Toyosi Onwuemene: The Access Gap in Bleeding and Clotting Care

Toyosi Onwuemene, Associate Professor with tenure Duke University School of Medicine, shared a post on LinkedIn:

“A patient at a critical access hospital developed a tracheal-innominate artery bleed.

A rare tracheostomy complication, this kind of bleeding emergency can kill a person in minutes.

The covering physician panicked.

There was no hematologist on staff, no bleeding and clotting service to call, and no formal relationship with a larger medical center.

He picked up the phone and dialed the nearest academic hospital several hours away.

He got lucky.

The hospital operator connected him with a bleeding and clotting specialist.

She walked him through the case in real time.

She recommended laboratory testing. She advised on blood products to transfuse.

She explained how to stabilize the patient long enough for transfer.

Together, they bought the patient enough time to survive.

But then the conversation changed.

The specialist would not document her recommendations.

She declined to write a consult note.

She refused to accept any medico-legal risk.

As far as she was concerned, the conversation never happened.

Now the physician found himself in an uncomfortable position.

He had received excellent advice. But now, he felt exposed. Left alone to manage a bleeding emergency for which he had no expertise, the undocumented phone call offered no legal protection.

If anything went wrong, he was on his own.

He crossed his fingers and hoped for the best.

When expertise exists but cannot reach the bedside

Last month, I described the ownership gap in bleeding and clotting care: the moment when clinical complexity creates a gap in which no one clearly owns the final decision.

A different version of the same problem happened during the physician’s phone call. This time, the phone call exposed not only an ownership gap but also an access gap. The expertise that existed had no formal way to get to where it was needed at the bedside.

I closed last month’s newsletter with a question for health system leaders: how should specialized expertise be organized, accessed, and delivered to clinicians when they need it most?

This phone call exposed three gaps in how health systems organize specialty care.

1. The phone call never became a documented clinical encounter

The bleeding and clotting expert on the other end of that call delivered exactly what the physician needed—expert clinical judgment.

What she could not deliver was documented clinical care. Her hesitation was understandable.

The healthcare system gave her no formal mechanism to provide clinical recommendations while also protecting herself professionally.

By advising a clinician she’d never met at a hospital with which she had no formal relationship, she was operating outside any institutional framework designed to support her delivery of real-time expert judgment.

For the specialist, the problem was the absence of a structure that made a different decision possible.

Although this phone call may appear exceptional, the underlying structure is remarkably common. When difficult clinical questions arise, physicians bridge the access gap using informal curbside consults from trusted colleagues.

While these curbside conversations often provide the needed guidance, they help mask a deeper systems problem:

Curbside consults persist because the healthcare system has no reliable way to transform real-time expert judgment into accountable, documented clinical care.

If health systems expect frontline clinicians to have access to bleeding and clotting specialist support during emergencies, they must create structures that allow such expertise to be delivered, documented, and protected.

These structures must also support patient-centered and defensible care even when the specialist never physically sees the patient.

Physicians at the front lines must be supported by real-time specialist judgement.

2. The phone call operated outside the hospital’s clinical infrastructure

The physician eventually gained access to a bleeding and clotting expert through persistence and luck.

Relying on his own resourcefulness, he created his own pathway to access.

No formalized access pathway to emergency bleeding and clotting expertise was provided by his health system.

When healthcare systems fail to build formal access pathways, physicians create their own.

Many hospitals continue to organize bleeding and clotting expertise around outpatient clinics and formal consultation services. Yet complex bleeding emergencies occur in emergency departments, operating rooms, and intensive care units.

Complex bleeding emergencies also do not discriminate between academic centers and community hospitals. The places where specialized expertise is needed most are often the places least connected to it.

Healthcare systems need innovative models of bleeding and clotting care that deliver expertise directly to the bedside.

3. The phone call could not be reproduced reliably

Our story has a happy ending; but it could have unfolded differently.

What if the specialist had been unavailable?

What if the operator had connected the physician to the wrong service?

There was no backup, no regional coverage model, no shared bleeding and clotting service. There was no system designed to ensure that the next physician facing the same emergency would receive the same support.

Health systems continue to treat bleeding and clotting expertise as a local asset.

A hospital either has it on staff or it does without. But small critical access hospitals may never have every subspecialist on site.

And they shouldn’t have to.

The better solution is to build systems that allow specialized expertise to extend beyond the walls of the hospital where it physically resides.

One approach is to develop system-wide hematology capability or make bleeding and clotting expertise available through regional networks.

It’s Time to Rethink the Last Mile of Bleeding and Clotting Care

As healthcare systems navigate growing clinical complexity, increasing specialization, and workforce shortages, it is time to reckon with reality. The question is no longer whether emergencies like this one will happen.

The law of probabilities tells us they eventually will. And when they do, an unprepared health system will experience it as a catastrophic event, rather than an eventuality that could have been mitigated.

The physician in this story eventually reached the right expert.

The next physician may not.

That difference should not depend on luck.

It should depend on infrastructure.

The future of bleeding and clotting care is not simply developing more expertise.

It is building systems that reliably deliver the expertise we already have.

In the next edition of Hematology Access Insights, I will explore several emerging models that are beginning to solve this ‘last-mile’ delivery problem and what they may teach us about the future of specialty bleeding and clotting care.”

Proceed to the video attached to the post

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