About this game
A night on call at a cancer centre, played as a detective case file. The pager gives you a patient and a headline number; you spend a small budget of tests while they deteriorate, name what it is, present the one result that separates it from the next-best suspect, and make the first move before the confirming test comes back. TTP, HUS, HIT, DIC, acute promyelocytic leukaemia, tumour lysis, leukostasis and brain metastases all share headlines and separate on a handful of findings.
How to play
- 01Read the page, then spend your orders: every test costs time the patient does not have.
- 02Cross off the suspects the results do not fit.
- 03Name it, and present the result that sinks the next-best suspect.
- 04Choose the first move. Some of them cost a heart.
Controls
- 1 - 9
- Order that test
- A - G
- Cross a suspect off
- Enter
- Name it, then confirm
- Escape
- Back
- Space
- Pause
What you will practice
- Separate the thrombotic microangiopathies from the other causes of a low platelet count
- Name the finding you separated them on, not just the diagnosis
- Start the treatment that cannot wait for the confirming test
The clinical content
The patients are invented; the criteria are not. Every result is generated from a threshold published in the guideline or consensus document cited on the item - the PLASMIC features for TTP, the 4Ts for HIT, the ISTH score for DIC, the Cairo-Bishop and Howard definitions for tumour lysis - and no generated value is allowed to land in the band where two clinicians would disagree. First moves are graded against what those documents recommend, and a move is only called dangerous where a strong recommendation says so.
Written to ISTH 2020/2025, ASH 2018, ELN 2019/2022, EANO-ESMO 2021, CNS 2019.
Sources
- Zheng XL, Vesely SK, Cataland SR, et al. ISTH guidelines for the diagnosis of thrombotic thrombocytopenic purpura. J Thromb Haemost. 2020;18(10):2486-2495.
- Zheng XL, Vesely SK, Cataland SR, et al. ISTH guidelines for treatment of thrombotic thrombocytopenic purpura. J Thromb Haemost. 2020;18(10):2496-2502.
- Zheng XL, Al-Housni Z, Cataland SR, et al. 2025 focused update of the 2020 ISTH guidelines for management of thrombotic thrombocytopenic purpura. J Thromb Haemost. 2025;23(11):3711-3732.
- Bendapudi PK, Hurwitz S, Fry A, et al. Derivation and external validation of the PLASMIC score for rapid assessment of adults with thrombotic microangiopathies: a cohort study. Lancet Haematol. 2017;4(4):e157-e164.
- Cuker A, Arepally GM, Chong BH, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv. 2018;2(22):3360-3392.
- Cuker A, Gimotty PA, Crowther MA, Warkentin TE. Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood. 2012;120(20):4160-4167.
- Lo GK, Juhl D, Warkentin TE, et al. Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost. 2006;4(4):759-765.
- Fakhouri F, Zuber J, Frémeaux-Bacchi V, Loirat C. Haemolytic uraemic syndrome. Lancet. 2017;390(10095):681-696.
- Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017;65(12):e45-e80.
- Iba T, Levy JH, Maier CL, et al. Updated definition and scoring of disseminated intravascular coagulation in 2025: communication from the ISTH SSC Subcommittee on Disseminated Intravascular Coagulation. J Thromb Haemost. 2025;23(7):2356-2362.
- Sanz MA, Fenaux P, Tallman MS, et al. Management of acute promyelocytic leukemia: updated recommendations from an expert panel of the European LeukemiaNet. Blood. 2019;133(15):1630-1643.
- Tallman MS, Altman JK. How I treat acute promyelocytic leukemia. Blood. 2009;114(25):5126-5135.
- Röllig C, Ehninger G. How I treat hyperleukocytosis in acute myeloid leukemia. Blood. 2015;125(21):3246-3252.
- Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004;127(1):3-11.
- Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med. 2011;364(19):1844-1854.
- Wada H, Thachil J, Di Nisio M, et al. Guidance for diagnosis and treatment of disseminated intravascular coagulation from harmonization of the recommendations from three guidelines. J Thromb Haemost. 2013;11(4):761-767.
- Döhner H, Wei AH, Appelbaum FR, et al. Diagnosis and management of AML in adults: 2022 recommendations from an international expert panel on behalf of the ELN. Blood. 2022;140(12):1345-1377.
- Le Rhun E, Guckenberger M, Smits M, et al. EANO-ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of patients with brain metastasis from solid tumours. Ann Oncol. 2021;32(11):1332-1347.
- Ryken TC, Kuo JS, Prabhu RS, Sherman JH, Kalkanis SN, Olson JJ. Congress of Neurological Surgeons systematic review and evidence-based guidelines on the role of steroids in the treatment of adults with metastatic brain tumors. Neurosurgery. 2019;84(3):E189-E191.
- Chang SM, Messersmith H, Ahluwalia M, et al. Anticonvulsant prophylaxis and steroid use in adults with metastatic brain tumors: ASCO and SNO endorsement of the Congress of Neurological Surgeons guidelines. J Clin Oncol. 2019;37(13):1130-1135.