Editor ’ s Corner
Summertime Blues
A
The content of the Editor ’ s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated .
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T THE TIME of writing this column , the calendar has just turned to August and another July has come and gone . There ’ s plenty of lore about the “ July effect ” in a teaching hospital . The staff and faculty are a little more on edge . The newbies are anxious , and – well – new . Some of the patients are oblivious ; some are edgy and making not-quite-funny jokes , like “ No experimenting on me by the students – okay , doc ?”
Anxiety is pervasive . The interns and new fellows don ’ t want to make any mistakes . Everyone is on time , or even early , for rounds . And , the Epic electronic medical record folks , in all their wisdom , have classified my new fellows as medical students , so none of them can sign notes or orders or write chemo . Epic fail . Sigh .
July also means peak season for thrombotic thrombocytopenic purpura ( TTP ) here in North Carolina .
Recently , I was called in to see a woman who was said to have TTP , presenting with a hemoglobin of 3.3 g / dL , a platelet count of 20 × 10 9 / L , and mental-status changes . And , of course , this happened at 4 a . m ., because these consultations always come at 4 a . m . The only aspect of her case that didn ’ t fit the pattern was that this happened in the wee hours of a Wednesday morning – not a Friday . Other than that , it seemed to be a straightforward consultation .
Until I got in front of the microscope . Turns out there were macro-ovalocytes , but no schistocytes . The woman also was refusing her vitamin B12 shots . Awesome .
While this was happening , I learned that there was a 42-year-old woman with a history of four strokes , new-onset thrombocytopenia , anemia , elevated creatinine , and neurologic symptoms who had been sitting in the emergency department since 4 a . m . She was admitted to a floor team who didn ’ t call for a consult until 8:30 a . m .
The fellow on the consult team – the same one who was on overnight – and I flew across the bridge to the hospital to look at the smear .
I ’ m at the microscope and Ow ! The sharp pointy schistocytes poke me in the eye . We spring into action : The patient is moved to the medical intensive care unit and my fellow and I call to have a line placed and get ahold of the transfusion medicine staff to start apheresis .
After the excitement has calmed , my fellow declares , “ We were like the TTP response team !” In July , we needed one .
Later that night , an outside emergency department calls for a transfer . A woman has a platelet count of 80 × 10 9 / L and delirium . There are no signs of anemia , hemolysis , or renal dysfunction . Still , they asked us , “ Can you take her and call her TTP ?” Our response : “ Um , no . July .”
When the new residents start , my patients are mostly delighted , and maybe slightly impatient . The patients love to share their experiences and journeys . The new trainees are a fresh batch of people to listen to their sagas . The students are thrilled , too , when they realize , “ It ’ s just like you told us in lecture !” Fellows are a little harder to impress , asking more questions like , “ How do you know when to change therapy ? How do you know when a symptom is a side effect ?”
And sometimes – especially in July – the universe is quirky . This month , we had three patients in one week who came in with hydroxyurea-induced leg ulcers and needed phosphorus-32 or ruxolitinib . My fellow asked if she could make a dot phrase in Epic – a standard order set - for this scenario .
July at our institution also means the hemophilia nurses take “ vacation ” to staff Hemophilia of North Carolina ’ s summer camp , a retreat for children living with bleeding
Alice Ma , MD , is professor of medicine in the Division of Hematology and Oncology at the University of North Carolina School of Medicine in Chapel Hill .
disorders . This leaves me to answer phone calls and handle ( or not handle ) the tasks that normally fall to them . I quickly realized that no , I actually don ’ t know how to write a prescription for clotting factor in Epic . Apparently , “ 500 unit vial ” is not an acceptable unit to dispense , despite the fact that the factor is dispensed in 500 unit vials . Is it August yet ?
During the month of July , I try to schedule myself on service so I can be in a position to help the beleaguered fellows on call over the weekend . I also brought in cookies stuffed with brownies , because they help . Not a lot , but at least some .
I offered one to the fellow who was on call the previous night as she threw herself into a chair .
“ Got a call last night from someone who wanted to speak to the sickle-cell doctor ,” she explained . “ The guy wanted a second opinion about his son who just got diagnosed with sickle cell .” That led to the following exchange :
“ So , how old is your son , sir ?
“ Two years old .”
“ Sir , you need the pediatric hematology fellow .”
“ Can ’ t you answer a simple question ? The doctor wants to start my son on penicillin , but isn ’ t there an herb or a natural remedy he can use instead ?“
“ Sir , where is your son being seen ?“
“ At Duke .”
“ Sir , you ’ ve called the University of North Carolina .”
Have another brownie-stuffed cookie . Or two . After all , it ’ s July .
Alice Ma , MD
14 ASH Clinical News September 2018