BMT- Rotation in Review

Posted by Anonymous at Monday, June 25, 2012

I completed my rotation last Friday in Bone Marrow Transplant at the UofM, and am still amazed at how interesting this field is!

Just think- clinicians have the potential to eradicate certain cancers in patients with high-dose chemotherapy followed by an infusion of allogeneic (donor) or autologous (self) stem cells to “repopulate” the patient’s marrow- its quite incredible! Whether a patient has arrived for transplant, or readmitted to the floor several years after, pharmacists play an integral role in the care of these patients.

In order to start to understand the complexities of BMT, the first several weeks involved extensive reading of primary literature and review articles to get a better view of the course of transplant and medications used throughout the process. By working up and following patients during their 3+ week stay, I was able to dive into how to approach patient workups, monitor labs, and implement medication changes. I really enjoyed being a part of the rounding team every morning, and felt the more I learned about the transplant process, the easier it was to suggest pertinent adjustments in therapy.

During the course of the rotation, I was able to get a better idea of just how important it is to truly appreciate the pharmacokinetics and dynamics of drugs. Dr. Frame, a master of pharmacology, challenged us to integrate therapeutic knowledge with an understanding of physiologic principles and literature-based evidence. Although this is not an easy task and will take practice, I believe that keeping this concept in mind will help me develop my clinical skills this year and beyond. 

I highly recommend this rotation to anyone interested in clinical pharmacy, as it features taking ownership of complex patients and developing knowledge of drug therapy. I will miss the BMT team, but am thankful to have had the chance to be a part of it!

BMT: a badge of honor

Posted by Anna at Wednesday, June 20, 2012

I can't believe my first rotation is coming to a close. Five weeks have really flown by, and I'm shocked by how much I have learned in such a short period of time. While I am thrilled to be coming out of this rotation only mildly battered, I am sad to leave the welcoming health care team that staffs 7W as well as the amazing patients.

As promised in my last post, I wanted to briefly touch on how pharmacists (and student pharmacists!) make an impact on this service. Pharmacists are well recognized as experts on medications, and their wealth of knowledge is not lost upon the health care team running adult BMT. In order to keep this concise, below you’ll find just a small taste of the questions directed at pharmacy:

• A patient has consistently dropping cell counts, which is not altogether uncommon in this patient population. However, could any of the patient’s medications be contributing to this trend? If so, what change would you recommend?
• A patient is unable to keep anything down due to the chemotherapy regimen we conditioned her with. What do you recommend after standard anti-emetic therapy has been attempted?
• The patient is still throwing up. What else can you suggest?
• A patient has been admitted with severe graft-versus-host disease of the skin. What type of therapy would you recommend to control the disease? What literature is your recommendation based on?
• A patient is experiencing significant changes in mental status. Which drugs could be the culprits? Are there any specific tests or concentrations you need to assess? What about drug interactions?
• Your poor patient has been hiccuping non-stop for a day with no relief in sight. We've tried Thorazine, but what else could help him?
• A patient has end stage renal disease. Does this change your recommendation for chemotherapy doses? What is the basis of this decision?

Overall, this rotation was eye-opening. It truly helped me to determine my strengths and weaknesses, and it also allowed me to start developing important skills crucial to a successful career in pharmacy. I highly recommend this rotation for anyone who wants exposure to a unique and dynamic patient population. You also typically have at least a few other classmates on rotation with you, which honestly was pretty awesome!

The next time you hear from me I will be reporting from my rotation with a generalist pharmacist in the Pediatric Emergency Department!

BMT: and what's the half-life of that?

Posted by Anna at Saturday, June 02, 2012

Why the title? I am on rotation with Dr. Frame working with UMHS Adult Bone Marrow Transplant, and if you know only one thing about a drug, I recommend it be the half-life as you will undoubtedly be asked about it.

This is my first rotation, and I have now completed my 2^nd week. I will say that the first week was definitely busy, overwhelming, and consisted of many late nights trying to get up to speed on what was going on with the patients in this service (refer to Roxanne's post for more details!). I think the stress of this was definitely eased by the classmates also on this rotation: Roxanne, Katrina, and Philip. You’ll see blog posts from the first two as well, so you will definitely get a feel for BMT if you follow us!

This service is quite different from many others. We have had anywhere from 21 to 27 patients on the floor total, with the majority of patients being scheduled admits. The patients come in about one week prior to their transplant in order to undergo the appropriate preparatory regimens. After transplant, they remain on the floor until they have recovered enough to thrive again on their own—typically, this takes at least two weeks after successful transplant. As a result, we will follow patients over a very long period of time and try to keep them as healthy as possible. Due to the nature of the transplant, the patients are severely immunocompromised for an extended period of time, making infection prophylaxis and treatment a crucial component to this rotation. Additionally we encounter a lot of nausea/vomiting issues, graft-versus-host disease, and any other disease state or chronic condition you can imagine. In BMT you see it all!

I am always curious as to what an average day looks like for each rotation, and here we have a pretty standard schedule:

• I arrive around 7:30am to review patients for any issues that have come up overnight. I then modify or adjust recommendations as needed.
• Rounds start around 8:30-9:00am. In attendance: Pharmacist, Pharmacy Students, Attending Physician, Nurse Practitioner/Physician Assistant. During rounds we will typically be ready to make any recommendations regarding our patients, and we are usually quizzed and questioned by Dr. Frame or the Attending Physician.
• Rounds end anywhere from noon to 1:30pm. Then we grab a quick lunch!
•  After lunch we meet with Dr. Frame to review our patients and any new developments. We will discuss any number of topics we have been assigned and also address any questions we have. Here we will also briefly present our patient cases and discuss what we need to prepare for the next day.
•  Topic discussion with other oncology pharmacy students occurs at 3:00pm, where we meet with an Oncology Pharmacist to discuss pertinent topics to our patient population. This requires varying amounts of reading the night before.
• 4:30pm: go home! At home I will do assigned readings, review my patients again, review material I feel needs more attention, and prepare for the next day!

So far, I have really enjoyed this rotation. It requires a lot of work, a lot of preparation, and you have to deal with a decent amount of stress regarding what questions you might be asked at any moment (often regarding mechanism of action and/or drug kinetics/half-life…) Overall, I have found it to be challenging but incredibly interesting!

In my next post, I hope to describe in more detail what types of interventions pharmacists (and pharmacy students!) make and how the pharmacist is a crucial member of the BMT team.

Why is everyone talking...

Posted by Sarah Thiel at Tuesday, October 19, 2010

about poop?

Now, I know that many of you will read this and have the same reaction I did. As students, we chose pharmacy over nursing and medicine for various reasons, but for me (especially after I worked as a nurses aid at a nursing home in Germany one summer), I knew I did not want to physically handle or care for patients they way a nurse or physician may be required to, and that included seeing, handling, or discussing "bodily habits".

So what does this topic have to do with pharmacy rotations?

While attending rounds everyday last month on the Bone Marrow Transplant service, it got me wondering why half the time the medical and nursing team was talking about poop. What does poop have to do with being a pharmacist? I mean, I know we learn about constipation and diarrhea in therapeutics, but how much is poop really going to impact my therapeutic plan?

Well, the answer is- A LOT!

Color, consistency, frequency (or lack thereof), volume, and even the smell of excrement can tell you a lot about a bone marrow transplant patient.

First, there are concerns of graft versus host disease (GVHD) in these patients. Simply put, this is when the transplanted stem cells and resultant mature immune cells recognize the patient's body as foreign and begin attacking. The most common sites for this to occur are the skin, liver, and gut. To diagnose and grade GVHD of the gut, stool volume has to be >500ml.

Second, poop can tell you about infections. BMT patients are severely immunocompromised- we just completely whipped out their own immune system and gave them back stem cells that take time to develop into mature immune cells (in the BMT world, thats called engraftment). Therefore, infections of any kind can pose a serious threat to these patients. If the patient is having diarrhea, is it C-Diff? rotavirus? adenovirus? Other potential causes? And if you smell something extremely foul...there's a good chance its C-diff.

Third, poop can tell you about other complications. If there is no poop, does the patient have an illeus? Will they need parenteral nutrition if it doesn't resolve? Or is it just constipation from antiemetic and analgesic medications? If the stool is black and tarry or bright red, that can tell you there is a GI-bleed (upper verses lower respectively).

All of these affect how you treat a patient and your therapeutic plan as a student pharmacist. From pharmacokinetic dosing of immunosuppressants to prevent GVHD, adding steroids or other therapy to treat GVHD of the gut, adding antimicrobial or viral therapies to treat infections, addressing possible GI bleeds, to requesting a nutrition consult, knowing all the gory details about your patient's poop can help you choose the best therapeutic plan for you patient.

So why is everyone talking about poop? Because sometimes in life, crap actually is important.

Got BK?

Posted by Jody at Sunday, August 29, 2010

“What is BK?” I asked the same question when I found out my patient had “BK”.

As I am rounding with the team one day I hear the attending mention my patient has BK. I immediately start racking my brain, what in the world is “BK”? I have no idea. I turn to my classmates and ask them. They respond, “BK? I thought he said PK.” Well then, “What does PK mean?” (This is the reason you ALWAYS stand as close to the attending as possible – they’re quiet talkers.) Whatever my patient has I know one of the symptoms they are experiencing is hematuria and they are going to be treated either cidofovir or leflunomide. My classmates and I are completely lost and ask our preceptor. He informs us that the attending was talking about “BK”. But our preceptor would not give us any further information. He told us we should research it tonight and gave us one clue, to start with renal transplant patients.

Returning to answer the question: “Do you have BK?” The answer: Yes, you most likely do have BK.

What is BK?

BK refers to the BK virus (BKV), and up to 90% of healthy adults are infected with the virus. The virus was first reported in 1971 in a renal transplant patient, and thus the virus was named after the patient’s initials. BK is a polyomavirus that is transmitted via the respiratory tract, especially during early childhood. The initial infection is usually asymptomatic, but it can result in a mild fever or upper respiratory symptoms. After the initial infection the virus remains latent for years in the kidneys and does not reactivate until a state of immunosuppression. In renal transplant patients BK virus manifests as nephritis (i.e. BKV nephritis), however in bone marrow transplant the clinical manifestation is hemorrhagic cystitis (HC). The presentation of HC is hematuria, bladder spasms, frequent urination, and dysuria due to inflammation of the bladder mucosa.

Diagnosis and Treatment of BK

Once symptoms of HC occur a qPCR of the plasma and urine is ordered. If results are positive the patient is then treated. However, there is no approved treatment for BKV. Clinical trials have been investing various drugs to combat the virus. Currently, trials with cidofovir and leflunomide have shown positive outcomes yet further research is warranted in both the virus itself and treatment options.

After my basic search of BKV it was time to tackle articles on clinical trials. In rotation, when a preceptor asks you to “look-up” or research something it doesn’t just mean hit Wikipedia and get the general information. We are pharmacy students, soon to be pharmacists, once we understand the condition/disease state we need to understand the treatment options and know what works (or doesn’t) and why. (A helpful hint my preceptor gave me, read the literature and know it because no one else will)

Bottom line: The learning never stops.

In need of stem cells?

Posted by Jody at Tuesday, August 17, 2010

I am starting my first rotation at UofM in bone marrow transplant (BMT) with Dr. Frame.

On the first day, of my first rotation, I was quite nervous – I had no idea what to expect. All I knew was that I would be with two other students from my class which helped ease by nerves a little. My classmates and I were to meet Dr. Frame in the cafeteria. We all thought, “Here we go, our FIRST rounds ever.” When Dr. Frame came he sat down with us and explained how we wouldn’t be attending rounds until tomorrow. He explained that with no knowledge of BMT we would feel lost and overwhelmed. (However, this feeling of lost and overwhelmed lasted the entire first week). Dr. Frame gave us an overview of BMT, described the different types of transplant and the common diseases that needed transplant. I was able to understand beyond the basics (allogenic transplant = a donor and recipient, and an autologous = the patient’s own stem cells). We talked in detail about the actual process of transplant, and In the simplest terms (for either an allo and auto), the patient receives chemo in order for the primary disease to go into remission, next the stem cells are mobilized for collection (either the patient’s or a donor’s), the patient receives a conditioning regimen of chemo and then the actual transplant occurs.

After our quick overview of BMT, he gave each of us a list of 5 patients and told us to take the rest of the day to thoroughly learn two patients in detail. By 11am we were free to go. My classmates and I thought it was awesome; we’d go home, spend a few hours learning our two patients and be done for the day. Little did we know, that when Dr. Frame said, “take the rest of your day to learn two patients” he really meant the rest of the day. As I read the patient charts I had to continuously stop and look up almost every other word. There were so many terms and acronyms I had never seen before, things like “BK virus”, “ECP held due to bleeding” or “PCA (0.4/10/14)”. I literally spent the rest of the day trying to decipher the H&P and progress notes.

The second day came and finally we were able to attend rounds. Needless to say, even after my day of studying and researching I was still lost. Dr. Frame did a great job explaining the terminology we didn’t know and the different procedures. As the first week went on things started to come together, especially since there were discussion sessions at the end of each day. All students on rotations for oncology/hematology/BMT would come together for the last 1-2 hours for a discussion session lead by one of the preceptors. Each topic came with a reading assignment to help facilitate the discussion (or to help those of us who had forgotten the topic from therapeutics). The topics that were focused on were specific conditions commonly seen in cancer patients, such as, tumor lysis syndrome, febrile neutropenia, anemia, WBC growth factors, nausea/vomiting, and pain.

After the first week things really started to come together, which also made rounds even more exciting. Each day there was at least one patient with a new condition or problem that we had never learned about in school. However, this also meant we’d be hitting the books once we left the hospital – talk about a fast learning curve!