While my predilection for Cardiology comes from my career before medicine and its link to exercise, my interest in most fields of medicine is somewhat a result of how tangible the system is. The heart pumps blood in tubes by generating pressure; there are valves that help flow; there are equations to calculate output which is a direct result of pump strength and frequency. Cardiology screams physics. The same can be said for Respirology. Even Gastroenterology and Nephrology revolve around concepts like concentration, pressure, volume overload, and output, which are things I can relate to in some way or another. It's all just fluids in tubes, baby. My brain is not so welcoming to things like Immunology, which I cannot physically interact with. "Less tangible" fields like this get a side-eye from my soul, the same way you would sneak a nervous peak at a guy wearing a Nickelback shirt at a bar. Enter: Hematology, the study of blood and its disorders.
I was nervous, mostly because Hematology was a subject I felt that I "got through" while in medical school, rather than learned thoroughly. But I was also excited; I had just come off my Neurology block --and if there's one thing I'll make clear in my ceaseless yammering on this website, it is that I hate Neurology-- and I was ready to get back into the world of internal medicine.
Mr. I - 51 years old, admitted for an eosinophilic asthma exacerbation. Hematology consulted after a spontaneous hematoma into the left leg.
Mr. I was admitted to the hospital for an eosinophilic asthma exacerbation (a type of asthma typically associated with a later onset in life, a lower response to inhaled corticosteroids, and a high level of white blood cells called eosinophils). This necessitated a brief stint in the ICU, and then forced isolation on the ward due to COVID exposure in the ICU. He was also on hemodialysis for longstanding end-stage renal disease, and had a history of unusual clots.
Our Hematology consult service became involved in his care due to his history of spontaneous clots. For as yet unknown reasons, Mr. I had a tendency to clot at much higher levels than the average person. He had already rendered an AV fistula (a surgically constructed access site to arteries and veins used for dialysis) unusable due to a clot on the venous side; he developed an extensive clot in a central catheter (a tunnelled IJ line) inserted under his left clavicle that was inserted as a replacement access point to his AV fistula; this necessitated its removal and insertion of a second IJ line under his right clavicle. Thank fuck this line was still working, but he did develop another spontaneous clot (known as a DVT) in the deep veins of his right arm while in hospital which required frequent monitoring to ensure it didn't extend more centrally. It should not come as a surprise that he was on a whack-ton of anticoagulation, or blood thinners, which just as well given he suffered from frequent episodes of atrial fibrillation, an arrhythmia that makes you more prone to clots in your arteries.
Under normal circumstances, the Hematology team would not have been involved in this case since he was admitted for completely different issues, and his blood thinning treatment was already established and stable. However, in his whistle stop tour through seemingly every department in the hospital, Mr. I developed a spontaneous, atraumatic, hematoma in his left buttock. In other words, a blood issue needed the blood people to take a look.
It is worth distinguishing the difference between a hematoma and a bruise, both being words that appear relatively often in the common vernacular but which can be misunderstood. Both processes consist of blood leaving arteries and veins and entering spaces in which they normally do not belong. A bruise, however, often involves smaller blood vessels (arterioles and capillaries) that leak blood in such a fashion that they don't alter the space or physiology in the area in which they are found. We've all developed bruises after a vigorous bump or tumble that evolves through the ugliest rainbow imaginable and rarely need medical attention. A hematoma (the suffix "oma" derived from Greek, and used to describe a mass or tumour) often involves an injury to a larger blood vessel, which means far more blood accumulates in a particular pocket. This results in a mass of blood with more defined boundaries, that can often interfere with surrounding structures due to how large of a space they occupy. Some require delicate evacuation; some require invasive surgical intervention; some can be fatal.
Each part of the body suffers in subtly different ways when invaded by a hematoma. In the limbs, which are divided into rigid pockets by the inflexible fascia that surrounds muscles, the doctor's biggest worry is the development of compartment syndrome. Compartment syndrome is a rapid increase in pressure within a space that obstructs other blood vessels, damages nerves, and can eventually lead to tissue necrosis. The sequelae of untreated compartment syndrome inevitably includes death of the patient.
Mr. I awoke one morning to searing pain on the posterior aspect of his left hip, which radiated down the back of his leg, and rendered him unable to use his left foot. It's a classic picture of sciatic nerve compression, and in a patient on heavy blood thinners, the worry was a rapidly progressing hematoma compressing all the local structures in his leg. An ultrasound of his hip and thigh confirmed the presence of a large hematoma that predictably, had not been present on his admission. Our orthopedic surgery colleagues took him to the OR right away and drained two litres of blood from his left buttock. While his pain resolved completely, his left foot remained limp, worrying the team he had suffered permanent damage to the sciatic nerve.
His anticoagulation therapy was immediately stopped to reduce the changes of further bleeding, which put him at risk for further clots. The next three weeks consisted of assessing his hematoma with ultrasound or CT scan and deciding if it was stable enough to restart anticoagulation. This process was as much an art as a science given that we still didn't know why he was prone to such frequent clots. The entire process was derailed when a follow-up ultrasound in his right arm (to track the previously mentioned clot) revealed another spontaneous hematoma he didn't even feel in his right shoulder.
This highwire balancing act between treating someone's bleeding (with cessation of anticoagulation) and their clotting (with augmentation of anticoagulation), is a frequent dilemma in patients who are allowed to have as many competing diagnoses as they damn well please. In this patient, clotting in yet another vascular access site could mean loss of the ability to receive life-saving dialysis. However, expansion of his hematoma could mean further loss of function in his only leg (he had a right-sided, below-knee amputation for completely unrelated reasons). Never again will I complain about waking up with a sore back.
Mr. J - 74 years old, admitted to the Nephrology ward for sepsis, later determined to be secondary to cellulitis of the leg. On peritoneal dialysis.
The tragic part of this very well-structured Hematology rotation was the overnight call shifts at this particular hospital. The responsibilities for a certain number of first year residents, from a handful of different teams, included covering five separate wards overnight: hematology, nephrology, respirology, gastroenterology, and cystic fibrosis. You are supported by the fellow from each respective team, whom you can call at any time of night at their home, but you are the first call for any patient on any of those wards. Nephrology patients, being some of the sickest in the hospital, are the most frequent page to the on-call resident covering this shift (yours truly).
At 21:00 one night, a nurse on the Nephrology ward paged me about a patient who was "refusing all treatment." When I got to the ward, I was expecting sky high blood pressure, or blood potassium at dangerously high levels, which is par for the course in people on dialysis. Instead, I was told in a huff that "he refused his blood test tonight and he won't take any of his meds." Who did I find in the room but the most peaceful, smiling patient who answered "of course!" when I asked if we could chat. Here is how our conversation went: Me: Hi Mr. J, how are you tonight? Mr. J: Oh, all is well I guess.
Me: I heard you weren't too keen on some of your medications tonight, or a blood test. Is everything alright?
Mr. J: Sure! But the nurse told me I had a new medication and then walked out, and normally I don't get blood tests at night, so I am confused. I'm blind so I can't even see the colour of this new pill!
It took me three minutes to discuss his new medication (a dissolvable powder that would help lower his blood potassium), and the subsequent blood test that would verify his potassium didn't continue to climb. We spent another five minutes discussing local sports, and I left the room with a hearty "God bless" from him. The nurse taking care of Mr. J seemed dumbfounded he was suddenly okay with this new medication and his blood test. I suppressed my snark and bid everyone goodnight. I wish it wasn't such a novel idea that patients are apprehensive about treatment they don't understand.
Mr. K - 65 years old, admitted for shortness of breath due to volume overload, with suspicion of a failing kidney transplant as the cause.
Mr. K suffered from Hemophilia A, a condition characterized by deficiency of Factor VIII, one of a host of clotting factors that controls how your body controls bleeding. However, he was not admitted for a hematological issue. In fact, many consult services in a hospital become involved in supporting the treatment of a patient simply because they have a longstanding diagnosis that merits supervision from the specialists in question. In Mr. K's case, he received frequent Factor VIII infusions since he couldn't make this clotting factor himself. We followed along with the horror show that was his admission and simply made recommendations on how to titrate his infusions to suit whatever treatment he was undergoing.
We did not change anything when he was admitted with pulmonary edema (fluid "on the lungs"). We did not budge when it was determined his failing, transplanted kidney was to blame. We did not bat an eyelash when he was found to have a staphylococcal blood infection and put on antibiotics. We did take notice, however, when that infection travelled to his prosthetic hip and lodged itself in the joint; he would require surgery to address it and that meant bleeding (necessitating an extra dose of Factor VIII). Really, that was it.
Doctors will make much ado about being diligent practitioners, even when they are only peripherally involved, such as we were with Mr. K. Ultimately, our involvement amounts to floating along like the Hematology Fairy and sprinkling some treatment onto a patient before fluttering away, no matter how sick they are. Teamwork has its perks, I guess.