Patient Care and Procedural Skills in Hematology
Core concepts
Patient care in hematology is built on a disciplined diagnostic sequence: confirm the abnormality, characterize it (morphology, flow cytometry, cytogenetics/molecular), then link it to a clinical syndrome. Candidates should be fluent in the workup of anemia (reticulocyte index, iron studies, hemolysis screen), thrombocytopenia (pseudothrombocytopenia, TTP, HIT, DIC), and coagulopathy (PT/PTT mixing studies, factor assays).
Procedural competence includes safe bone marrow aspiration and biopsy: consent, anticoagulation reversal, site selection (posterior superior iliac crest), and recognition of complications. Lumbar puncture in suspected CNS involvement, central line care, and transfusion administration (two-person verification, monitoring for TACO/TRALI) are also fair game.
Traps
- Treating a low hemoglobin before checking the reticulocyte response.
- Calling thrombocytopenia immune before excluding pseudothrombocytopenia on a smear.
- Missing that a normal PTT does not exclude lupus anticoagulant; mixing studies that fail to correct suggest an inhibitor.
- Transfusing platelets in TTP or HIT without indication.
Worked example
A patient with microangiopathic hemolytic anemia, schistocytes, platelets 18,000, creatinine 2.4, and normal PT/PTT: the pattern is TTP until proven otherwise. Do not give platelets; proceed to plasma exchange and ADAMTS13 testing. A normal PT/PTT does not argue against TTP.
Rule of thumb
The smear is the hematologist's physical exam-always ask what the peripheral smear shows before committing to a diagnosis.