Rotation 1: The Gospel According to Frame

Posted by Emily at Wednesday, June 17, 2015

My first rotation was something of a baptism by fire as I was assigned to the adult bone marrow transplant service at a large health center with Dr. David Frame.  As you can imagine, bone marrow transplant patients are a complicated population, so walking into the hospital on the first day was equal parts terrifying and exciting.  The first week was overwhelming as my two fellow rotation-mates and I learned to navigate the (abbreviation-filled) world of BMT.  For example, a typical progress note for a BMT patient might start something like this:

XY is a 40 yo male w/ AML in CR1 s/p 3+7 (idarubicin/ara-C) and s/p 3 cycles HiDAC followed by FluBu4 conditioning for MUD allo PBSCT on 5/1/15.  Admitted for intractable N/V/D with concern for GVHD.

Translation:  XY is a 40 year old male with acute myeloid leukemia in his first complete remission status post a chemotherapy course consisting of 3 days of idarubicin and 7 days of cytarabine, as well as three cycles of high-dose intermittent cytarabine, followed by four days of fludarabine and busulfan as preparatory conditioning for a matched unrelated donor allogenic peripheral blood stem cell transplant on 5/1/15.  Admitted for intractable nausea, vomiting, and diarrhea with concern for graft-versus-host disease.

Phew!  Fortunately, Dr. Frame gave us a high-level overview of the tenants of BMT on our first day.  There are two main types of bone marrow transplant: autologous and allogenic.

Autologous transplants are simply rescue therapy for patients who require incredibly high doses of chemotherapy to treat their blood cancer.  The patient's own hematopoietic stem cells are harvested and stored, the patient is given a course of high-dose chemotherapy that essentially wipes out their entire immune system because the regimens are so myelosuppressive, and then those stored stem cells are reinfused into the patient to save them from the toxicity of the chemo they received.

Allogenic transplants are a little bit more magical, as Dr. Frame put it.  In allogenic transplant, a patient's immune system is wiped out ("ablated") by high-dose chemotherapy, and then replaced with stem cells from a donor.  The idea is that the new immune system from the donor will recognize the patient's cancer cells as foreign and attack them, with the goal of getting rid of the cancer all together.  However, allogenic transplants are a careful balancing act because while we want the new cells to attack the cancer, we don't want them to attack the rest of the body.  Unfortunately, this is a relatively common occurrence in allogenic BMT referred to as "graft-versus-host disease" or GVHD.  Thus, allo patients are placed on immunosuppressive regimens including medications that are often used in solid organ transplant like tacrolimus or cyclosporine, mycophenolate, sirolimus, and/or steroids in order to prevent GVHD.

GVHD is a big concern for allo patients, but infection is a major issue for all BMT patients, especially immediately following transplant when patients' white blood cell and neutrophil counts essentially drop to zero.  Thus, all patients are placed prophylactically on an antibiotic, an antiviral, and an antifungal.     

The learning curve was steep, but I started to speak the language of BMT and feel more comfortable after those initial two weeks.  A typical day on this rotation looked something like this:

0630-0800 - work up patients at home 

I was never very clear on what it meant to "work up" patients before starting this rotation.  It's a phrase we hear thrown around a lot during pharmacy school, and it simply refers to following your patients' progress, monitoring their lab values, and most importantly, combing through their drug therapy to make sure all medications and doses are appropriate.  "Working up" a patient means developing a pharmacist care plan, complete with assessment of each issue and your plan to address and monitor the problem.  Patient work ups are the core of clinical pharmacy practice and are crucial if you want to meaningfully contribute to patient care during rounds.  I developed my own monitoring form specific for this rotation, since most BMT patients receive similar infectious disease prophylactic regimens, nausea and vomiting regimens, pain regimens, etc.  Having a service-specific form helped me to be more efficient as I increased my patient load.

0900-1200 - rounding with the medical team

The team was made up of an attending physician, "physician extenders" like physicians assistants and nurse practitioners who took rotating ownership of a fraction of the patients, a discharge planner, a registered dietician, and of course - the pharmacist!  Rounds generally lasted anywhere from two to four hours depending on the attending physician and the number of patients on the floor on any given day.  We would visit each patient's room as a group, and after the NP or PA presented an update of the patient's condition and problems that needed to be addressed, we would all go in to speak with the patient in person.  Rounding was not as high pressure as I expected it to be.  While Dr. Frame (and everyone else on the team!) loved to quiz us, they were all very understanding of the fact that we are still students and this was only our first rotation.

It was also very cool to see Dr. Frame's genius in action.  The team - including the attending physicians - frequently turned to him for recommendations and explanations as to why a certain medication/regimen/dose was preferable to another.  BMT is a very guideline-driven service.  Because Dr. Frame helped to write/overhaul so many of the BMT treatment guidelines here based on the best available evidence, and because the medical team trusts his knowledge so much, one of the physicians referred to these protocols as "The Gospel According to Frame".  To me, this exemplified the pivotal role pharmacists play in providing patient care of the highest quality.  Even patients knew Dr. Frame as "the drug guy" or "that pharmacist I was telling you about", and this was because Dr. Frame treats every patient with as much care and attention to detail as if they were his own family member - and he encouraged us to do the same.  I hope to one day inspire that same level of confidence and appreciation from my patients as Dr. Frame does from his.

1300-1500 - patient and topic discussion with Dr. Frame and/or Dr. Benitez, the PGY1 resident who was on rotation with us this month

Topics included management of chemotherapy-induced nausea and vomiting, posterior reversible encephalopathy syndrome (or PRES, a serious side effect of the immunosuppressant tacrolimus), Clostridium difficile infections, pain management, graft-versus-host disease, cytomegalovirus, neutropenic fever, pharmacokinetics, management of fungal infections in immunocompromised patients, respiratory syncytial virus, engraftment syndrome, and more!

evening - read journal articles, prepare answers to questions that came up during topic discussion, work on nursing in-service project

My nursing in-service was on the anti-emetic drug dronabinol, a synthetic form of THC.

My favorite part of this rotation by far was the way Dr. Frame pushed us to really THINK.  He told us on the first day that he didn't care if we became bone marrow transplant experts; he was more interested in us learning how to think like pharmacists, to reason our way to appropriate recommendations, and to always ask WHY.  Every day on rotation was full of puzzles needing to be solved, and I had so much fun striving to really think every puzzle through mechanistically.  I used to think that Dr. Frame was some kind of pharmacy wizard who just magically knew everything.  But I quickly realized that he's not so much a pharmacy wizard as a pharmacy super sleuth who uses logic (and half-lives!) rather than magic to be so good at what he does.  (Even if allo transplants are a little bit magical.)

Overall, this was a fantastic, highly recommended rotation experience.  It solidified my interest in pursuing residency, and helped me to realize that I probably know more than I give myself credit for.  I'm looking forward to diving into my next rotation - pediatric generalist - ready to continue building my skills and my confidence!

Superman, Spiderman, and Captain American washing the windows at Mott