Like every other rheumatologist in practice for more than a decade, I remember all too well the days before biologic therapies. While some patients did well on gold, hydroxychloroquine, or methotrexate, far too many did not. Although they took the best agents available, many patients deteriorated despite my efforts. The advent of anti–tumor necrosis factor agents brought a “WOW” factor that many of us had never experienced in treating patients with rheumatoid and other forms of inflammatory arthritis. It’s a great feeling to prescribe a medication that puts a teenager back on the basketball court, allows a dad to play soccer with his kids, and permits a young mother to not only care for her child but also return to her job. While these new agents do not benefit every patient, I feel fortunate to be practicing in the biologic era.
As a rheumatologist, my life is oriented to the office rather than the inpatient setting. I go to the hospital to have lunch in the doctors’ dining room more frequently than to see a patient. Some of my colleagues laughingly ask if I’m lost if they see me near the ICU. However, once in a while I have the opportunity to really make a difference in an acute life-threatening situation. I was recently called by a hospitalist for an urgent consultation in the critical care unit. The patient was a 28-year-old first-year student at an Eastern medical school. She had become ill while visiting her family in San Francisco. After several visits to emergency departments for what was called bronchitis or a viral infection, she had become progressively more short of breath. When she eventually developed hemoptysis, someone finally ordered serologies. It was then clear that she had new onset lupus presenting with pulmonary hemorrhage. Knowing the very guarded prognosis in this setting, I immediately ordered three days of high-dose solumedrol. However, her blood gases did not improve and the chest X-ray looked terrible.
Because of her age and desire to have children, I was reluctant to begin cyclophosphamide. After reviewing the literature, I decided to begin plasmapheresis with oral steroids. I then had to leave town for a couple of days on ACR business. I stopped at the hospital on my way home from the airport. Walking into the ICU, my heart sank when I noted that my patient’s bed was empty. However, I soon learned that she had been transferred to the transitional care unit. I walked down the hall and entered her new room. There was my patient, out of bed and walking without oxygen. I really don’t know who was happiest—the smiling patient, her concerned parents, or her very relieved rheumatologist. I spent the rest of the day in a state of euphoria!
