Editor’s Corner
What We Do When We Don’t Know
What to Do
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.
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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● WE ARE IN the middle of a global “Oh, crap” moment. One of
those moments when we’re in over our heads, the water keeps
rising, and we don’t know how to swim. You know the moment
I mean. You’ve probably been in one or two yourself.
I remember one of my own: I was moonlighting in an ER
when the triage nurse called me to see a young woman who
brightly announced that she had just consumed a delicious meal
of smoked sausage, red wine, and aged cheeses and that she was
on Nardil, a monoamine oxidase inhibitor (MAOI) known for interacting
poorly with tyramine-rich foods like – you guessed it
– smoked sausage, red wine, and aged cheeses. The patient declared
she didn’t feel good. Her blood pressure was 240/140 mm
Hg … at first. She then looked up at me, rolled her eyes back, and
passed out – thunk! – and produced a blood pressure of 60/palp.
Oh, crap.
The nurse looked at me and said, “Now what?”
“I’ll be right back,” I called as I sprinted for the workroom,
where I frantically rifled through the pages of the textbook.
(Again, this was way before the internet and smartphones.)
“MAOI, MAOI, MAOI,” I chanted as I looked for the right vasopressor
agent to order – one that wouldn’t kill the patient and
get me sued. Luckily the answer (ephedrine) was in the portion
of the textbook that hadn’t been ripped out or damaged by coffee
stains. Phew.
Not all “Oh, crap” moments end so well. I was a first-year
fellow when all-trans retinoic acid (ATRA) was first approved by
the FDA. We gave ATRA to our first 2 patients with promyelocytic
leukemia. They did great. The disseminated intravascular coagulation
(DIC) stopped, the counts rose, and the patients went home.
Amazing!! But, 2 weeks later, they were back and they were not
doing great. White blood cell counts were 400,000/mm 3 . Oxygen
saturation levels were in the low 80s on a 100% non-rebreather
mask. Chest X-rays were whited out. I made a peripheral blood
smear and found weird, agranular mature neutrophils. Lots of
them. And no blasts. That can’t be right, I thought, so I made another
smear. Same result. Now what? The oxygen saturation levels
fell some more.
I bludgeoned my poor attending for answers. “I’m just the
fellow. I check the checkboxes, but you’re supposed to make
the checkboxes for me!”
“Shut up and let me think,” he snapped back, which is
attending-speak for “Oh, crap.”
In retrospect, it is obvious what was happening – differentiation
syndrome. But this was before we all knew what the
differentiation syndrome was.
Sometimes an “Oh, crap” moment results from a combination
of a lack of knowledge and a lack of resources. Back
when I was a resident, the ER at Philadelphia’s Veterans
Administration Hospital was staffed at night by a poor, beleaguered
resident and a nursing assistant (NA). The NA could
do two things: take vital signs and make phone calls. The
resident was responsible for all other tasks. Put in IV, check. Do
EKG, check. Set up albuterol nebulizer, check. Hang blood for
transfusion, check. Mix nitroprusside drip and hang for the
patient with malignant hypertension, check. One of my former
attendings told me about being on call at the Philadelphia
VA’s ER in 1976 when a whole bunch of Legionnaires started
coming in – as in the patients for whom Legionnaires’ disease
was eventually named. Taxicab after taxicab pulled up to the
ER, disgorging coughing, hypoxic veterans, with just a resident
and an NA to cover. Oh, crap.
And AIDS was getting to be a thing when I was a medical student.
What was the causative agent? How was it transmitted? At
how much risk were health-care workers who were exposed to infected
patients? Why were there no T cells? OK, it’s caused by a
retrovirus, but what the heck was up with the fevers? And the infections?
And the cancers? We were asking all these questions
while we were frantically looking and learning and trying things
out. Over the years, we have continued to have more “Oh, crap”
moments with HIV/AIDS. Highly active antiretroviral therapy?
Great. Immune reconstitution? Oh, crap. After 30 years, HIV is
now considered a chronic disease. We have effective therapies,
combination pills, and can manage most side effects and cancers
and infections, but there are still disparities in care and we
still don’t have an effective vaccine.
We will swim out of this “Oh,
crap” moment with observation,
discovery, teaching, and caring.
Which brings us to 2020’s medical “Oh, crap” moment. Yes,
I mean COVID-19. It’s morphed from a problem in China, to a
problem on cruise ships, to a problem in blue states, to a problem
everywhere. We’ve gone from thinking that only health-care
providers taking care of infected patients need to wear a mask to,
“Are you kidding?! Everyone needs to wear a mask!” And exactly
what is up with the overwhelming thrombosis? Is it DIC? Is it not
DIC, but like DIC?
We will swim out of this “Oh, crap” moment the way medical
science and health-care providers always have: with observation,
discovery, teaching, and caring – don’t forget the caring.
And of course, plenty of sweating, working, and trying things that
don’t work until we find the things that do work. And admitting
mistakes and going down dead ends, and publicizing those dead
ends and admitting when we just don’t know what to do. Out of
chaos will come organized recovery and the “Oh, crap” moments
will become just another set of anecdotes in our collective medical
memories. Because figuring out what to do when we don’t know
what to do is what we do.
*This column is written with respect to and unity with those suffering
loss and grief during this global health crisis.
Alice Ma, MD
Associate Editor
6 ASH Clinical News July 2020 Bonus Mid-Year Edition