Hematology/Oncology... intense but great

Posted by Elizabeth Kelly at Thursday, September 22, 2011

First off, I would like to apologize for not blogging sooner, but if the fact that I haven't gotten to it yet says anything about how busy my month has been I don't think anything else can. I was on the hematology/oncology rotation with Dr. Shawna Kraft at UofM Hospital this past month.

I am going to split up the rotation between the first two weeks and the second two weeks.

First two weeks:
The first day was a little overwhelming, I was with another student in my class and the first thing we did was go on rounds and each get assigned 6 patients to work up and be ready to go over and present to Dr. Kraft. I also discovered all the people who can make up a team: an attending, a fellow, a senior resident, two interns (first year residents), two medical students, a pharmacist, and us the two students. It was also really interesting how their was an attending for hematology with a fellow, and then a completely separate attending for oncology, with no fellow. So the team I was on would go with one or the other and then switch with the other team and go with the other attending. Hematology is leukemia and lymphoma patients. Oncology patients were mostly people coming in because they are having symptoms related to their cancer like neutropenic fever (lots of infectious disease), pain (morphine up the wazoo), nausea/vomiting, etc. Hematology is basically considered to be more complicated and that is why they have fellows and not oncology.
And then also on the first day we were given a quiz. I did terrible. I felt like I knew nothing. We were given the quiz at the beginning of the rotation and then we also took it at the end. I actually got a 12/30 the first time and improved to a 24/30 today when I retook it. Hey, it was hard! Anyways...
So, to basically summarize the first two weeks it was the other student and I trying to figure out what was going on with our patients while also attending "boot camp" which was a series of topic discussions lead by the different cancer pharmacists. For example, neutropenic fever, anemia, tumor lysis syndrome, etc. For me at least I was feeling pretty bogged down and not getting anywhere close to the amount of sleep I needed.

Second two weeks:
Everything changed the third week however. The first two I was nervous about talking to the doctors about potential changes and felt like a lowly student. Then an epiphany hit and I was all over them like white on rice. I was making suggestions all over the place, monitoring my patients therapy much closer, and becoming a true member of the team. It was great, I felt so sad leaving them today on my last day. I think they got really used to the other student and I being there to help them with everything they need.
Some examples of the great interventions I felt I made:
- clarified allergies (note: if someone says they had a red face to Keflex, does not mean they have an allergy to penicillins!!)
- thorough counseling on Lantus Solostar
- pain management dosing
- antibiotic dosing
- called a patient's wife to clarify a home regimen.
- and of course much more.
If you notice some of the things I did, its what you will do on any rotation. To the future P4s: become involved as much as possible. Its sad to say, but even though the MD's are super smart and well meaning, they are just as human as you and I, and will make mistakes/not know everything.
The only thing that truly sucked about this rotation was the patients who passed away, or the ones you knew you were sending home to hospice for them to pass away there. There were some really great patients though and by the end of the rotation they were MY patients. I worried about their pain, how their liver function was, or if their vanco trough was going to be therapeutic. It's truly a great population to work with. Also, Dr. Kraft is a great teacher and even though it felt overwhelming at first, the other student and I both learned a lot and I appreciate everything she did for us. I would definitely do this rotation again if given the chance.

RoTaTiOn 2 - POH

Posted by Melanie at Friday, September 02, 2011

For my second rotation, I am in Mott Children's Hospital on the pediatric oncology/hematology (POH) unit with preceptor Dr. Erika Howle.

So far, a typical day involves working up the patients I have been assigned, rounding with the team, and attending boot camp. That's right.... boot camp!

Boot camp is a two week long introduction to oncology that takes place for two hours every afternoon. Tuesday = Pain; Wednesday = Nausea/Vomiting; Thursday = Neutropenic Fever. During these sessions, the P4s on POH are joined by the P4s on Adult Hem/Onc and Gyn/Onc. These sessions are very informative and cover topics that are commonly seen on rotation.

Friday I had a topic discussion with my preceptor about Sickle Cell.

I also have to document notes on my patients in TheraDoc, as well as interventions I have been involved with. For this documentation, I am required to become familiar with the protocol that my patients are receiving, which can be found at http://childrensoncologygroup.org/. It is important to become familiar with the protocols so that you are able to make sure the patient is receiving the correct therapy for that day.

For example, the following is a treatment protocol for Hodgkin Lymphoma:

Drug/Dose/BCCA Administration Guideline
DOXOrubicin/25 mg/m2 on days 1 and 15/ IV push
vinBLAStine/ 6 mg/m2 on days 1 and 15/ IV push
Hydrocortisone/ 100 mg on days 1 and 15/ IV in 50 to 100 mL NS over 10 to 15 min
Bleomycin/ 10 units/m2 on days 1 and 15/IV in 50 mL NS over 15 minutes
Dacarbazine/ 375 mg/m2 on days 1 and 15/ IV in 250 to 500 mL NS or D5W over 1 to 2 hr

The protocol will also indicate which toxicities will likey occur with each drug and when therapy might need to be dose adjusted or omitted. For example:

Hepatotoxicity: DOXOrubicin only
Bilirubin (mmol/L) Dose Modification
2-35 100%
35-85 50%
greater than 85 Omit DOXOrubicin. Substitute cyclophosphamide 375 mg/m2

The protocols will also indicate what supportive therapy should be initiated. For example, antiemetics or PCP prophylaxis.

Overall, this week has been challenging, dealing with three unfamiliar subjects: oncology, hematology, and pediatrics. However, I have learned and great deal and even got to observe a bone marrow biopsy!

The Next Step

Posted by Shannon Hough at Saturday, January 16, 2010

January already.

December came and went with the ASHP Midyear Meeting, the holidays

and residency applications. This year's ASHP Midyear Meeting was held in Las Vegas, NV. I attended the meeting in order to learn more about first year (PGY1) residency programs. I could not believe how many people were at the meeting, including the number of pharmacy students looking for residencies. The photo at the right was taken at a student poster session. The majority of people in the room were students! It was a great experience to be at such an impressive meeting.

After weighing all of my options, I decided where I wanted to apply. So I polished up my applications and sent them off. I requested letters of recommendation and transcripts. Most pharmacy residency programs stopped accepting applications in early January. Over the next few months, I hope to receive invitations to interview for a PGY1 placement, and keep my fingers crossed for a good match.

This month, I also started my rotation in inpatient hematology and oncology at the University of Michigan. This rotation is unique in that there are two hematology/oncology teams, each of which sees both types of patients. Each team spends half of the morning rounding with an oncology attending physician, and the other half with a hematology attending physician. I am on one of the teams, and follow all of the patients that one of the physicians on the team sees. So far, I can see a huge role for a pharmacist with these patients. Cancer can change how the liver, kidneys and bone marrow function. Chemotherapy regimens alone have complex, highly individualized toxicities requiring patient-specific therapy. I have had to consider all of these factors in learning about the care of this patient population.

The team that I round with is quite pharmacy friendly. My fellow P-4-parter-in-crime and I reply to many "Hey Pharmacy..." questions from our residents and medical students. The residents often times make changes to the patient medication profiles as we make our recommendations. (Just one more reason we need to be very accurate in our recommendations!) I'm looking forward to learning more about the pharmaceutical care of hematology/oncology patients as the month continues.