Summertime Blues

Alice Ma, MD
Professor of Medicine in the Division of Hematology and Oncology at the University of North Carolina School of Medicine in Chapel Hill

At 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 20×109/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 80×109/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 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.