Editor ’ s Corner
With a Little Help From My Friends
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At time of press , we were saddened to learn that Harold Roberts , MD , passed away on September 9 . We will have more information about Dr . Roberts ’ s life and legacy in the November issue .
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 .
Have a comment about this editorial ? Let us know what you think ; we welcome your feedback . Email the editor at ACNEditor @ hematology . org .
O YOU HAVE A SECOND TO TALK ABOUT A CASE ?”
It ’ s a line heard on phones and in offices the world over . A colleague , stumped by a patient outside his or her experience , reaches out to phone a friend .
As a coagulation specialist secure in my ivory ( or Tar Heel blue ) tower , when the inquiry comes my way , it ’ s often easy to handle . It typically starts the same way : A colleague – limited by lab results he can ’ t get back in a timely fashion and faced with a patient who needs an evaluation or procedure – explains , “ I have this patient with a bleeding disorder and her labs are a little funny .” According to the patient , everyone in her family is a “ free bleeder ,” and she needs her central nervous system aneurysm clipped . The simple answer is to send the patient to our Benign Hematology Clinic , where it ’ s easy for me to order a bevy of labs , done on site with excellent reliability – a luxury for which I am always grateful .
Other times , the question arises from inexperience with something that we in “ Coag-ville ” see all the time . “ She says she has von Willebrand disease . She ’ s 36 weeks pregnant and wants an epidural . Her labs look normal . Is it okay ?”
Sometimes the phone calls are harbingers of a coming upsurge in disease . I recently got my first call from a colleague in the community about a woman with progressive pancytopenia , fevers , and splenomegaly . It was hemophagocytic lymphohistiocytosis – a condition that has seemingly become epidemic in hospitals .
We are in the midst of a flurry of cases of a thrombotic thrombocytopenic purpura – like state caused by intravenous abuse of Opana ER – an oral , long-acting oxymorphone that is coated with a substance that was supposed to make it impossible to grind up and inject . It turns out that the abuse-deterring magic coating sometimes leads to rip-roaring thrombotic microangiopathy . The first patient we saw with this condition was spotted on the monitor in the medical intensive care unit ( MICU ) injecting a powdery substance through her apheresis catheter .
There ’ s always an uptick in phone-a-friends in the fall , as newly graduated fellows settle into jobs as attendings and realize that life as a grown-up doctor is a bit more unsettling than they thought it would be . Others call to check their work or get some positive strokes , like my former fellow who diagnosed a case of acquired hemophilia in his first week of practice , or another who figured out a woman had iron-deficient polycythemia vera in his first month .
I remember being on the phone with my former attendings nearly weekly during my hematology consultation services as a first-year attending . My colleagues at the University of North Carolina were off at an international conference and I was left holding the bag – feeling alone and insecure . Doug Cines , MD , of the University of Pennsylvania , was my lifeline . He talked me through my first “ bleeding clotter ” patient in the MICU , as well as my first “ clotting bleeder .”
He also was on the line helping me with a patient with hemolytic anemia without a warm antibody , or a cold agglutinin , but with a lytic antibody that seemed to be cold-reactive . It turned out to be paroxysmal cold hemoglobinuria – thanks to Dr . Cines for the moral support .
And I have to give a shout out to Harold Roberts , MD – a man feared by many in his heyday , but whom I considered the most patient , kind , and thoughtful colleague – who was endlessly tolerant of my requests to run just one more case by him . Once , I had a female patient who I was convinced was taking some sort of super-warfarin ; she had multiple episodes of bleeding , several stays in the
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 .
intensive care unit , and bleeding into her retropharynx with airway loss twice , as well as instances of gastrointestinal and retroperitoneal bleeding that were all responding to high doses of vitamin K .
I was leery of being too cynical at the start of my career , so I asked Dr . Roberts if a case had ever been described with an inhibitor to the carboxylase , or some acquired deficiency of the epoxide reductase . He launched into a recollection of “ warfarin eaters ” he had known in his career and shared an article from the Southern Medical Journal describing a woman with recurrent bleeding episodes due to brodifacoum ingestion like my patient . In fact , it was my patient . Some mentors provide you with literature pertinent to your patient ; Dr . Roberts went a step farther and supplied an article about my patient . I ’ ll never be that good .
I still have patients whose conditions defy all rational disease mechanisms , requiring me to call a colleague . Recently , I was telling a colleague who specializes in myeloproliferative neoplasms about a confusing , complicated case of essential thrombocythemia . “ So , I have this woman whose platelet count was shooting up to 1.4 million on hydroxyurea and then abruptly dropped to 200,000 two weeks later without a change in therapy . Have you ever heard of such extreme platelet fluctuations ?”
My voice trailed off as I recalled that I had heard of such a set of cases reported by Ayalew Tefferi , MD , and colleagues about 10 years ago . We presented this patient at a conference , and , it turns out , all my colleagues had one or two of these patients in their clinics , too . They were just waiting to run it by someone … .
The give and take of medical knowledge and medical lore – and occasionally superstition – are not a substitute for evidencebased medicine . But , for patients with uncanny diseases who don ’ t read the literature and for the doctors who care for them , phoning a friend is priceless .
Whom have you called for help ?
Alice Ma , MD
10 ASH Clinical News October 2017