me an example of that.
Dr. Jennifer Bryan: So for example, sometimes people will say, "Oh, this person is eating a sandwich. They look like they're doing okay. They're talking on their phone. They're talking with friends," and instead of these being signs that somebody's feeling better, these can actually be very important strategies for people to manage their own pain. And so, if I see somebody who is asking for food in the emergency department or is trying to get a plug for their phone, that's not a sign for me that they're feeling better and we need to cut back on the pain medication. That's just yet another indication that I need to ask them how they're doing and say, "How is your pain right now? Is it better? Is it worse? Are we heading in the right direction?"
Blair Bigham: This is all very enlightening for me. This is, I think, super helpful. Can you tell me a little bit more about other things emergency physicians can recognize or see in these patients that might reassure them that additional opioids, for example, are in fact the right thing to do?
Dr. Jennifer Bryan: I mean, one thing we can do and we do so often in emergency medicine is look to the literature.
Blair Bigham:Yeah. Is there evidence around this?
Dr. Jennifer Bryan: Yes. Yeah. So there are a pair of papers, they're a little older now, both published in the States where most of the research on sickle cell is getting published. And they're fascinating, because one looked at how suspicious emergency physicians were that people with sickle cell were misusing their opioids. Emergency physicians thought that the rate was quite high. Up to 20%, quite high.
When we look at the Canadian data around the proportion of folks that are prescribed opioids and how many are using them for reasons other than pain management, that number is somewhere between 9% and 10%. Now, in the States, the other paper that I think is particularly interesting is the one that looks at what is the proportion of folks living with sickle cell that were using their opioids for reasons other than pain control and that number is actually very low. So it was down around 2%.
Blair Bigham: Wow. So we-
Dr. Jennifer Bryan: Yeah. So actually less than what you would expect.
Blair Bigham: So closer to 10% in the general population and 2% in the sickle cell population. So is it fair to say that this concern around promoting addiction or dependence by offering narcotic therapy in patients having sickle cell crisis, it's like a myth out there? It's just we can plainly say there's evidence that just is not the case.
Dr. Jennifer Bryan: Absolutely. So no doubt, there is an opioid epidemic, right?
Blair Bigham: Sure.
Dr. Jennifer Bryan: We see that every single shift in the emergency department, right? But the thing to remember, and this was stated really clearly by one of my colleagues who's an expert in addiction medicine, Dr. Hasan Sheikh: “The opioid epidemic is not being driven by sickle cell.”
Blair Bigham: Right, right. So you're so passionate about this and you're such a clear communicator and you know the literature so well, how did you get focused on sickle cell treatment? Was that from your work as an emergency physician?
Dr. Jennifer Bryan: So it was through my work as an emergency physician and as an educator. So I credit a student at that time, quite a few years ago, who is now a resident in emergency medicine, Dr. Sarah Alavian who is very interested in sickle cell and prompted me to ask some very difficult questions. After a discussion with her about her interest in sickle cell, I had a very frank conversation with a patient in the emergency department. This was a young man who had complications related to sickle cell since a young age, not an uncommon story. I asked him what it was like for him coming into the emergency department, and one of the first things he told me was about having to present himself in a certain way in order to get the support of emergency department providers.
Blair Bigham: How so?
Dr. Jennifer Bryan: And so, he talked about as a young Black man that he felt he wouldn't be taken seriously if he came to the emergency department dressed as he would normally dress. He said, "I can't come in here in a hoodie asking for morphine if I want to be taken seriously."
Blair Bigham: Oh wow.
Dr. Jennifer Bryan: That was heartbreaking for me to think that someone would feel like they had to be dressed up or to present themselves in a certain way in order for us to care about them.
Mojola Omole: Do you think that if you asked patients that they probably feel as if racism and bias plays a bigger part in not receiving adequate care?
Dr. Jennifer Bryan: Yes. Yeah, absolutely. So, while sickle cell disease can affect people of all races, in Canada, most of those who are affected are Black, especially most of those in the GTA are Black. And so, they're dealing with not only complications of a life-limiting disease that are often invisible to others in the midst of an opioid crisis where the treatment is often opioid analgesia, but they are also dealing with anti-Black racism and stigma. And so, while we would like to think that we are immune to anti-Black racism in healthcare, we don't leave those biases at the door when we go to work, and our patients do notice and are aware and are concerned about not being treated the same as others in the emergency department.
Blair Bigham: Jennifer, there are actual targets, there are recommendations about how we should do this. Go into educator mode for me and give me the 101. What does every ER doc need to know to incorporate into their practice tomorrow to meet this Ontario standard?
Dr. Jennifer Bryan: So the Ontario Clinical Handbook from 2017 is an excellent resource and I would suggest that all emergency physicians take a minute, just have a little flip through and see, what are we supposed to be doing for patients living with sickle cell who come for our health plan in the emergency department? One of the key recommendations: there is a target for time to analgesia and that target is 30 minutes from triage.
Blair Bigham: Wow. I do not meet that standard.
Dr. Jennifer Bryan: It's ambitious, it is aspirational, but I believe that it is doable. In order to reach that target, there are a number of different things that need to happen in our departments. First off, this needs to be a team effort, and that's been the most important part of our emergency department working group on sickle cell. It has been that we involve physicians and nurses and social workers and our red blood cell disorders, clinic, and most importantly, our patients and community advocates. Working together, we're trying to reach that goal, reach that target.
When we look back at the data to see, "Okay, how long is it taking for people to get analgesia? What are the things that promote faster access to pain medications?" There were a couple of things that really stood out. And so, those are ones that we have been emphasizing in our emergency department to try to advance care. So one was the patients getting pain medications before they would have normally been seen by a physician. And so, what's happening there is those are our nurse advocates. So those are our nurses at triage who are identifying patients who need pain medication quickly who are able to then approach the emerge docs and say, "Yep, I know we've got 4 or 5 hour wait times right now but can we get pain medication started for this person?"
Blair Bigham: Gotcha. Very cool.
Dr. Jennifer Bryan: The other thing that makes a big difference and that is something that's possible for every emergency department is having a standard approach to care. For our department, that's in the form of an order set.
Blair Bigham: Oh wow.
Dr. Jennifer Bryan: Yeah. That was developed a number of years back in cooperation between the emergency department and our hematology team and pharmacists. We've revised that just over a year ago now with direct input from patients, from community advocates, from many members of the emergency department team and other healthcare providers throughout the hospital.
And so, that order set includes not only that 30 minute time target and some specific recommendations for pain medications but also advice on how to spot other complications of sickle cell and an explicit statement around supporting some of those coping strategies that we were talking about. So the importance of having access to food and to water and to not mistake someone being on their phone or trying to distract themselves as a sign that they're doing okay but emphasizing you need to ask about pain.
Blair Bigham: So if I were your resident and we were doing a simulation, what would the top three things that you would want me to do be, in order to pass that simulation: what narcotic, what dose of narcotic, how frequently... I'm thinking ABC's here, right? Boom. What exactly would you want your resident to do where you would go, "You nailed that care"?
Dr. Jennifer Bryan: So the first thing I would want the resident to do is to prioritize seeing the patient, right? Even if it's a quick chat and you're going to go back and do your full physical exam later, but that initial, let's just see what's going on right now is incredibly important. I would want to see the resident recognize the expertise that the patient has. And so, most of the patients that I see in the emergency department, this is not their first time coming to the emergency department and they know their bodies well. And so, my first question is, "How can I help? What do you need from us tonight?"
Blair Bigham: Right, because they're going to know what works for them presumably. Gotcha.
Dr. Jennifer Bryan: Yeah, absolutely. Yeah. Now, we have specific recommendations on starting doses for opioids depending on if the person has opioids regularly at home so if they're more familiar with opioids or if they're opioid-naïve. But most of the time, what I'm starting the patients on is what they're asking for, because they know what's worked for them before. The other thing that I would say is to be sure to pair the opioids with non-opioid analgesia, it works very synergistically. To also have acetaminophen, to also have ibuprofen or ketorolac - they can work very well together. So not forgetting those other options as well. So on our hospital formulary we have a sublingual fentanyl and the only indication is for people living with sickle cell. So it's an option if we're having difficulty getting good IV access which, unfortunately, is not uncommon for folks that have had multiple episodes and many emergency department visits.
Blair Bigham: That was a Masterclass in sickle cell crisis. Thank you so much for joining us, Jennifer.
Dr. Jennifer Bryan: Well, thank you so much. I appreciate it.
Blair Bigham: Dr. Jennifer Bryan is a founding member of the UHN Emergency Department Sickle Cell Working Group and an ER physician at UHN.
Mojola Omole: Lance Archer is a sickle cell patient as well as an advocate for the Sickle Cell Awareness Group of Ontario. Thanks for joining us today, Lance.
Lance Archer: It's my pleasure to be here. Thank you.
Mojola Omole: Dr. Bryan just talked to us about the ideal treatment for cases of sickle cell which is pain relief within 30 minutes of coming into the door, comforts like a phone charger, food, hot water bottle, blankets. Your experience here, how close does that match with yours?
Lance Archer: I'd say it's pretty close. That's my experience in general. Recently, I've noticed that there has been a shorter wait time for me in seeing a physician, typically within 30 minutes upon arrival at the ER so that's good. I'm usually met with a warm blanket. I'm usually given fluids almost immediately so it's quite similar.
Mojola Omole: Can you tell me a little bit about what... I know it's hard to describe what the pain during a crisis is, but on average, how often would you say that you have crises?
Lance Archer: On average, I would say I would experience varying degrees of crises. There are some that I'm able to successfully manage at home and then there are those that require hospitalization. The ones that require hospitalization are excruciating pain. This is pain that is not responding well to my medication regime here at home. It feels like bone pain. It's so intense that I'm unable to move that area of my body. For example, if it's in my shoulder, I cannot lift the arm. If it's in my hip, I cannot walk. It feels so distressing, so uncomfortable that it clouds my judgment. I'm not able to think clearly. I'm not able to process things effectively. I'm just consumed by the pain. I get the image of a shark just gnawing on the bone.
Mojola Omole: Gosh.
Lance Archer: That's what it feels like when it's extremely severe and that's when I know that I need to be seen within the hospital setting.
Mojola Omole: How often do you think that happens like that?
Lance Archer: Yeah. So my last hospitalization was in March of this year. I do take a medication prescribed to reduce the frequency of pain crises, so that has been very helpful for me. So since being on this medication, I know that my hospitalization has reduced. I think in March, that was the first in six years-
Mojola Omole: Oh good.
Lance Archer: -that I was hospitalized. Yeah.
Mojola Omole: Okay. If it's not too hard for you, can you tell me what your worst experience with a crisis has been in the emergency department?
Lance Archer: Yeah. So I would say this is by far the worst experience would have been a significant delay in being assessed. I believe that it took several hours, maybe minimum of two and a half hours before I was ever seen. I felt as if I was neglected because I was placed in what appeared to have been a supply closet-
Mojola Omole: Oh goodness.
Lance Archer: -and medical staff, they were coming in and out and I was reaching out for some sort of support for pain relief and being ignored. That experience has not left me. That was in 2015, I believe. I'd say that's the worst.
Mojola Omole: That sounds very traumatic, to be ignored when you're screaming out that you're uncomfortable, you're in pain.
Lance Archer: Yeah, definitely. I remember just having a conversation with a gentleman, I'm not sure what his position was within the hospital, and I was saying, "Imagine I'm here desperate for some relief and people are coming in and out and ignoring me." I wasn't boisterous, I wasn't loud, I wasn't screaming. I know that each time someone came in I was asking if someone could please provide me with some sort of pain relief but to no avail.
Mojola Omole: I'm so sorry that was your experience. That sounds really horrible.
Lance Archer: Mm-hmm.
Mojola Omole: So would you say that treatment varies from hospital to hospital?
Lance Archer: I'd say so. I remember being at least two hours away from home once and I had a crisis while visiting my uncle. I was taken to the hospital within his community and that experience too stands out as one of the worst I've had where it seemed as if people were not aware of treating sickle cell disease, they were more interested in what am I doing so far from where I live. That experience did suggest to me that it varies, that many persons are not aware of the treatment protocol for sickle cell disease. There was another time I was hospitalized and there, too, I had significant delay in being assessed. So it really does seem like there are varying degrees of response to sickle cell crises in hospitals here in Ontario.
Mojola Omole: Do you think that other people in the community who have sickle cell, do they know which hospitals that's good at responding and which hospitals to be avoided?
Lance Archer: Mm-hmm. I think that we currently have some hospitals we consider to be centers of excellent care in the way that they approach managing a crisis. Within the community, we encourage patients with sickle cell disease to visit these sites. Unfortunately, some of these sites are really far from where they live but some patients sound to me that they're willing to take that journey because they know that they have a better chance of receiving optimal care.
Mojola Omole: I imagine people go to pretty far lengths to get to their preferred hospital.
Lance Archer: Many of my friends are within the city of Hamilton. And so, we know that this is the go-to hospital because we have our hematologists there, we have physicians; we know that the staff are well-versed on how to manage it. But within the community, I've heard that an individual that once had to travel an hour to get to a center of excellence.
Mojola Omole: That's a lot to do when you're in excruciating pain and you can't move whatever area is actually being affected.
Lance Archer: I agree. Yeah, and-
Mojola Omole: Noting how many hospitals you're bypassing.
Lance Archer: Right.
Mojola Omole: I mean, within an hour drive of anywhere in the Golden Horseshoe, you're driving by at least three or four hospitals.
Lance Archer: Yeah. I suspect when you are really being wracked with pain, when you feel as if you are about to die, you are desperate for optimal care and it pushes you to get that. It's so unfortunate. It's so unfair as well but it's that moment of desperation where you just need to be heard, you need to be seen, you are willing to do whatever is necessary to get that.
Mojola Omole: Have you personally felt that stereotype that when you go to the emergency department that you are drug seeking? Do you think you've had that experience?
Lance Archer: Personally, I have not. It has never been overtly expressed to me. I think I'm privileged, though, to be honest, because people meeting me, they would consider me an intellect. They would have meaningful conversations with me. And so, their bias around drug seeking in patients would not necessarily match the way I present so I can see where that has not been my experience.
Mojola Omole: So one of the ways that sickle cell patients can appear to be similar to drug seeking behaviors is just that frequent visit to the ER which you've said, thank goodness with the medication you're on, that's decreased. Let's say you first came to the hospital and they gave you medication, you went home. How often is it that you have to come back again in a less than 24 hour timeframe?
Lance Archer: Yeah. Before the medication, it was quite common. I remember in the past before being on hydroxyurea, I would have been discharged today and then back in the hospital this evening. I remember going back to the hospital three days later. I remember going back to the hospital a week later. Specifically, in 2014, I was really at death's door. I would say that because the frequency of hospitalization was so regular, so often that I can see where people would be concerned about what's happening with this young man. Why is he here so regularly? Before the medication, I'd definitely say that I've had experiences two days later, a week later, and when I was a really young child, less than 24 hours.
Blair Bigham: Oh wow. What's one thing that you would really like physicians to know about the patient living with sickle cell?
Lance Archer: I want them to know that a pain that goes untreated will only make future efforts at managing pain much more difficult. And so, if they continue to be guided by their biases about drug seeking behavior and be guided by their ignorance or deficit in knowledge about sickle cell disease, they are contributing to the likelihood that persons with sickle cell disease will have future complication, future challenges managing their pain.
And so, I want them to show compassion. I want them to check their biases. I want them to do what is necessary to treat the patient with sickle cell disease because all of that which I'm asking for is consistent with the oath to do no harm. It's consistent with the code of ethics that guide the profession so I really want them to check their biases. I really want them to know about sickle cell disease. I really want them to give the patient the treatment that they deserve.
Mojola Omole: So if people wanting to know more about sickle cell and living with sickle cell, is there a website? Is there webinars? Where can they go to just get that information?
Lance Archer: We have a website here in Ontario sicklecellanemia.ca and we actually have a Sickle Cell Summit that's coming up in November, November 4 and 5. This is targeted at improving equity in care being provided to patients with sickle cell disease. And so, I'm just encouraging persons to check out our website, sicklecellanemia.ca where they can find more information about the summit as well.
Mojola Omole: Wonderful. Thank you so much.
Lance Archer is a sickle cell patient and an advocate for sickle cell awareness in Ontario. He's currently located in Hamilton.
We just finished listening to Dr. Bryan and Lance Archer talk about the state of sickle cell treatment and their experience in Ontario. Blair, you work in emergency department, I'm not sure if you've seen patients who have sickle cell in crisis, can you tell me what your experience with this has been?
Blair Bigham: Yeah. I certainly see less sickle cell in the community hospital where I locum now, compared to as a resident at McMaster. I got to say, I was listening to Jennifer and then Lance going, "Oh my goodness, I do not think I meet that 30-minute standard of care." I had a sickle cell crisis patient not too long ago and oh, if she were to rate me as her MD that day, I don't know.
Without any type of qualification or rationale, I was not attentive and I wasn't reassessing her pain as frequently as I should have and this really bothers me. But at the same time, it's so helpful to hear from Lance. It's so helpful to have insights into his community of friends who have sickle cell disease about just how frequently we're failing that community and failing to manage that disease properly. Knowing that there's this 30-minute guideline, I'm definitely going to raise this with my own group to make sure that our triage teams and our physicians can try to maybe undo some of this terrible delay that people are experiencing getting pain control.
The biggest thing I took away from Jen's comment is just ask them what works for them and give them that drug and they know their disease and they probably know how to get their pain under control faster and better than I do.
Mojola Omole: So let's step back a bit because I think it's important to, it's like our own mini M&M that we can have with you now, is if looking back, why do you think you were giving suboptimal care? Was it just you weren't aware that you were supposed to check frequently? If you can examine your treatment of that patient, what do you think was done wrong or where did you think you went wrong?
Blair Bigham: Well, I just promised not to make excuses and this will sound like a lot of excuses. So I saw this patient in a chair, I didn't see them in a bed, I saw them in a chair in a hallway. They did not look like they were in pain.
I probably saw about 35 to 40 people in eight hours which is double what I was trained to see. I feel immense pressure when there's 50 people in the waiting room to move volume. We have a very high left-without-being-seen rate at my hospital, people who just don't stick around to see a doctor, and that really bothers me that people who thought they were having an emergency couldn't bear the wait. Some of those people might not have been having emergencies and they self-select out but some of those people very well might have been having emergencies. And so, it bothers me a lot that we're just not able to keep up with demand.
A lot of these patients who are having pain, not just sickle cell pain, but a lot of our emergency department patients with pain get assessed and then they get sent back out to the waiting room to wait for test results because we have no beds, we have no place to put them. And so, once you're in the waiting room, you don't get reassessed. There is no nurse assigned to say, "How's your pain? How's your nausea? How are you feeling now?" It's shocking when you verbalize it out loud. It's not the way an emergency department was meant to run.
Mojola Omole: As I'm not emergency doctor so I can have the professorial role of being the chair of the M&M to say that part of this is, it's a system issue, right? In the sense of just the function of the state of our emergency departments across Canada. And then, the other part of it is that the sickle cell patient was lumped in as another patient having pain not realizing that sickle cell crisis is very different than someone having-
Blair Bigham: Renal colic-
Mojola Omole: Chronic pain-
Blair Bigham: Yeah, if they're renal colic. Yeah. Exactly.
Mojola Omole: Or renal colic, right? And so, a part of that could be improved from a systems point of view in the sense of what like Dr. Bryan said about having a protocol for a patient who's coming in with sickle cell-
Blair Bigham: But that once... I'm just going to push back on that Jola because there's something unique about the emergency department where emergency departments in this country have been thrown under the bus because you would never allow your lap chole post-op to go to a waiting room and not be monitored by a nurse because the PACU is busy. They have to go to the PACU and they have to have one-to-one or one-to-two nursing in the PACU. There are places that we don't compromise on care, and postoperative care in a PACU is one of them.
But for some reason in the emergency department, it's okay for me to send people with chest pain back out to the waiting room while we await their trop. It's okay for me to send a sickle cell patient or a suicidal patient back out to the waiting room while we await a medical workup. There's something unique about the emergency department, I think, and I'm biased here because I'm an ER doc, but we've allowed the emergency department to be thrown under the bus and we've lowered the standard of care there in ways that we never do in other parts of the hospital.
Mojola Omole: Well, I would say that I understand what you're saying. In this particular situation dealing with the patient with sickle cell, I also don't think someone with chest pain should be in the waiting room. But dealing with patients with sickle cell, we know that having crises increases the likelihood, shortens their mortality. Currently, their mortality is about 42 to 47 years is their life expectancy, right? The more crisis of vaso-occlusive that they have, the more organ damage they can have further on.
Blair Bigham: Totally.
Mojola Omole: If they get avascular necrosis of their hip and all of these other complications. So, in a way, almost as the Trojan horse to improve emergency departments when we're talking about pain, is that, similar to what is being done at UHN, because of champions like Dr. Bryan is that, if you're a sickle cell patient, you're identified at the door at triage that this patient has sickle cell, they get pain medication within 30 minutes, they're in the room, comforts are given, they're reassessed.
Blair Bigham: Yeah.
Mojola Omole: That should be the standard for every patient-
Blair Bigham: Well-
Mojola Omole: But I will advocate for a group that's the most vulnerable in our population which is when you're racialized, you have a lot of biases when you're coming in already.
Blair Bigham: Totally.
Mojola Omole: And so, I'm going to advocate for that group, right? We're talking about a small group. When you look at it about the data for, at least in the US, is about 2% of kids are born with sickle cell anemia but we're talking about not necessarily a large group of patients that we have to standardize the care for. If we start that with sickle cell, maybe there's other patients that we have to identify standardizing the care that it's not just emerges viewed as the dumping ground or a factory to pump patients in and out but that we're actually taking care of the patients for what they came for.
Blair Bigham: But the emergency department game is small populations, right? We see many, many, many small populations because we're a generalist service. We see everything that walks through the door. I don't know that I can prioritize a sickle cell patient having a crisis over another ridiculous case that I pulled in from the waiting room recently, which is an elderly racialized man who was a bit confused. I called him back in from the waiting room after his head CT showed a subdural with shift. He was sitting in a wheelchair in the waiting room with a subdural bleed and he came in altered. In what other world would that man not have been given a bed and nurse monitoring while we worked him up for bleed?
It's gotten to the state now where this is tolerated and it seems acceptable to hospitals that the emergency room is just not providing adequate care to any of our small populations. And so, I don't know how you rank those and say, "Well, we're going to pull in that CTAS 2 to patient right away because they have sickle cell disease but we're not going to pull in an altered man who's confused," or, "We're not going to pull in a woman who's eight weeks pregnant with left lower quadrant pain suddenly. She's going to wait in the waiting room until her ultrasound comes back." There's so many populations that need care that just aren't getting them these days in Canada's emergency departments. I don't know how to fix that immediately but I'm going to take your comment in the spirit it was intended that how about we start small, how about we have one win, and maybe sickle cell is that win.
Mojola Omole: Blair, this has been a very spirited M&M discussion.
Blair Bigham: Sorry, I got a little heated there.
Mojola Omole: No, a little spice is good. It's the reality of the job that we do and this is the reality of the job that you do, right? And so, there's the theoretical when we have things in papers and then there's how do we actually implement what is supposed to be standard of care so I think it's really important to have that conversation.
Blair Bigham: Being short staffed and overwhelmed is not unique to an emergency department. Everyone in healthcare right now is working their butts off and we all just have to raise the bar and just get people the care that they need despite that burnout and fatigue that we're all experiencing.
And so with that, we'll wrap up this week's episode of the CMAJ Podcast. Thank you so much for listening. We'd really appreciate it if you could share, like, or spread the word on social media or wherever you download your audio from.
Mojola Omole: Or just let my family know they should listen because they don't listen.
Blair Bigham: I'm sure my chief is listening right now. Anyways, thanks so much for joining us. We'll see you next week. I'm Blair Bigham.
Mojola Omole: I'm Mojola Omole. Until next time, be well.