Editor’s Corner
Benign Hematology Isn’t So Benign
A
S A BENIGN HEMATOLOGIST, I get a lot of questions about what
I do and the kind of medicine I practice. When my parents
want to tell their friends what type of doctor I am, they’re usually met with confused questions.
My parents: “She’s a hematologist – you know, a blood doctor.”
Friend: “So she treats leukemia?”
(This is where I lose them.)
My parents: “I think she’s talked about leukemia before... .”
That’s when I start getting the questions from my mom. “Do you
cure leukemia?” she asks me. Well, I say, I haven’t ever before,
and I’m probably not going to start now – assuming that anyone
can ever really “cure” leukemia. (Apologies to all the now-outraged leukemia doctors reading this column.)
Mom: “So, what do you do?”
Me: “I treat blood diseases that aren’t cancer.”
Mom: “Like what?”
Me: “Well, like low blood counts and high blood counts, too
much bleeding, abnormal clotting, and... .”
Mom: “I think you should work on leukemia; it sounds more
dramatic. Our friends would think it’s more exciting. What
do we even tell our friends you do?”
I’m sure my benign hematology colleagues have lived through
similar conversations.
For better or worse, benign hematology just doesn’t seem as
exciting as malignant hematology. I try to jazz it up when I’m
speaking with residents who are weighing their career options
and tell me they love hematology, but hate oncology.
“You could totally consider a career in benign hematology,”
I say, trying my best to sound persuasive and enticing. “We see
clotting disorders, bleeding disorders, anemias, and thrombocytopenias. We figure things out, and our patients mostly don’t die.”
Except when they do – or when they at least give us quite
a scare with their attempts to achieve a post-mortem state. As
it turns out, benign hematology isn’t always so benign, and the
close-call scenarios we encounter sell the “exciting” nature of
benign hematology better than I ever could.
Take the case of the young woman with a long history of
antiphospholipid syndrome – managed on warfarin without incident for 14 years – who presented with stuttering abdominal pain
after three weeks. She then came in with Budd-Chiari syndrome,
ASHClinicalNews.org
a clot in her inferior vena cava
extending to her right atrium, an
international normalized ratio
(INR) of 8, and a platelet count
of 12. For the record: A platelet
count to INR ratio of 1.5 is bad.
Oh, and did I mention her history of heparin-induced thromAlice Ma, MD, is an
bocytopenia? There was nothing
associate professor in the
benign about her case.
Department of Medicine,
And then there was the genDivision of Hematology
tleman with wide-open aortic inand Oncology, at the
sufficiency and mitral regurgitaUniversity of North
tion with acute heparin-induced
Carolina School of
thrombocytopenia who needed
Medicine in Chapel Hill.
emergent valve replacement.
His end-stage renal failure and
dialysis dependence prompted us
to use the anticoagulant argatroban – rather than
bivalirudin – which unfortunately led to significant thrombosis on the operative field. Despite
multiple argatroban boluses and an argatroban
drip raised to doses much higher than we initially
recommended, when the bypass catheter was
removed it was dripping with clot. The surgery
was aborted, and the patient was found to have
a