Rotation 5: Inpatient Bone Marrow Transplant

Posted by Makenzie at Sunday, November 24, 2019

A typical day for me during inpatient bone marrow transplant (BMT) started at 7am, where I would work up patients prior to 9am rounds.  Most BMT patients are in the hospital for at least seven days (usually more) post-transplant which allowed me monitor long-term changes in therapy.  Despite BMT being a specialized unit, the patient caseload was diverse.  It included patients receiving who were receiving conditioning therapy prior to transplant and post-transplant patients awaiting engratment.  It also usually included at least two patients who were readmitted.  Readmission reasons usually included neutropenic fever or workup for graft vs host disease.

After working up patients I would meet with my preceptor to go to interdisciplinary rounds.  There were three attendings for the inpatient BMT unit who would rotate inpatient rounding weekly.  There would be 8-14 patients on our service and rounds typically lasted 1.5-2.5 hours, usually longer at the beginning of the week and then shortened throughout the week as the attending became more familiar with each case.  The rounding team included mid-level practitioners, a nutritionist, a BMT pharmacist, a case manager, and sometimes a social worker.

After rounds, there may be a number of patient-related activities to follow up on.  If a patient was being discharged, we would make a medication schedule and they would receive a visit from the BMT pharmacist prior to leaving.  The autologous transplant patients would typically only be discharged on twice daily acyclovir (in addition to any medications they had prior to admission) while the allogeneic transplant patient would need careful counseling regarding their immunosuppressants.  Other post-round patient care activities included immunosuppressant dosing, renal insufficiency dosing, or any other research regarding medications.  During my time at BMT they were two patients who had acute GVHD that was refractory to steroids which required a significant amount of follow-up research.  Afternoons were generally dominated by topic discussions or working on projects such a patient case presentation or journal club. 

Overall, BMT had a steep learning curve due to the specialized nature of the unit and the amount of emerging therapies.  However, it helped me become an independent learner and keep current on recent literature.  BMT patients, due to their immunocompromised state, were also on prophylaxis antibacterial, antifungal, and antiviral medications.  At least half of the patients would spike a neutropenic fever during admission and would require broad-spectrum antimicrobials.  Since I have an interest in infectious diseases, being on the BMT service helped me keep current with antimicrobials and examine more closely some less common infections.