Summary
A young man walks into a hemophilia treatment center. He’s limping, certain his ankle is bleeding again—same as always. But this time, the team discovers the pain may be coming from something else, something that isn’t in the patient’s chart. The team now faces a choice: treat what they can see—or look for what they can’t. 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’s medical team found a way to help—and not just the patient’s 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’t What Hurts the Most
Dr. Raj Bhardwaj: This season of DDx is produced in partnership with and sponsored by Sanofi. This story combines details from several real cases. Details have been changed for privacy.
HOOK
Dr. Bhardwaj: A young man walks into a hemophilia treatment center. He’s limping, certain his ankle is bleeding again—same as always.
But this time, the team sees something more.
Joseph Stanco, DNP: 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—to what’s said, what’s unsaid, and what’s hidden between the lines.
This is DDx, a podcast from Figure 1 about how doctors think.
I’m Dr. Raj Bhardwaj.
If you work in healthcare, you’ve felt it—that moment when communication breaks down.
Maybe a physical therapist catches something, but it doesn’t make it back to the physician.
Or a nurse sees a red flag, but the rest of the team doesn’t hear about it.
Those gaps?
They can get in the way of giving patients the care they deserve.
This season on DDx, we’re going inside hemophilia treatment centers—places where teamwork isn’t optional. It’s what holds everything together.
You’ll hear stories from the people who do this work every day—how collaboration really works, what it looks like in real time, and what happens when it breaks down.
These aren’t hypotheticals. These are real patients, real decisions—and real consequences.
In this episode, you’ll hear from Joseph Stanco—a family nurse practitioner at Northwell Health’s 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’ll hear how Joe and his team saw a young man with the kind of pain they thought they knew inside out—but the real story wasn’t what showed up on the chart.
And how, with the right kind of teamwork, they found a way to help—not just his joints, but his whole life.
CHAPTER 1: THE ANKLE MYSTERY
Dr. Bhardwaj: It’s a Thursday morning at the hemophilia clinic. The waiting room is quiet, except for the shuffle of sneakers—one patient, a young man in his 20s, limping just a little.
He tells the nurse, “It’s my ankle again. It always is.”
He’s missed work twice this week.
He says the pain is so bad he can’t focus.
The team starts prepping for what they’ve done a hundred times before—treat the bleed, send him home.
But this time, something makes them pause.
Stanco: He was limping slightly. He was avoiding putting weight on it, but he wasn’t really in distress, more exhaustion.
Dr. Bhardwaj: He’s 22, living with a severe hemophilia that’s 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.
Dr. Bhardwaj: This is where the team faces a choice: treat what they can see—or look for what they can’t.
CHAPTER 2: A DIFFERENT KIND OF PAIN
Dr. Bhardwaj: They 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.
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.
Dr. Bhardwaj: And for maybe the first time, the patient opens up.
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’s the only story you’ve ever had words for.
Stanco: And 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.
CHAPTER 3: THE TEAM STEPS IN
Dr. Bhardwaj: Pain isn’t always what shows up on an X-ray or a chart. Sometimes, it’s the weight someone’s been carrying for years—the kind that doesn’t 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’s remarkable about this team is that they get that.
Joe knows he can press pause on the checklist, actually listen, and—because he’s not alone—bring in someone who can offer additional help.
That’s 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.
Stanco: We’re told as boys—like, you know—boys 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—that vulnerability isn’t allowed.
Dr. Bhardwaj: It’s tough to talk about the kind of pain you can’t point to on a body.
But sometimes, all it takes is one person to show that it’s 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: 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.
Stanco: 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: It 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’t always what—or where—you expect.
Stanco: I 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’s invisible—to 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 Figure 1. Figure 1 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!