Summary
A young man calls his doctor – he has hemophilia and joint pain – he knows what this is, he’s had it before: it’s a knee bleed. He’s given himself three doses of blood clotting factor, but it’s not working. When he arrives at the hemophilia treatment center, his care team takes a closer look – and what they find will change everything. To move forward requires education, collaboration, and trust. In this season of DDx, the podcast about how doctors think, we’re going inside hemophilia treatment centers – to show how collaboration really works, what it looks like in real time, and what happens when it breaks down.
Cindy Bailey PT, DPT, OCS, SCS, ATC
She is a past Assistant Professor of clinical practice in the dept.s of biokinesiology and physical therapy at the University of Southern California & Mt. St. Marys physical therapy doctorate programs. Her post graduate work included an advanced residency at Kaiser West Los Angeles in manual orthopaedic physical therapy and a post doctoral fellowship at USCs Keck school of medicine in medical educ. teaching and learning. With her Certified Athletic Training and physical therapy sports specialty backgrounds she is an invited speaker and provider at multiple conferences and events such as the Pan Am Games, several U.S. Olympic teams, Israeli Macabbi Games, the World Ice Skating Championships and collegiate ice hockey. She is also one of the worlds leading instructors in kinesiology, leuko and sports taping strategies.
Dr. Bailey, as a co-lead author, wrote the USA Guideline for use of Musculoskeletal Ultrasound (MSKUS) in the HTC and as co-author has published articles on MSKUS in the journals Haemophilia and The Journal of Ultrasonic Medicine. In 2021 she was named as the NHF Physical Therapist of the year and has been chosen as the provider representative for the NHF conference for 2022 and 2023. Dr. Bailey’s current committee positions are with the Western States PT coordinating committee, NHF PT working group, Indiana Partners Program PT education, and she was elected to the World Federation of Hemophilia Musculoskeletal executive committee. She is also a co-facilitator of international bi-monthly musculoskeletal ultrasound rounds for the purpose of provider education and collaboration.
DORIS V. QUON, MD, PHD
Doris V. Quon, MD, PhD is the Medical Director of the Orthopaedic Hemophilia Treatment Center at the Luskin Orthopaedic Institute for Children in Los Angeles, California. Her focus is caring for adult patients with hemophilia and other bleeding disorders and their co-morbidities. Dr. Quon obtained her M.D. as well as her Ph.D. at the David Geffen School of Medicine at University of California, Los Angeles. She completed her residency in Internal Medicine and Fellowship in Hematology-Oncology at UCLA Medical Center. She is board certified in Hematology.
Dr. Quon serves as the medical advisor to the Hemophilia Foundation of Southern California, which is the local National Bleeding Disorders Foundation Chapter. She is a member of several professional societies, including the International Society on Thrombosis and Haemostasis, the American Society of Hematology, the National Bleeding Disorders Foundation, and the Hemostasis and Thrombosis Research Society. Dr. Quon has authored or co-authored numerous peer-reviewed articles and serves as the Principal Investigator of clinical trial studies involving hemophilia therapies including gene therapy.
Transcript
DDx SEASON 12, EPISODE 1
When It’s Not a Bleed
DDx Script: WHEN IT’S NOT A BLEED
RAJ: This season of DDx is produced in partnership with and sponsored by Sanofi.
Some details of this case have been changed for clarity and privacy.
HOOK
RAJ: A young man with hemophilia calls his doctor—he says he’s having a knee bleed.
He’s in pain. His knee is warm, swollen, and locked.
He’s already given himself three doses of his clotting medication. It’s not helping.
He’s frustrated. His mom is worried. Together, they insist: they know what this is.
They’ve seen this before.
But when he arrives at the clinic, his care team takes a closer look—and what they uncover changes everything.
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? 2
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.
And in this episode, you’ll hear from two people who know this kind of teamwork inside and out.
Dr. Doris Quon is a hematologist and medical director of the Orthopedic Hemophilia Treatment Center in Los Angeles. She’s spent more than two decades treating bleeding disorders and leading complex care teams.
And Cindy Bailey is a physical therapist and the center’s co-director. She’s been working with hemophilia patients for nearly 30 years.
Together, they were part of the team that revealed a diagnosis no one saw coming.
CHAPTER 1: “WE KNOW WHAT THIS IS”
Let’s recap. We have a young man with hemophilia. A swollen knee. Three doses of his regular medication, clotting factor. And no relief.
This is how it starts.
The patient and his mom are certain it’s a bleed.
He calls his hematologist, Dr. Doris Quon. 3
Dr. Quon: So the patient’s on the phone and he’s extremely concerned because his knee is still in pain and he just wants to treat ’cause he believes it’s a bleed and he has run out of factor at home. He just wants more factor delivered to him. And so he’s insisting, I just need factor.
RAJ: The patient has been treating this presumed bleed for four days now with no improvement. But Dr. Quon won’t call in more clotting medication—not until she sees him in person.
Dr. Quon: It’s not that we didn’t believe it was a bleed, I was just concerned that if it’s not responding, there could be a lot of different things going on.
RAJ: Here’s what’s going through Dr. Quon’s mind.
Dr. Quon: If he’s not responding to factor, my thought, well, does he have an inhibitor, so patients can develop an antibody against their treatment. One of the biggest complications of hemophilia treatment is development of an inhibitor. And then, well, if it’s not responding to factor, then maybe it’s not a bleed and it’s pain from something else, which is my other thought, of course.
RAJ: The patient shows up at the clinic on crutches.
Dr. Quon: You can see annoyance in his face, but that’s somewhat expected because he is in pain. And believe me, patients who have blood in their joints. It is unpleasant.
RAJ: To the patient, it feels obvious—this is a bleed. But for Dr. Quon, something isn’t adding up.
Dr. Quon: And it’s not that we didn’t believe them. I was concerned, truly, because the worst case scenario would be this inhibitor. The best case scenario is that it is not blood and there’s something else going on.
RAJ: Dr. Quon follows her usual approach. 4
Dr. Quon: I went up to Cindy like I always do when it’s a musculoskeletal problem and I said, Cindy, do you have time to do an ultrasound? So and so came in. He’s developed knee pain. He’s treated several times and the pain is not improving.
Cindy Bailey: I am Cindy Bailey. I’m the physical therapist at the Los Angeles Orthopedic Hemophilia Treatment Center, and I have been a physical therapist here since 1997 and three years ago I also took on a duo role and I’m now the director of the Hemophilia Treatment Center as well.
Dr. Quon: She’s been my go-to person for any questions regarding physical therapy, muscles, how they work, musculoskeletal pain. I’ll ask her about any pain you can imagine that a body can have. She’s a wealth of information from a physical therapy standpoint.
RAJ: Cindy Bailey’s background is in sports medicine—orthopedics, athletic training, all of it. Which means when a joint starts acting up, she brings a different lens to the table.
CHAPTER 2: “THE HISTORY THAT LED TO THIS MOMENT”
RAJ: Cindy and Dr. Quon review the patient’s history.
Dr. Quon: So the background is that he had a meniscal tear in that knee, had seen our orthopedic surgeon, and so we knew there was a problem previously in that joint. Although that didn’t occur to me immediately. I just thought, well, maybe there’s something else going on.
Cindy Bailey: I’m thinking this is the patient who had the water polo background. Hmm. I wonder if that possible tear has gotten larger and now he is having that piece of that meniscus a little bit outta place and it’s locking his knee, which is the normal version of a meniscus tear, uh, rearing its ugly head.
RAJ: And it’s during that back-and-forth—Dr. Quon talking with Cindy—that the full picture comes into focus. 5
Dr. Quon: When I was talking to Cindy, because she recalled the patient too, she’d seen him previously and we both were kind of like, oh yeah, he has this meniscal tear.
RAJ: Cindy uses point-of-care ultrasound—right there in the clinic—to see what’s going on inside his knee. And by comparing it to the other knee, she shows him exactly what’s normal and what isn’t.
Cindy Bailey: And so when we do the ultrasound on the injured area or the bleeding area that they think is bleeding, they can see that, oh wow, okay. That meniscus did not look the same as his other knee. One of these things is not like the other.
RAJ: The ultrasound image is dramatic.
Cindy Bailey: The meniscus looks like a triangle, like a piece of pizza. And he had this gray slash lightning bolt that came through it and the other side did not, it looked like a gray piece of pizza. So they could see the difference in how that looked. It was really an eye-opening moment for the patient and his mother to see that that meniscus did not look the same as the meniscus we had seen in his other knee.
RAJ: But the patient still isn’t entirely convinced.
This is the dilemma with chronic illness. When symptoms feel familiar, patients trust their bodies. But sometimes, what feels like a repeat… isn’t.
Cindy Bailey: They were like, oh, wow. But it’s still bleeding. It’s still bleeding, and we’re like, Nope. Do you see on the screen of the ultrasound, when you look at a baby ultrasound, you see all the black around that baby, and then you see the white of the cartilage and the bones that are forming? Well, that tells us that when you’re looking at this ultrasound screen, that if it’s black, it’s normal fluid, just like the normal fluid around a baby. If it is a grayish speckly in that black area, that tells us that the heme in the red blood cell is reflecting and we’re getting a speckle, well, you don’t have any speckles. This is dark black fluid around this meniscus and just 6
outside the medial part of your knee where you’re having the problem. And so that tells us there’s no blood there because it’s dark black with no speckles and they still are like, oh, that’s fluid. It’s gotta be blood. It’s gotta be blood.
RAJ: Instinct told this patient this was a bleed—just like all the others. But instinct can’t see cartilage. It can’t read an ultrasound. That’s where the clinicians come in.
Dr. Quon: We told him what we thought, that this most likely isn’t bleeding and that it, was fluid from the meniscal tear, which can happen. Your symptoms were consistent with this. Clearly the factor wasn’t working because it’s not a bleed, and he just did not seem completely convinced. Just, just his face just didn’t have the like. I know it’s a bleed still because it was so painful and this is what the pain feels like when I have a bleed. And it makes sense because it probably feels very similar to a bleed because you do get fluid and there is distension which causes pain. It’s just a different type of fluid.
RAJ: The next step is to drain the fluid from his knee.
Cindy Bailey: Pulling out that fluid can give a huge pain relief to the patient because there’s a lot of pain receptors on the inside of any joint capsule. So if you get the pressure off of those pain receptors, the reduction of pain is immediate and it is significant. And so we explained that to the patient and his mother, and we said, we would love to drain your knee or aspirate it under guidance so we know exactly where the pocket of fluid is. We could see it. On the ultrasound, we know where the pocket of fluid is and so we know exactly we can watch the needle go into that pocket of fluid to where it needs to be, and then we can drain the fluid as much as possible. And the patient agreed. So we got everything set up.
CHAPTER 3: “THE EVIDENCE”
They bring in the center’s orthopedic surgeon. He’s experienced.
The patient trusts him.
His knee is cleaned, numbed. 7
Then the needle—wide as the tip of a pen—is guided into the joint.
Then slowly, the fluid is drawn out.
For a moment, no one says anything.
For years, pain meant bleeding. But now, they are seeing something else entirely.
Cindy Bailey: When we drew the fluid out, the effusion, you could see that we had three tubes. There was so much fluid in there. I don’t doubt he was in massive pain. But when we drew and aspirated the fluid out, it was a beautiful yellowish, oily fluid, which is normal synovial fluid. It’s like the oil in your joint. It’s just when your body gets irritated inside a joint or inflamed by something, it produces more and more and more. your body thinks, oh, this joint is in peril and I need to help it move better. And so it produces more synovial fluid. And in that way you get a swelling or an effusion of that joint, which is what had happened and we were drawing off that extra fluid so that those pain receptors inside that capsule would not have as much pressure and the patient would have less pain. Now, what that did for the psyche of the mom and the patient was phenomenal because they could see there’s no blood in there. It’s just, it’s yellow tubes of fluid, which are beautiful.
CHAPTER 4: “THE TURNING POINT”
RAJ: This wasn’t just a different diagnosis. It was a kind of identity shift.
For a person who’s spent decades learning to treat every pain as a bleed—this was something new.
Cindy Bailey: They were like. We didn’t know we could have swelling without blood. And this is really something that is new to us to think of something that could be a quote, injury or a problem, a condition that does not include bleeding since my son has hemophilia.
RAJ: It was a turning point, for the patient and his mom. 8
Cindy Bailey: And so it’s really becoming a teaching, teaching moments where because patients have such good prophylaxis, if they’re using it correctly, they forget, well, yes, you have this condition of hemophilia or bleeding disorder, but your body still has normal injuries as well.
We still have, now that kids are participating in activities and sports or adults in jobs that are more demanding of their body, they have normal injuries. They have muscle strains, they have ligament overt stretches and tears. They have sprained ankle meniscus tears, rotator cuff injuries. So they have the same type of musculoskeletal problems that anyone else would have as well if they’re doing those same activities.
RAJ: And something in this patient’s history made him more vulnerable to this kind of injury.
Cindy Bailey: This young man was involved in water polo for years and many, many people who do the eggbeater kick, for extended period of time, or even just one that was wrong or mis-cue on the movement, and you can get some damage in the meniscus areas.
So this was something that was, they weren’t thinking of it as like he could never have, they weren’t thinking of it as a normal type of injury. They were thinking because of my hemophilia, anything I ever have will also include bleeding. But now that we have such good products, that is not necessarily the case.
And that was a very wonderful educational point that we could make with this family. And then educate them at the end of the visit. After that education, we could give them the options for future treatment.
RAJ: Not every joint pain is bleeding, even in a person with hemophilia. But when you’ve lived your whole life assuming it is, recognizing the difference takes more than evidence. It takes trust. 9
After aspirating his knee, the patient’s pain drops from a seven to a three—just from draining the fluid. They wrap his knee, give him new crutches, and from there, the plan is simple: a little rest, some ice, and a gradual return to movement.
CHAPTER 5: “COLLABORATION IS THE DIFFERENCE”
RAJ: This is what collaborative care looks like—not just getting the diagnosis right, but treating the whole patient.
In this case, teamwork means the difference between treating a meniscus tear like a bleed—and seeing that not every pain in hemophilia is about hemophilia.
And this shift in thinking? It doesn’t happen in isolation. It happens because the right people are in the room—together.
Dr. Quon says no to more clotting factor. Cindy sees the signs of something mechanical.
Together with a larger team, they use tools—and trust—to show this patient what is actually going on in his body.
Dr. Quon: In this particular case, having the physical therapist with the ability to do the ultrasound. It is a big difference because he wouldn’t believe it otherwise, that if we didn’t aspirate the knee, he would continue believing despite having the ultrasound evidence that he would continue believing that there’s blood in his knee. Keep insisting he needs more factor and treat. And treat and treat.
RAJ: And as a clinician working as part of a team, you don’t just get more information, you get the insight to really understand what that information means.
Dr. Quon: Cindy and I work closely together in the clinic. She’s the expert on musculoskeletal pain, if you will, and having her there to evaluate the joint with me gives me a little more confidence in our diagnosis. And the ability for her to do the ultrasound, just gives us extra information to help with the diagnosis. 10
RAJ: This kind of collaboration not only means better decisions, it means that care happens faster.
There’s no waiting for an outside referral, no scheduling months out for an MRI or orthopedic consult.
Everyone’s in the same building, sometimes with offices along the same hallway.
They talk. They re-check the patient’s history. They compare notes. And they move—together.
Cindy Bailey: Because we can all collaborate and we are all there, right at the same time, it saves the patient, number one in pain and misery because we can help them with their pain immediately by aspirating under ultrasound guidance.
Dr. Quon: We work together to treat the patient as a whole. In some instances, it may not be a physical problem, but an emotional issue or work related, family related psychosocial and the social worker may need to get involved. I think it’s just really important to deal with the patient’s pain, not just on a physical level, but also a mental level if they need it.
Cindy Bailey: We’ve shown in studies time over time that our patients who are treated at comprehensive hemophilia treatment centers, which means they have all the core providers, that they have a longer lifespan and they also have a higher quality of life. And so I think that that does need to be duplicated in all manners of care, whether that’s your family doctor, whether that’s a cancer clinic, a dialysis center, whatever it might be. If they can have all their care providers that normally see those patients that they would have to be referred out to, well, why not hire them in that centre, and when the patients come in for their appointments they see them, if they need to, every single visit.
CHAPTER 6: “LESSONS”
For clinicians listening: Remember to be open-minded with your DDx. Not every swollen warm joint in a patient with hemophilia is a bleed. 11
Sometimes the treatment doesn’t work—not because it’s the wrong dose, but because it’s the wrong diagnosis.
And in those moments, collaboration isn’t just helpful. It’s the best way to see the full picture.
SHOW CLOSING
RAJ: Thanks to Dr. Doris Quan and Cindy Bailey 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!