Monday, November 18, 2013

Hail to the Little Victors: Pediatric Oncology at Mott Children’s Hospital

Posted by Rachel Lebovic at Monday, November 18, 2013

If I told you that my pediatric hematology/oncology (peds hem/onc) rotation was my favorite rotation to date and it confirmed that I want to pursue a career in oncology, you might think, “who could ever want to work with children dying of cancer?” While this area of expertise is certainly not for everyone, I will try to use the rest of this blog post to explain why I am eager to work as a clinical pharmacist specialist in oncology (and possibly even pediatric oncology) in the future.
First, the daily routine on rotation. On most days, I would arrive at Mott Children’s Hospital between 7-7:30am to work up my patients before meeting with my preceptor around 8:15-8:30am to discuss the interventions we wanted to make on rounds. Rounds started at 9am and lasted anywhere from 2-4 hours. Then, I would eat lunch and meet with my preceptor to talk more thoroughly about each patient, discuss what happened on rounds, and determine our plan for follow-up, monitoring, or counseling needed that afternoon. After handling any patient care issues, we would go down to the cafeteria for topic discussions and case presentations. I was very fortunate that my preceptor, Dr. Erika Howle, would take hours out of her busy day to help her students learn. The first week of rotation was a little crazy because we prepared one chemotherapy topic discussion and one supportive care topic discussion every day. In my opinion, the craziness of the first week was well worth it because it allowed me to start contributing to the peds hem/onc team almost immediately. Throughout the remaining four weeks, our topic discussions focused on different disease states, such as leukemias (ALL, AML), lymphomas, neuroblastoma, sarcomas, and sickle cell disease. At the end of the day, I would follow-up with the hem/onc team regarding any medication-related patient problems and look at any new patients before heading home to prepare for the next day’s topic discussion.
This schedule was fairly constant with the exception of Wednesdays. In fact, Wednesdays on the peds hem/onc service are so different that they are colloquially known as “Wacky Wednesdays.” On Wednesdays, the peds hem/onc department holds several meetings. At 7am there is an immunoheme conference where an attending, the oncology fellows, and others discuss complex cases involving immunology. At the 9am meeting, all of the peds hem/onc attendings and the current inpatient care team of a nurse practitioner, interns (1st year medical residents), a senior resident, medical students, the pharmacist, and pharmacy students all meet to discuss current complex oncology cases. I loved listening to all of the experienced practitioners discuss the benefits and risks of different options for each patient – especially if I was helping care for that patient. Then, we started rounds at 10am and stopped for the tumor board meeting at noon. Tumor board is a joint meeting between the peds surgeons and peds hem/onc team. The practitioners look at scans then decide if a patient can go to surgery to have their tumor resected or if they need more chemotherapy to shrink the tumor before surgery is a viable option. After the conclusion of tumor board the team would finish rounds and address any patient issues the remainder of the afternoon.
In my spare time, I worked with a resident, another P4, and a pharmacist on a special project. After Mott Children’s Hospital heard about a hospital in Brazil that covers its chemotherapy with superhero-themed chemotherapy covers, we decided to pursue a similar project at Mott. Here is a video with our inspiration: We contacted the hospital in Brazil, a plastics company, Disney, and others to start figuring out how to implement a similar chemotherapy cover program. I know this project will take a long time to be fully implemented, but I can’t wait to see how the kids like the chemo covers once they arrive!
Another special experience on the peds hem/onc service came on Halloween. Many members of the inpatient care teams in the hospital dressed up, and the hem/onc team was no exception. On rounds that morning, we had Mary Poppins, an Incredible, a bunny, two witches, Snow White, and a fairy!
Besides special fun projects and dressing up on Halloween, one of the big plusses to the peds hem/onc service is the tremendous impact you can have on patient care. An example of the interventions that I made on this rotation included changing a PPI to an H2RA (one type of acid suppressor to another) to avoid a drug interaction with a chemotherapy agent.  I was also able to adjust anti-nausea, pain, and bowel regimens to make patients more comfortable and help the team dose/monitor/adjust antibiotics to treat infections and neutropenic fever. Furthermore, I followed which chemotherapy agents each patient was to receive each day, made sure they were clinically able to receive the medication based on their blood counts, communicated to the inpatient pharmacy about which patients were going to receive chemo, and answered any questions the families had about the chemotherapy agents. Another plus to working with the peds hem/onc service is the continuity of care in an inpatient setting. Since many children require several rounds of inpatient chemotherapy, practitioners get to know the patients and their families.
In my mind, I can’t change that these children were diagnosed with cancer, but I can try to help them achieve their goals of care – whether they are cure, comfort, and/or palliation. I can help these kids just be kids, and that is an amazing feeling. Furthermore, the other members of the inpatient team rely heavily on pharmacy due to the specialty medications used in this patient population, which made me feel like a valuable member of the team. Yes, there are some patients who lose their battle with cancer, but in most cases the survival rates are actually much higher in children than adults, so there are fewer sad stories than you might think. Lastly, it is really rewarding to adjust patients’ medications to help them live more comfortably, especially if their goals are palliative.
Have I convinced you yet? It’s okay if peds hem/onc isn’t for you, but if you were skeptical, maybe now you won’t think I’m as crazy for loving this rotation and pursuing a career in oncology (and likely pediatric oncology) pharmacy.

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