Summary
A young man walks into a hemophilia treatment center. He鈥檚 limping, certain his ankle is bleeding again鈥攕ame as always. But this time, the team discovers the pain may be coming from something else, something that isn鈥檛 in the patient鈥檚 chart. The team now faces a choice: treat what they can see鈥攐r look for what they can鈥檛. In this story, we explore the many ways and forms pain can present, and the importance of treating the whole person. With the right kind of teamwork, the patient鈥檚 medical team found a way to help鈥攁nd not just the patient鈥檚 joints, but his whole life.
Joseph Stanco, DNP
Family Nurse Practitioner at Northwell Health, President of the Hemostasis and Thrombosis Nursing Association
Joseph Stanco, DNP, is a doctorally prepared Family Nurse Practitioner at the Northwell Health Hemostasis and Thrombosis Center (HTC), a lifespan clinic specializing in the care of individuals with inherited bleeding disorders. He serves as the President of the Hemostasis and Thrombosis Nursing Association (HTNA), and has earned national recognition for his contributions to nursing practice, patient advocacy, and person-centered care in bleeding disorders. He has led multidisciplinary teams, managed clinical trials, and developing national nursing certification in hemostasis and thrombosis and authoring national care guidelines.
Transcript
DDx SEASON 12, EPISODE 4
Hemophilia Treatment: When the Bleed Isn鈥檛 What Hurts the Most
Dr. Raj Bhardwaj: This season of DDx is produced in partnership with and sponsored by Sanofi. 鈥奣his story combines details from several real cases. Details have been changed for privacy.鈥�
HOOK
Dr. Bhardwaj: A young man walks into a hemophilia treatment center. He鈥檚 limping, certain his ankle is bleeding again鈥攕ame as always.
But this time, the team sees something more.
Joseph Stanco, DNP: 鈥�I was able to look in his joint, and there wasn’t an effusion there. So there wasn’t fluid that I could see. But he was describing this pain, so his pain was real. And so then we had to think about, you know, other things that this could be.
Dr. Bhardwaj: In this case, the most important clues come from listening closely鈥攖o what’s said, what’s unsaid, and what鈥檚 hidden between the lines.
This is DDx, a podcast from 天美mv传媒 about how doctors think.
I’m Dr. Raj Bhardwaj.
If you work in healthcare, you鈥檝e felt it鈥攖hat moment when communication breaks down.
Maybe a physical therapist catches something, but it doesn鈥檛 make it back to the physician.
Or a nurse sees a red flag, but the rest of the team doesn鈥檛 hear about it.
Those gaps?
They can get in the way of giving patients the care they deserve.
This season on DDx, we鈥檙e going inside hemophilia treatment centers鈥攑laces where teamwork isn鈥檛 optional. It鈥檚 what holds everything together.
You鈥檒l hear stories from the people who do this work every day鈥攈ow collaboration really works, what it looks like in real time, and what happens when it breaks down.
These aren鈥檛 hypotheticals. These are real patients, real decisions鈥攁nd real consequences.
In this episode, you鈥檒l hear from Joseph Stanco鈥攁 family nurse practitioner at Northwell Health鈥檚 Hemostasis and Thrombosis Center in New York.
Joseph, who prefers to go by Joe, has spent over a decade working with people who have bleeding disorders, helping them manage not just the medical side, but the everyday struggles that come with chronic illness.
Today, you鈥檒l hear how Joe and his team saw a young man with the kind of pain they thought they knew inside out鈥攂ut the real story wasn鈥檛 what showed up on the chart.
And how, with the right kind of teamwork, they found a way to help鈥攏ot just his joints, but his whole life.
CHAPTER 1: 鈥奣HE ANKLE MYSTERY
Dr. Bhardwaj: 鈥奍t鈥檚 a Thursday morning at the hemophilia clinic. The waiting room is quiet, except for the shuffle of sneakers鈥攐ne patient, a young man in his 20s, limping just a little.
He tells the nurse, 鈥淚t鈥檚 my ankle again. It always is.鈥�
He鈥檚 missed work twice this week.
He says the pain is so bad he can鈥檛 focus.
The team starts prepping for what they鈥檝e done a hundred times before鈥攖reat the bleed, send him home.
But this time, something makes them pause.鈥�
Stanco: He was limping slightly. He was avoiding putting weight on it, but he wasn’t really in distress, more exhaustion.鈥�
Dr. Bhardwaj: He’s 22, living with a severe hemophilia that鈥檚 made his life anything but simple.
He grew up in foster care and hasn’t visited this clinic in nearly two years.
He says his ankle causes him to miss work and keeps him up at night.
But an exam shows something different.
Stanco: When we asked him to walk, his gait was normal. And when we asked to examine his ankle, there wasn’t swelling there. And when I was moving his ankle, he wasn’t expressing pain. 鈥�
Dr. Bhardwaj: This is where the team faces a choice: treat what they can see鈥攐r look for what they can鈥檛.
CHAPTER 2: A DIFFERENT KIND OF PAIN
Dr. Bhardwaj: 鈥奣hey perform an ultrasound.
Stanco: And we do perform ultrasound in our clinic and so I was able to look in his joint and there wasn’t an effusion there. So there wasn’t fluid that I could see. And then we went through the ultrasound together and I showed him on the screen his joint, and that there wasn’t an effusion there. And that led the conversation to a different place. And I let him go there. I always tell patients, you live with your bleeding disorder. You are the expert with living with a bleeding disorder. It’s upsetting to a patient if they are managing their chronic condition and then you’re telling them what they’re feeling is not real.鈥�
Dr. Bhardwaj: So they talk.
Stanco: These are very difficult conversations. And sometimes we avoid them because we don’t want to offend someone or we don’t know if we can help. But sometimes, just having the provider listen and the patient being able to express themselves can make a difference.鈥�
Dr. Bhardwaj: And for maybe the first time, the patient opens up.鈥�
Stanco: And he had said that he had these feelings of isolation, feeling sad, feeling down were just normal for him. And he didn’t know any different.
Dr. Bhardwaj: Pain can live in a hundred places at once. In your history. In your mind.
In the story you tell yourself because it鈥檚 the only story you鈥檝e ever had words for.鈥�
Stanco: 鈥夾nd just because the patient was not presenting with physical pain, does not mean he didn’t have emotional pain or that this pain was not real.鈥�
CHAPTER 3: THE TEAM STEPS IN听
Dr. Bhardwaj: Pain isn鈥檛 always what shows up on an X-ray or a chart. Sometimes, it鈥檚 the weight someone鈥檚 been carrying for years鈥攖he kind that doesn鈥檛 fit neatly into a diagnosis.
Stanco: When the physical evidence doesn’t always match the patient story, it doesn’t mean that the patient is wrong. And I try to step back and look at the whole patient and see, let me see if I can listen differently.
Dr. Bhardwaj: What鈥檚 remarkable about this team is that they get that.
Joe knows he can press pause on the checklist, actually listen, and鈥攂ecause he鈥檚 not alone鈥攂ring in someone who can offer additional help.
That鈥檚 how people stop being cases, and start being heard.
Stanco: Teamwork helps because you can rely on someone else’s expertise to help you put all those pieces of the puzzle together. And in that case, that’s when I rely on our other team members and especially our social worker to help this patient put that story together.
Dr. Bhardwaj: The social worker comes in. They do a mental health screen. The patient scores high for depression and anxiety. They talk about stress, stigma, what it means to always have to be strong.鈥�
Stanco: 鈥奧e’re told as boys鈥攍ike, you know鈥攂oys don’t cry. And just to be silent. And that stays with you as you grow up. Men in our society, you can talk about, physical pain, being injured, but other types of pain, anxiety, being afraid鈥攖hat vulnerability isn’t allowed.
Dr. Bhardwaj: It鈥檚 tough to talk about the kind of pain you can鈥檛 point to on a body.
But sometimes, all it takes is one person to show that it鈥檚 safe to let your guard down.
And when that happens, the whole conversation changes.
Stanco: So after his discussion with the social worker, he was calmer and, you know, not as guarded as when he first came in. And that allowed us to continue our conversation about what we can offer to help.
Dr. Bhardwaj: 鈥�Instead of writing a referral and sending him home, the team builds a plan: support for his mental health, practical help for his pain, a safe place to talk, and a reason to come back.
厂迟补苍肠辞:鈥� And so during our discussion we went over different options. Our social worker was able to sit with him too, to find therapists in his area. And we also have here like a sliding scale for patients that can’t afford a therapist.
And then I went in and discussed any medication and to say that these feelings may feel normal cause he lived with them for so long, but it doesn’t have to be that way. And so we were able to provide care to more than just the joint, but the whole person.
CLOSING: LESSONS IN CARE
Dr. Bhardwaj: 鈥奍t would have been easy to have just sent this patient on his way.
But often the most important work is asking the next question.
In chronic illness, pain isn鈥檛 always what鈥攐r where鈥攜ou expect.
鈥�厂迟补苍肠辞:鈥�鈥奍 always discuss with patients that if they’re taking their factor and the pain is still there, then it could be something else. They are a whole person, not just their [remove if not hemophilia case] factor. It doesn’t treat everything. It treats their bleeds, but it doesn’t treat their underlying pain. And chronic pain is emotional pain.
Dr. Bhardwaj: The lesson here is simple: To heal what hurts, you have to see what鈥檚 invisible鈥攖o look beyond symptoms and scans, and recognize the person behind them.
SHOW CLOSING
Dr. Bhardwaj: Thanks to Joseph Stanco for speaking with us.
This is DDx, a podcast by 天美mv传媒. 天美mv传媒 is an app that lets doctors share clinical images and knowledge about difficult-to-diagnose cases.
I’m Dr. Raj Bhardwaj, host and story editor of DDx.
Head over to figure1.com/ddx where you can find full show notes, speaker bios and photos.
This season of DDx was produced in partnership with and sponsored by Sanofi.
Thanks for listening!