Internship Rotation 10: Oncology, 2 Weeks

We spent this rotation with 4 preceptors so it was a little crazy getting back and forth for patient visits and note co-signing (we sign all of our assessment notes and then the preceptors co-sign before they get put in the medical record). One of the preceptors does only outpatient work so we spent time with her visiting the radiation oncology clinic and meeting with patients who were in for follow-up exams or radiation appointments. One of the preceptors is over the ENT and oral surgery in-patients so we saw cancers of the head and neck with her and the other two cover the in-patient cancer unit where most other cancers are treated. A few things I learned in this rotation:

• Certain cancer treatments can actually be related to the development of other cancers. One of my patients was in remission from breast cancer but then developed leukemia and the thought was that it was related to her chemotherapy for the breast cancer.
• Radiation treatments are like repeated severe sunburns in the same spot for the duration of the treatment (which is typically several weeks or more). The radiation machines are in lead-walled rooms with thick lead doors. The patients are the only people in the room when the machines are running. The systems are so technically advanced that they adjust to the patient's breathing to keep the radiation beam calibrated exactly on the site for treatment.
• Stem cell transplants are now performed instead of bone marrow transplants. Similar cells are transplanted but the techniques are different. Instead of the painful hip donation site portrayed in TV shows or movies, the cells are drawn out in more of an IV type device. The cells can either come from the patient themselves (autologous) or from a matched donor (allogeneic).
• Those who undergo stem cell transplants from a matched donor develop sort of a dual immune system so that two immune systems are fighting off the bad cells. Unfortunately, the donor cells can also fight against the native cells and lead to graft vs. host disease which can be fatal.
• When certain chemotherapy drugs are administered in patient rooms, radiation monitors must be used to check the levels of radioactivity and the rooms are completely covered to keep the chemicals off the floor and furniture. There are large black barrels to hold all waste from the room to ensure that there is no outside contamination.

Types of patients I saw in this rotation: stem cell transplants, breast cancer, leukemia, neck/tonsil cancer, pancreatic cancer, and cancer patients in remission being treated for other illnesses such as infections, and surgical scar resections. As for nutrition therapies for these patients, I worked with intermittent, nocturnal, and continuous tube feedings as well as oral diets. On a side note-this is the first rotation where I actually worked with a prisoner. There were always police guards in the room with the patient and the patient was handcuffed to the bed. I never felt unsafe but it was an interesting situation.

As you may know, my own mother is a breast cancer survivor who underwent chemotherapy and radiation treatments. I was asked by one of the preceptors if this rotation was more difficult for me since I had a personal experience with cancer. I answered that I didn't feel that it was more difficult because my mom had a positive outcome. She's been in remission for a few years now and she tolerated her treatments fairly well. I felt like the rotation was fulfilling because I got to make a difference in helping someone else's family member to have a positive outcome.

Up Next: Surgical GI, 3 Weeks

Internship Rotation 9: Enteral Nutrition, 4 Weeks

Enteral nutrition refers to nutrition provided through tube feedings. We spent this rotation in the medical intensive care unit (MICU) and the neuro ICU. We worked with patients who could be fed orally still but put most of our focus on patients who needed to be fed through a tube. Tubes can be put through the mouth, nose, or abdominal wall into the stomach or small intestines.

NOTE: This is NOT a picture of a patient from our hospital; it is a picture that I found on the internet. The red arrow is pointing to a nasally-placed feeding tube.

Some experiences from this rotation:

• We watched the placement of a nasojejunal feeding tube for a patient with severe acute pancreatitis. This means that the feeding tube was passed through the patient's nose, through his stomach and into the jejunal portion of his small intestine. Unfortunately, the placement didn't go too well because the patient wasn't very happy to be having a tube crammed down his throat while he was nauseated. Once the placement was done, they did an x-ray (which they always do to make sure we're feeding into the right portion of the digestive tract and not into the lungs) and found that the tube had gotten stuck in his stomach. So, they took it back out and didn't feed the patient (it's not advisable to feed a patient with pancreatitis prior to their small intestine because earlier feeding in the GI tract will lead to pancreatic stimulation. In the case of pancreatitis, the production of more enzymes leads to pancreas autodigestion and breakdown so the patient could potentially lose their pancreas and develop type 1 diabetes).
• We also saw patients who needed Blakemore tubes to stop bleeding in their esophagus. Blakemore tubes are balloons that blow up inside the esophagus to put pressure on bleeding areas similar to compressing a cut to stop bleeding externally.
• We spent some time with a respiratory therapist who showed us all of the options for ventilation. Many of our patients were intubated so learning about the machines attached to them was important for us to use in assessing the clinical status of our patients. We saw patients on ventilators, oscillators, ECMO and other respiratory machines.
• Unfortunately, the unit where we worked this time held many of the sickest patients in the entire hospital. It was not uncommon to have a patient die most days of the week that we were in the unit (including at least two of my patients).
• Types of patients we saw in this rotation: stroke, suicide attempts, alcohol withdrawal, brain damage, seizure, respiratory failure/distress, end stage COPD, pneumonia, trigeminal neuralgia, intracranial hemorrhages (many that had occurred while shoveling snow), pseudo-aneurysm, septic shock, bacteremia, and fungemia. Many patients were intubated and sedated (with propofol, which provides 1.1 calories per mL, some patients were receiving over 1000 calories per day just from their sedation).
• We used many types of feeding formulas such as Jevity 1.2 (the numbers refer to the amount of calories per mL), Osmolite 1.5, Glucerna 1.5, Nepro with Carb Steady, and Oxepa.
  

Up Next: Oncology, 2 Weeks