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Welcome to the Pediatric Hematology/Oncology inpatient rotation (aka “Team B”). We look forward to working with you. The following documents purpose is to provide guidance about your rotation with our department. Please let us know if there are other helpful additions you think would add to your education and understanding expectations.To best prepare for this rotation please do the following prior to starting the rotation:Read the goals and objectives that are provided to you in New Innovations and sign off they have been readObtain sign-out about the patients the day prior to coming on serviceBegin thinking about your personal goals and objectives of this rotation and any specific topics you hope to learn about. General Purpose and GoalsThe goal of this rotation is to allow the resident to become familiar in recognizing, diagnosing and treating common oncologic and hematologic disorders, at the appropriate level of a general pediatrician. With the support of a large team, including an attending, and usually a fellow and/or ARNP, you will manage up to ten inpatient patients on the hematology/oncology service.Within every “Heme/Onc” patient there are many general pediatrics problems, in the context of an immunocompromised patient. By participating and guiding their care we hope you have a better appreciation for signs and symptoms to notice prior to diagnosis, when to refer to more high level care, and what makes these patients unique. In addition to the inpatient service, we hope to educate you about basic management of chemotherapy, through rounds with our ARNP. While we do not expect you to follow these patients in solely for chemotherapy, we hope you can learn from the daily discussion about these patients and their management. In addition, there are often consults by other services that ask very relevant questions to a general pediatrician. Therefore, we will involve you in these consults at times as well. Education comes in many forms: rounds, sit down discussions, consults and through education of families. We would like you to be involved in all forms of education during your rotation as both a passive and active learner.At the end of your rotation we hope and expect you will feel more comfortable with the management of these complex patients, and when to pick up the phone and involve us. Specific Learning ExperiencesInpatient ServiceYour primary time spent will be managing the inpatient patients, which is up to ten patients. These typically will be the ‘sickest’ kids on the floor as they require the most attentionThe general structure of your day is as follows:6AM: Sign-outIf at 6AM you are over ten patients please allocate “over-the-cap” kids. See below for more details1 6:15AM-8AM: Pre-round on patients, prep notes and see sickest patients first8AM-9AM: Morning report, Grand Rounds etc. 9AM-9:20AM: See remaining patientsPlease ensure all patients are seen by at least one team member (intern, senior, or fellow if residents are unable). With very few exceptions patients should be seen prior to rounds so that proper plans can be made during rounds9:20AM-9:30AM: Run the list with senior/fellow to ensure any questions about management etc. are answered prior to rounds. The fellow will run the list with the attending prior to rounds as well, to ensure all team members are on the same page. If there is no fellow on service, then the list should be directly run with the attending.9:30AM-11:30AM: Bedside Rounds (including brief rounds/discussion with chemotherapy patients by ARNP)11:30AM-12PM: Tie up orders, touch base with consultants12PM-1PM: Noon conference1PM-4:30PM: Finish notes2, finish up administrative duties, teaching3, consults4, admissions5, etc.4:30PM-5PM: Run list with fellow/attending prior to sign-out5PM-6PM: Finish up work6PM-6:15PM: Sign out6Prior to 8:00 AM any urgent/emergent questions/concerns regarding patient care should be directed to the overnight attending. The inpatient fellow may be available/present, but this is not the expectation. After 8 AM the fellow should be available to field any concerns. Allocating “over-the cap” kids is at the discretion of the fellow and senior resident. See below for more details. We ask that all notes are signed and sent to the on-service attending by 3PM. If you are having a hard time doing this, please talk to your senior, fellow etc. for some guidance on methods for improving this. This allows time to do admissions, partake in consults, didactics and follow-up on patients. Twice a week the team should sit down (clinical work allowing) with either the on-service attending, back-up attending or on-service fellow, to discuss a topic (~ 20 minutes). The list of topics our department feels are important to cover in some detail are in the Resource binder. Please discuss each week with the attending(s)/fellow which topics you will be covering. In addition, the senior should pick one topic to discuss during the block (last week on service during an afternoon where majority of team is available. ideally). If there are medical students, especially 4th year Sub-I’s, they also should be encouraged to pick a topic to discuss during the month. It is the expectation that the 2nd year (senior) will see consults with the fellow and/or attending during their month. The intern/medical student is encouraged to see consults as time allows. The fellow/attending will screen the consults to determine those that have the most educational value and contact the senior to have them review the case and either see the consult prior to the fellow/attending or with them, depending on the timing, complexity and scheduling constraints. Admissions may come from the ED, outside hospital, clinic or planned from home. Those from clinic or planned from home will have a H&P +/- orders from the provider that saw the patient in clinic. In these scenarios, you should meet the family, ensure you understand the story, examine the patient to have a baseline and ensure all orders are accurate and up to date (if already put in).If you receive an admission but already have ten patients, the admission will still be done by the senior or intern for educational purposes, and the Team B census will be adjusted by the senior/fellow/ARNP/attending to maintain a patient cap of 10. When signing out to the overnight resident, please let them know Who the first call (fellow/attending) is so they can contact them at the beginning of the night. When a fellow is on call he/she should always be first call, but if the fellow cannot be reached the attending should then be called. Who the daytime attending is so that notes on patients admitted overnight can be sent to them. (Unless the overnight attending comes in and sees the patient. Ex: New diagnosis). Notes are sent to the attending who sees the patient next.DischargesAll discharge medication reconciliations must be reviewed by the fellow, nurse practitioner, attending or pharmacist prior to discharge. This helps prevent outpatient medication errors as we know some of these discharge plans can be quite complicated. All patients should have an outpatient follow up appointment arranged in our clinic prior to discharge. The inpatient ARNP can help arrange this.Educational OpportunitiesTumor Board: Monday 12:30PM It is expectation that residents will attend tumor board every Monday (unless there is a specific noon conference that requires attendance beyond the regular curriculum). Food is typically served (ask the on service attending/fellow to confirm). Here we discuss more recent diagnoses, including their work-up and management plan. This is an excellent way to see how patients present to our service and the discussions that occur to determine management. Morning Report: Tues/Thurs 8AMAt least one Team B resident (intern or senior) will present a patient at morning report. If you plan to present a hematology/oncology patient, please discuss with fellow/attending/Dr. Bechtel to ensure case is a good learning case, and identify the most important teaching points. With advanced notice, we can help you by guiding your presentation, research and give some appropriate references to read so it can be a productive discussion. One of the attendings or fellows will try to attend if their schedule allows.New Patient Teaching: Every new oncology diagnosis receives a teaching sessions about therapy plan, supportive care protocols such as managing fever, by our ARNP (usually the inpatient one). We encourage you to observe one of these sessions. The meeting provides a lot of great basic oncology education. Touch base with the inpatient ARNP to determine timing of these.New Patient WorkupWith new oncology patients there are often many things to do to appropriately diagnose and initiate the proper treatment. This includes obtaining and reviewing radiology scans reviewing pathology, organizing/performing procedures, and consenting for biology and treatment studies. These will be arranged and reviewed by the attending/fellow on service, but you are encouraged to join the team during these discussions and ask questions about why certain protocols are being followed. Please ask!End-of-Life DiscussionsWhile these discussions are difficult, there is a lot of value in observing these discussions between the family and the palliative care team and the primary team. Learning to have these very difficult discussions with patients and families is an art. Please feel free to ask if you can be present during these meetings, particularly if you have been caring/will be caring for this patient in the hospital. It helps you understand a lot of the big picture and shift in management goals as well. Prior to starting the rotation, we ask that you review a few handouts, all of which are available on the pedsjax website, and hard copies are in the “office” on Weaver4. There is also a Blue Binder with laminated references in the physician pod on the “A-side” for you that includes grade/scales, the education topics to be taught and many other helpful tools. Presentations/NotesSee this handoutHematology/Oncology TipsA document with some general rules guidelines. But, these are just that, guidelines. They do not replace clinical judgement and you may find some patients’ management falls outside of these guidelines.Education Reading listThis is a list with many articles that are good references for topics we feel you should have some understanding of by the end of your rotation/pediatrics training. We understand you may not have time to read many during your rotation, but encourage you to use this as a general guide through residency, and to prepare for your board exam. A copy of each article are available in the attending office on Weaver 4, which you may copy if you desire. “The Cap”The inpatient resident team does cap at ten patients. If the inpatient census goes above this then the fellow (or ARNP if no fellow inpatient) will follow these patients. Every morning the senior and fellow can determine who should be on Team B and who is “over the cap”. Please minimize moving patients back and forth. This is detrimental to continuity of care and is confusing to families. Once patients have been moved off the resident team to the fellow/ARNP team, unless their medical status has drastically changed, or the resident service is low in numbers (i.e. < 6 or so), they should remain on the non-resident team. There is admittedly some gray area to this, but the overall goal is to maximize resident learning and to not have patients move back and forth daily . The sickest/potentially sickest patients should be on Team B as these are the patients who offer the most learning as well as to avoid residents being called to bedside of unfamiliar patients. Bone marrow transplant patients should always be on the resident team. There may be rare occasions where the residents learn about a patient during rounds (chemo or over the cap) that has potential to get sick overnight. The expectation is the overnight person would only be called if there is acute decompensation requiring immediate intervention. Otherwise, the attending/fellow should manage these patients. PresentationsIn order to standardize presentations, organize medical thinking, understanding and decision-making and speed up the rounding process (to allow time for formal didactic sessions or patient-specific teaching), each patient is presented in a standard fashion, as follows. Remember to speak clearly and do not rush. Also, we bedside round, therefore it is important to get through the information, but also present it to the family, so they understand the assessment and plan by the end, otherwise the purpose of bedside rounds (or part of it!) is not accomplished. Of note, knowing your parents (i.e. a family/patient that has been in and out of the hospital for a year versus a new family) is also very helpful in what you need to explain. Patient name is a age year old male/female with disease here for reason admitted. Issues have been pertinent problems. (Note: this is not the same things everyday…aka do not read off what CORES said on admit.Example: Joe Smith is a 9 year old male with ALL admitted for fever and neutropenia, found to have gram negative bacteremia, who is awaiting count recovery.For transplant patients, please give day of transplant (Day minus or plus ____) s/p type of transplant (Allogenic/Autologous) prior to disease. For an oncologist and hopefully yourself, this drastically shapes thinking.SUBJECTIVE-summarize major points since we last rounded. On Mondays, this may be perhaps a bit longer to cover what happened over the weekend. (i.e. patient had a fever and antibiotics started, now afebrile; increased pain-started PCA, now better; CT for fungus was clear; got chemo without problems, etc.) For new patients, a brief history (when diagnosed, major complications, where in therapy…) informs everyone and demonstrates your grasp of the patient. If everyone knows patient, reporting events over the last 24 hours is appropriate. This should NOT be a long statement, nor involve discussion of labsOBJECTIVE-last 24 hour vitals with Tmax, include ranges and account for abnormal if you can (ex: patient was febrile when tachycardic), Wt, I/O’s (balance + or – and oral intake and UOP of mL/kg/hr if relevant)Physical exam-report any major physical findings, not entire exam, in last 24 hours or important non-findings related to the problem list (i.e. no mucositis yet)Labs/Radiology:Anything in the last 24 hoursNOTE: if you are going to state an abnormal, understand if it is abnormal (but acceptable for this patient…i.e. low albumin) or even relevant to present at all. Saying something “Dropped” or is “abnormal” can upset families unnecessarily. If you are not sure, this is a good thing to discuss with the attending/fellow prior to presentingASSESSMENTRestate age and patient ID and generalizing statement of current status (sick during induction chemo or on palliative care or pain crisis-resolving, etc.) It gives you a breather and milliseconds to formulate your plan. Similar to your opening line. This is NOT the time to go through every detail, that is what plan is for (sometimes assessment and plan can overlap, so best to do things together so your thought process is easy to follow)PLANNote: this is similar to how notes are structured, except does not need to state every single medicationi.e. saying a patient has had Zofran as needed every day is NOT of valueWe encourage you to think through the problem, evaluate the data you have and try to think of a plan. Even if it is not complete, or not perfect, it is much better to work through the process and then receive guidance on how it can be improved next time. ONC: Diagnosis, Treatment protocol (on or off study) Day of chemotherapy cycle (even if not receiving chemotherapy this is relevant to the team and their care). Any upcoming relevant scans, chemotherapy etc. (ask the attending if you have questions)If an Allogenic Transplant patient a GVHD section should be discussed here:GVHD:Current prophylaxis. Levels (when? Goal range? Recent dose change)Treatment (if relevant)Assess disease: Skin, Gut, Liver and OverallChronic GVHD (if relevant, D+100)HEME: What are counts (generally you already gave me labs, so just assess them)? Ex: Pancytopenia, anemia only etc. Receiving (or not) transfusion due to goals of ____.ID:Antibiotics Day ___, is there a total course planned? why? (broad coverage due to fever and neutropenia, bacteremia with _____ etc.)Prophylactic medication, why? (due to prolonged neutropenia, previous infection, immunocompromised therefore needs PJP ppx) everyone’s major complication, what antibiotics and day of them, prophylactic meds as well, positiveRepeat cultures from ____ is +, negative, pending etc. CV/RESP:Hemodynamic or respiratory statusRespiratory interventions? Oxygen requirement?Home CV/RESP medicationsFEN/GI:Assessment of fluids and electrolytes, need for replacement, why are abnormalities present (acute illness, chemotherapy, etc.)Oral intakeConstipation (why?) and what are we doingDiarrhea, why? Testing?TPN changesRENAL:Hypertension, threshold? Medication needed?Urine output (especially if receiving chemotherapy), need for Lasix based on I/O balancePAIN/NEURO:Status (better, worse, stable), pain meds?, any other neuro issues?Other potential systems: musculoskeletal, skin, whatever is pertinent. PSYCH: Adjustment disorder? Anxiety etc.Medications being usedWho is following?SOCIAL-Who was present at bedside during rounds, who has been updated, any active issues. Be pragmatic and objective here. This is not time for commentary. Other comments: Do not worry if you repeat something in two different categories because you cannot figure out which one it goes in, and if you want feedback on how to stratify, just ask. The goal is to be thorough and as this improves, can then work on being succinct. Note: All systems will not need to be addressed or emphasized to the same degree for each patientNotesWhile we know notes can be arduous and time consuming, they have a few important purposes:Act as a form of written communication between team members and interdisciplinary team members to explain thinking and detail plans to better care for the patient. This does not replace speaking in person, but augments it.Documentation to justify billing for services. While we know residents do not bill, learning the importance of billing and putting this into your practice with note writing will benefit you long term, and simplify the process for the on service attending. A few notes about “must-do” are below.TIP: Read the attending’s addendum from the day before- it will give you an idea if something was missed or wording should be changed.H&PPlease ensure an updated history (Personal, Surgical, Family, Allergies) are in all H&P’s. Without this, the billing is drastically changed. It also provides context to the patient from a management standpoint. Progress NotesWe know copy forward is used, but PLEASE be careful to update the entirety of your note to relevant and correct information for that day (both objective assessment and plan). Transplant patients have a DIFFERENT note- with new patients please ensure you are using the correct note templateYour subjective can truly be a subjective: What happened overnight?Think of complaints or concerns brought to you from parents/patientsNOT “there Hemoglobin is 9 and they received a transfusion”. Now, if they had a reaction to blood, that WOULD be subjective. You do not need the long list of medications pulled in from EMR. It doesn’t update and can make some notes excessively long.Your assessment should be as such: Patient, underlying diagnosis, active issues (i.e. just because they came in for fever and neutropenia 10 days ago, I suspect by now that has changed…bacteremia, etc.) and clinical status (improving, stable, worsening, critical etc.)4857751049020ONC: B-Cell ALL in remission admitted at end of consolidation. Day 43 of therapy. No signs of active disease. Will hold further chemo until count recovery.HEME: Pancytopenia due to chemotherapy. CBC reviewed and goals of Hgb of 7 and plt of 10 met, therefore no indication for transfusion.FEN/GI: Constipation due to Vincristine. Continue Miralax dailyNausea secondary to chemotherapy that is well-controlled using Zofran ATC with Ativan PRN.ID: Fever and Neutropenia in an immunocompromised patient. Continue broad-spectrum abx (cefepime) to cover most common organisms until signs of count recovery. Blood cultures remain no growth to date.Need for Pneumocystis ppx due to immunocompromised state. Continue Bactrim on the Weekends. 00ONC: B-Cell ALL in remission admitted at end of consolidation. Day 43 of therapy. No signs of active disease. Will hold further chemo until count recovery.HEME: Pancytopenia due to chemotherapy. CBC reviewed and goals of Hgb of 7 and plt of 10 met, therefore no indication for transfusion.FEN/GI: Constipation due to Vincristine. Continue Miralax dailyNausea secondary to chemotherapy that is well-controlled using Zofran ATC with Ativan PRN.ID: Fever and Neutropenia in an immunocompromised patient. Continue broad-spectrum abx (cefepime) to cover most common organisms until signs of count recovery. Blood cultures remain no growth to date.Need for Pneumocystis ppx due to immunocompromised state. Continue Bactrim on the Weekends. For plan, as many patients are complicated, organizing by system is reasonable. However, for billing (and thought process) purposes, please group them into problems within systems. If you state the problem, the data assessed, and subsequent management, that is the best way to present the problem, and your thought process. Some things may be in your plan that are not specifically tied to a diagnosis-that is ok. Just put it in with the appropriate system (ex: NPO after midnight). See example below.Discharge SummariesSummary of admission does not need to include every detail, but main points, changes in management plan and complications.Please ensure medications are up to date in the reconciliation and pulled into note. Please ensure follow-up is confirmed with team and in depart process so family is aware of follow-up needed. Medications can be refilled in the hospital without issue with the exception of Hydroxyurea (for sickle cell patients) This can only be done with the permission of the attending after discussion with the sickle cell team. Also, for oral chemotherapy only an oncology physician can write for this, and often needs to still be held when they leave (based on counts) so please confirm this with oncology team. Evaluations/FeedbackIn-Rotation EvaluationWe encourage you to seek out feedback daily, but specifically at the end of the week when each attending finishes their inpatient time. We also encourage you to touch base with the fellow mid-block to discuss feedback (in both directions) and promote self-improvement in real time. End-of-Rotation EvaluationYou should receive some summative feedback towards the end of the rotation in person via the fellow or the most recent attending. Please seek this out if you feel you have not received it. In addition, you will receive a summative evaluation (under Dr. Bechtel’s name) that is a cumulative evaluation from all the providers that worked with you during your 4 week block. We have tried to make this a simple and useful process. If you have questions about your evaluation or want more insight or details, I am always happy to meet up to discuss further. Challenges/ConcernsIf you are having challenges, whatever they may be, we want to hear from you. Your first line of defense is your chief residents or myself, depending on the challenge. I can be reached via email or phone. Also, at the end of the rotation, if there is feedback you feel would be valuable to us, whether it be positive or negative, please pass this along in real time. We do not see our evaluations for months, and if it is something that needs tweaking, waiting multiple blocks will affect your colleagues as well. So please, do not wait! We are looking forward to working with you and welcome you to our exciting world! Please do not hesitate to contact me if you have any questions, concerns, or suggestions.Sincerely,Allison (Allie) Bechtel, D.O.Nemours Children’s Specialty CarePediatric Hematology OncologyDirector of the Oncology Survivorship ProgramDirector of Residents Medical Education in Pediatric Hematology/OncologyOffice: 904-697-2148 E-Mail: abechtel@ Phone: 904-470-0976 ................
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