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This is CME on ReachMD, I’m Dr. Biree Andemariam. Here with me today is Dr. Caroline Freiermuth. We will be discussing implementation of sickle cell treatments in our respective clinical practices.
Dr. Freiermuth, can you please address how you implement a therapeutic approach for patients that present to the emergency department?
Sure. So as an emergency physician, we're always taught to think worse first. I want to think about acute chest syndrome, especially if someone's complaining of chest pain or trouble breathing. I want to think about aplastic crisis, if someone looks extremely pale, or is complaining of decreased energy. If I suspect infection, I really want to run my algorithm and say, “Does this person meet SIRS criteria? Do they have sepsis? Do I need to initiate treatment for the sepsis bundle right away?” If I suspect acute chest, I really want to go ahead and get that chest x-ray, determine whether or not they need to be on oxygen, and start those broad-spectrum antibiotics. If I'm looking at their labs, I want to compare their hemoglobin and hematocrit to their baseline. You know, oftentimes we see these low levels and we forget to realize that patients live at that level. And we need to be careful and not just go straight for a transfusion. But really think about is this different for this patient? And is it contributing to their symptoms today? And typically, we would appreciate if, you know the hematologist would actually help us out with that.
The most common complaint we really see in the emergency department is pain due to vaso-occlusive episodes. And really, we want to treat that with parenteral opioids. There are multiple guidelines out there to help with this. The NHLBI has published guidelines, the American Society of Hematology has published guidelines, and the American College of Emergency Physicians actually published a point-of-care tool to help guide our management of pain in the emergency department.
Once we decide that a patient may be admitted, and sometimes even before, it may be helpful to start a patient-controlled analgesia, as this allows the patient some freedom to re-dose themselves. And in our really busy emergency departments, helps our nurses so they don't have to run back in there every few minutes to re-dose.
One of the most important things is really working as a multidisciplinary team. We want to reach out to our hematology colleagues. We want to get our social workers on board. We really want to open those lines of communication so that we're all on the same page and we can help really address everything that might be going on with a patient when they present to our emergency department. Especially if we choose to discharge someone, it is really important to ensure that they have the appropriate follow-up in place, and that they have a plan for how they're going to manage their pain at home.
So now I presented our clinical approach to the emergency department. Dr. Andemariam, could you please comment on the implementation of sickle cell treatments in your clinic sphere?
Absolutely. So in my clinical practice, which is an outpatient hematology practice, I see a mix of patient presentations. I see patients who need ongoing chronic disease management and prevention of complications. This includes managing their disease-modifying oral therapies, the treatment of their chronic pain, giving blood transfusions, as well as giving infusional drug therapy for patients who are on those types of treatments.
I also see patients who have acute manifestations of sickle cell disease. I do everything I can in my center to keep patients from going into the emergency department if they don't have to. This includes evaluating and treating their acute painful crisis episodes, as well as teasing out whether or not they have acute chest syndrome and need to be hospitalized for further treatment.
In my center, we have a multidisciplinary team, and every member of that team contributes to the care of each and every patient. This includes our physicians, our nurse practitioners, our nurse coordinators, our infusion nurses, our apheresis nurse, and a full-time dedicated social worker. We also work within a large hospital center, so we have access to primary care, obstetrics and gynecology, and all subspecialists. And we've established referral patterns for all the other subspecialists that they might need.
In this episode, we have addressed our approaches to implementing an initial treatment choice for sickle cell disease in partnership with patients and members of the care team. I would like to thank Dr. Caroline Freiermuth for joining me today. Unfortunately, our time is up. Thanks for listening.
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