DDx

A 5-year-old child and his parents boarded a plane heading for a new life. They were Syrian refugees, who fled conflict in their country and then lived a difficult life in a refugee camp. Now they were heading to Canada. But soon after arriving, there’s a problem. The child has hemophilia and due to hemophilia complications, a minor injury while traveling became a major concern. Add to this a language barrier and trying to understand a new culture. Dr. Robert Klaassen, a pediatric hematologist and lead of the Comprehensive Hemophilia Care Clinic at Children's Hospital of Eastern Ontario in Ottawa, Canada, shares his experience working with a family who overcame incredible barriers and the lessons learned along the way.

It was supposed to be a simple, low-risk procedure, but for this 61-year-old patient with undiagnosed hemophilia, undergoing a lithotripsy for kidney stones proved to be anything but. The patient was born in the 1950s in Taiwan, when many people in the country had never heard of the disease. So, despite signs throughout his life, the patient’s hemophilia diagnosis evaded him for decades. Dr. Yeu-Chin Chen, a hematologist at the Tri Service General Hospital's Hemophilia Care and Research Center in Taipei, Taiwan, shares this patient’s journey and how doctors should be on the lookout for signs of hemophilia, while understanding that symptoms can vary from patient to patient.

A young child living with severe hemophilia is adopted by a family in the United States. Prior to his adoption, due to a lack of resources and other challenges, his hemophilia was not properly managed. Dr. Meera Chitlur, a pediatric hematologist and the director of the Hemophilia Treatment Center at the Children's Hospital of Michigan in Detroit, has treated this patient since he first came to the U.S. As he grew older, like many children, he wanted to play sports. But for people with hemophilia, participating in sports brings great risk. Dr. Chitlur shares how together with the patient and his family, they navigated the challenges of growing up with hemophilia and how new treatment options for pediatric hemophilia have opened up a whole new world for kids living with the disease.

About 40 years ago a mother brought her 6-month-old child into the hospital. He was covered in bruises. Dr. Victor Blanchette, a pediatric hematologist at the Hospital for Sick Children in Toronto, Canada, met the patient that day and, following a severe hemophilia diagnosis, has treated the patient ever since. Dr. Blanchette recounts how during the patient’s childhood in the 80s, the approach to treating hemophilia was reactive, not proactive. This meant that normal childhood activities could lead to devastating bleeds. During this episode, we walk through the history of hemophilia and how its evolution toward preventive care has had an incredible impact on this patient and so many others.

A 30-year-old was in labor with her first child. Everything was going to plan … until it wasn’t. Dr. Azusa Nagao, a hematologist at Ogikubo Hospital in Tokyo, Japan, shares a case that illustrates how historically it was thought that women and people assigned female at birth could only be carriers of the disease, not have the disease themselves. This misunderstanding of hemophilia in women has led to women going undiagnosed and untreated with severe repercussions. For the patient in this story, it meant a frightening and dangerous birth experience that put her and her child at risk. Dr. Nagao also outlines efforts to educate patients and physicians about hemophilia, what to look for, and how to treat it.

A patient was experiencing severe knee pain. Unfortunately, this wasn't anything new. For decades, he’d been suffering from joint disease, caused by severe bleeding in his knees from a rare blood disorder — hemophilia A. The patient was born in the 1960s, a time when the life expectancy for patients with hemophilia was only 10 years. But as Dr. Annette Von Drygalski, a board certified hematologist and the director of the Hemophilia and Thrombosis Treatment Centre at the University of California, San Diego, explains, advances in hemophilia treatment throughout this patient’s life allowed him — and many others like him — to live a longer, richer life.

Go inside the minds of doctors who specialize in hemophilia — a rare, inherited bleeding disorder that once meant possibly not surviving past the age of 20. This season, we’ll explore the medical milestones that enable patients today to live longer, richer lives and examine the challenges yet to be tackled.

What can you do when your attending physician is a bully? Hear from two nurses, Melissa and Laura, about their experiences being bullied by a physician. For Melissa, it was notifying an on-call physician that a baby was ready to be delivered, only to be scolded for calling too soon. For Laura, it was being reprimanded by a physician who questioned her abilities as a nurse in front of a patient. So how do you respond to a bully, especially when the bully is in a position of power? Connie spoke with Carolyn Smith, an associate professor and associate dean of research, and author of "Standing Up Against Workplace Bullying Behavior: Recommendations From Newly Licensed Nurses" for insight. Carolyn, Melissa, and Laura all weigh in on standing up for yourself, calling out bullying, and sticking to your boundaries.

When is it okay to admit that you don’t know how to do something? Hear the story of Tamara Kuhn, a bedside telemetry nurse, who in a moment of crisis, used her problem-solving skills to keep her patient (and herself) safe. Tamara was caring for a patient who suddenly became violent. After calling for help, Tamara was given what she thought would be a standard restraint system. But what she received was not equipment she was used to. So how do you set yourself up for success in these situations? Connie spoke with Jill Clemmons, an acute care nurse practitioner, for insight. Jill discusses how taking care of yourself, preparation, and finding your why are key to navigating difficult situations.

What do you do when you know something is wrong with a patient, but don’t have the data to back it up?Hear the story of Diana Struthers Stanton, who, at the beginning of her 46 years in nursing, cared for a 10-year-old patient with Reye syndrome. The patient’s capillary refill had changed and was slowly getting worse and worse.Concerned, Diana spoke to her charge nurse and was told not to worry about it.She spoke with her colleagues who also told her not to worry.She paged the on-call resident in the middle of the night, but got the same response.Diana’s gut was telling her something was wrong, but she lacked the clinical data to back it up.So what do you do?For insight, Connie spoke with Dr. Sarah Kim, a specialist in emotion-focused mindful psychotherapy, about the importance of trusting your gut.We’ll also discuss being your patient’s advocate and learning to forgive yourself when things don’t end well despite all your efforts.

How do you know when generic symptoms are masquerading as something serious? Hear the story of Molly Lalonde, a pediatric nurse practitioner, who met an 11-year-old patient with an unexpected concern.While surprised by the patient’s inquiry, Molly took the time to listen and ask questions. In response to the patient’s heightened level of concern, Molly investigated further. Following an assessment by a specialist, it turned out the patient’s concern was warranted. So how do you recognize the zebra in a herd of horses? To get another perspective, our host Connie Levie spoke with Dr. Raj Bhardwaj, an urgent care physician and host of the DDx podcast. Dr. Bhardwaj details how to zoom out and get the bigger picture, the importance of respecting the concerns of your patients (just as Molly did), and following your spidey sense.

While nursing school equips you with valuable knowledge and skills, it doesn't prepare you for the real-life challenges you’ll face on the floor.They Don't Teach That In Nursing School is your go-to guide, offering unique solutions to the unexpected problems you'll encounter as a nurse.Each week Connie Levie (RN) presents the story of a nurse facing a specific challenge and its possible solutions.Our episodes are snack-sized, designed for your commute, break time, or just when you need to decompress and connect to a larger community of nurses.This podcast is a must-listen for nursing students, recent graduates, and seasoned professionals alike, who want a deeper understanding of the profession.Whether you're mastering a new skill, managing difficult bosses, or thriving in your nursing career, we've got you covered with practical advice and eye-opening stories from the field.They Don't Teach That In Nursing School is a limited (four episode) series that launches on Nov 1st! Give it a listen!

DDx has been nominated for three Signal Awards. Click the links below and vote for us now!Documentary: https://vote.signalaward.com/PublicVoting#/2023/shows/general/documentaryHealth & Wellness: https://vote.signalaward.com/PublicVoting#/2023/shows/general/health-wellnessBest Writing: https://vote.signalaward.com/PublicVoting#/2023/shows/craft/best-writing

Hi DDx listeners! We’ve got something special in the works, and we want you in on it. We're developing a new podcast by and for nurses - and we're searching for a host! It’s a show about innovative solutions to the most intense challenges - whether clinical or personal - that nurses face. In each episode, you, our host, will connect with fellow nurses who are grappling with specific challenges and unravel solutions that not only elevate their practice but also enhance their overall job satisfaction.Whether you're fresh to the nursing world or a seasoned pro, your voice matters. We're building a community of curious minds, a place where your insights and wisdom can light the way for others. This is a paid - not volunteer - opportunity. So, if you're ready to embark on a journey of camaraderie, inspiration, and learning, go to https://bit.ly/NursingPodcastHost Oh and keep in mind, our submissions will close on Sept 18 - so press that record button soon! Thanks!

Following a normal first trimester, a pregnant patient starts spotting. The patient’s care provider books an urgent ultrasound to see what is causing the bleeding. The main concerns are if the spotting is caused by a miscarriage or something else.Following the ultrasound, the technician calls in obstetrician Dr. Ashley Brant to review the results with the patient. There is a problem with the fetus’ heart — specifically, a condition called hypoplastic left heart syndrome. Essentially, the left side of the heart doesn’t develop normally and can’t pump blood in the way that it should.Hypoplastic left heart syndrome causes poor oxygenation, meaning the skin can be bluish or with dark discolorations. It also causes difficulty breathing, feeding, and lethargy. Treatment includes multiple surgeries after birth, and can even require a heart transplant. Without treatment, the condition is fatal.The patient is offered genetic testing to determine if the heart condition is a symptom of a larger genetic disease. Regardless, the prognosis is grim.The patient meets with Dr. Brant to discuss all of the options, including continuing or ending the pregnancy. “I think everybody who's in a situation where they're thinking about ending a pregnancy because of a major fetal anomaly, they are thinking about what is the kindest decision, the most loving decision that they can make for their baby,” shared Dr. Brant. “Nobody wants to be in this position. And they're thinking about what the experience is going to be like for this child.”The patient makes the decision to end the pregnancy through the dilation and evacuation method. However, the procedure cannot be performed in the state because of a heartbeat law in place at the time. And so Dr. Brant refers the patient to an out-of-state clinic where the initial procedure to stop the heartbeat can be performed. But, in order to be where the patient has the support of the medical team she knows and who has been by her side, the patient returns to her home state for the final procedure. “No one ever envisions themselves needing an abortion. No one ever thinks, ‘I want to have an abortion,’ before they're in a position of needing one. I would just encourage compassion and empathy and trying to understand the life that someone else might be walking in.”

A 35-year-old with several children discovers she is having a twin pregnancy. This is happy news, until a potential abnormality in twin B is found. Twin B is measuring much smaller than twin A — almost a full 10 to 14 days behind — and there is fluid around the fetus. While it is too early to diagnose, it appears there is a brain abnormality.The patient, with a lot of apprehension and many questions, sees high-risk obstetrician Dr. Maeve Hopkins. Genetic testing is needed for decision-making — to help determine if twin B can survive or if the patient’s life and twin A are at risk, meaning a pregnancy reduction will need to be considered. Dr. Hopkins orders a biopsy of twin B’s placenta.The results from genetic testing reveal that twin B has three sets of chromosomes, instead of two. This results in a rare genetic condition that causes severe birth defects. Most pregnancies in this situation end in either miscarriage or stillbirth. While there are very rare cases of live births, survival is generally limited to an average of five to seven days.Carrying the fetus poses significant risk to both the patient and twin A. There could be a build up of amniotic fluid and difficulty swallowing for twin B, which could lead to preterm labor symptoms and birth, as well as stillbirth. Losing twin B in utero may increase the risk of losing twin A and put the patient at risk, too.In this case, there are two options.One is expectant management, which is essentially to wait and see. The other is a multi-fetal pregnancy reduction, where the cardiac activity of twin B is stopped, and the patient continues with a single twin pregnancy. While pregnancy reduction is considered a fairly safe procedure, there is a small risk that the patient could still lose twin A.“I think she was somewhat in shock,” Dr. Hopkins shared. “And I think she wanted some guidance, which is always difficult when patients want to know what to do … it's a very personal, very familial decision for the patient … I generally say these are the risks to you, these are the possible outcomes, and these are the risks of a procedure. And a procedure likely carries less risk than continuing a twin pregnancy. And ultimately, she was able to make the decision.”The patient decides to move forward with the reduction procedure. Reflecting back, Dr. Hopkins shared, “What I've learned practicing high-risk OB is when you face a situation like this with a patient, it is impossible to know what decision that you would make if you were in that clinical situation … So just taking a step back and not necessarily trying to put yourself in the patient's shoes, but just stepping back and giving the information and just listening to the patient. I think as high-risk obstetricians, we're often the ones who have these stories and who see these patients, whether we're political or not, that's a life-saving procedure for us many times.”

A pregnant person is referred early in pregnancy to high-risk obstetrician Dr. Stacey Ehrenberg after an ultrasound detects an abnormally developing placenta. Dr. Ehrenberg diagnoses the patient with a molar pregnancy; a placenta that forms into a benign tumor with the potential to become cancerous. While the molar pregnancy will not survive, the patient also has a viable intrauterine pregnancy.Faced with this diagnosis, Dr. Ehrenberg counsels her patient about the risks of continuing or discontinuing the pregnancy. If the decision is made to continue, the patient risks developing mirror syndrome, a life-threatening condition marked by hypertension and edema. There is also significant risk of bleeding if any of the abnormal tissue is removed.If the decision is made to end the pregnancy, the patient faces the risks of any procedure done in a hospital; bleeding, infection, and damage to the surrounding organs, although this happens in less than 1% of cases. Regardless of the patient’s choice, Dr. Ehrenberg emphasizes that she and her team will support the patient, no matter what. The patient decides to continue the pregnancy. Dr. Ehrenberg and team develop a care plan to track both the molar pregnancy and the intrauterine pregnancy with weekly ultrasounds and blood pressure measurements. “I really watched her struggle throughout the pregnancy knowing that she knew that at some point the scale was going to tip and that this would no longer be safe for her to continue,” shared Dr. Ehrenberg. “Her hope, as was ours, was that she would be able to get far enough in pregnancy where the baby would be able to survive. She knew that this would probably be an extremely premature baby, but she was willing to take that risk to start her family.”But at 19 weeks, everything changes. “I didn't need vital signs. I didn't need to do a physical exam to know something wasn't right,” remembered Dr. Ehrenberg. “We got vital signs on her and I did a physical exam, and it was very clear to me that she had mirror syndrome and then we had to have the very difficult conversation that we knew that the baby was not yet viable, but it was no longer safe for her to remain pregnant.”The decision is clear: the only viable option is dilation and evacuation. But the procedure is not without serious complications and risks. “... These pregnancy complications are so complex,” shared Dr. Ehrenberg. “The physical aspects of it, the emotional aspects of it, the financial aspects of it … So I really just would love to see more kindness towards other people, more tolerance towards other people, more understanding that we don't understand all the time where other people are coming from and what they've been through.”

Meet three obstetricians who perform an essential medical procedure: abortion. Learn about their patients and how abortion affects both physical and mental health. From a molar pregnancy to fetal chromosomal abnormalities, these stories illustrate the life-saving impact of abortion, and its necessity within healthcare.  

It starts small. A slight pain in the foot, followed by an achy shoulder. There's some fatigue. The type of non-specific symptoms that often go ignored … until they can’t be anymore.A 37-year-old visits the family doctor, complaining of foot, shoulder and chest pain that progresses over weeks. And she's really tired. Otherwise, there’s nothing notable. She's just a busy parent. Being tired is normal, right? Sometimes that’s true, but in this case, this would prove to be a dangerous assumption. She visits her primary care provider who decides to run X-rays. There’s nothing to note other than an expanded area of cartilage at the end of the sixth rib. The doctor doesn’t think much of it at the time, but this would prove pivotal to solving the case. The patient is prescribed physical therapy, but it doesn’t help. It actually makes things worse. “She's getting very fatigued to the point where she's having to lay down in the afternoons. She can't really do her full family activities,” shares Dr. Suzanne Jan De Beur, an endocrinologist with a specialty in metabolic bone disorders at Johns Hopkins University School of Medicine in Baltimore, Maryland. “She gets terrible pain … And then eventually she was found to have a left hip fracture and needed surgery to repair the hip fracture.”This incredible progression — a hip fracture with no trauma at 39 years old — leads to more tests. She’s diagnosed with celiac disease, a wheat allergy that can cause weak bones from not absorbing vitamin D and other nutrients into the bones. This explains the fractures, but not the muscle weakness.She’s compliant with her celiac therapy, but it keeps getting worse — to the point of needing a walker. This is when the patient sees Dr. Jan De Beur. It’s at this time that a very small discovery leads to a very big diagnosis. It also leads to many lessons — one being to not only zoom in on one specific symptom, but to zoom out on a case over time so you can put the puzzle pieces of non-specific symptoms together and find your diagnosis.

In 1964, Nancy, a 5-year-old, is having her evening bath when her parents discover she has a lump on the skull the size of a grapefruit. This would mark the onset of a mysterious and debilitating disease that researchers are still struggling to understand. Over the next 40 days, medical professionals struggled to discover what was causing the lump on the skull. Each test seemed to exacerbate the swelling in Nancy's neck. In hindsight, that was a big clue, but it took doctors a while to recognize it. Instead, what happened next was a common mistake when it comes to patients with this disease. Nancy was diagnosed with terminal cancer. Doctors said she had less than a year. Yet, over the next few months, Nancy's condition didn't progress. She actually seemed to get better. Over the next few months, she was taken to a series of specialists. It was finally an oncologist who noticed something that was pivotal to her diagnosis ... her toes. Misshapen big toes — generally short and bending inward — are a hallmark of Nancy's disease. While Nancy had several telltale signs of the disease, diagnosing rare diseases is difficult in part because they’re exactly that: rare. “I can see how a practicing physician may feel a rare disease, ‘I'm never going to see it.’ But [this disease] is so striking that I think once you see someone with the disease … the image stays in your mind and even if someone, as a general internist or a pediatrician, never expects to see the case, you never know,” shares Dr. Eileen Shore, a medical researcher and geneticist specializing in musculoskeletal disorders at the University of Pennsylvania School of Medicine. And early diagnosis of this — and other rare diseases — is crucial, not only for treatment but to avoid diagnostic tests that can harm patients. While Nancy did finally receive a definitive diagnosis, many of the earlier diagnostic tests were actually causing more harm than good. “If you just have that in the back of your mind, that you have a vague image of what [it] is and see a patient who you think might have it,” says Dr. Shore, “to send a referral and get it confirmed, just think of the difference it would make in that family's life.”