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!
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