BMT nursing questions

KelRN215, BSN, RN · Mar 30, 2013

When I worked in the hospital, the nurses on the stem cell unit never had more than 2-3 patients, day or night. I do, however, have a friend who works in stem cell at another hospital across the street and she can have as many as 4-5 patients at night.

Leukemias are probably fairly common... in pediatrics, AML will proceed to transplant automatically while children with ALL will only get transplanted if they have relapsed or have failed induction therapy. I've also seen donor transplants for MDS and various other non-cancerous bone marrow failure syndromes such as aplastic anemia, thalassemia, fanconi anemia, etc. Working in a large university's BMT unit, you will probably see it all. Auto transplants are also becoming more and more common... many children with brain tumors and all of my patients with neuroblastoma get auto transplants.

PacoUSA, BSN, RN · Apr 1, 2013

At my hospital, BMT is considered critical care, as the nurses on that unit have to take the critical care class as would all nurses working in ICU and stepdown. My former classmate works in BMT and she has on average 2-3 patients she tells me. I don't really know what kind of populations she has had as patients however, but I think it would be very interesting to work on that unit, she seems to really like it a lot.

LaRoseRN · Apr 1, 2013

Hey there! Huge Congrats!

I did my senior practicum in BMT too & LOVED it. It's not for everyone, but it was definitely for me. I remember it being a steep learning curve because, as you mentioned, we really hadn't learned much about BMT during nursing school.

Now I work as a Pediatric BMT RN. We usually have no more than two patients, sometimes we share 1.5:1, 1:1 (and in really serious cases 2:1!) but on adult units it can be 3:1, and on mixed BMT/Heme/Onc it might be closer to 4:1 or 5:1 (but I think 5 is too much if blended with a BMT patient!)

Here's a taste:

Folks get super sick on BMT -- we "condition" them with very high-dose chemotherapy (Imagine the equivalent of 1 years worth of chemo given over 6 days) that ablates the bone marrow, then we infuse them with either donor stem cells (allogeneic) or their own cells (autologous, sometimes called a "rescue") -- then we manage the symptoms of the high dose chemos et al while they grow their new marrow/immune system back. Those who receive cells from a donor source take a lot longer, and require immunosuppressive drugs for life so they don't reject the transplant.

It's an incredible process, and very hard on the patients. During my senior practicum, my preceptor told me "we basically bring them to the edge of death and back again..."

With no WBC counts, they are prone to infection, their bone marrow is essentially non-existent so they need multiple platelet and blood transfusion (or FFP, Albumin...) until their counts are back up. Antibiotics/Antivirals/Antifungals are the norm. The chemo can be cardiotoxic, hepatotoxic, and can fry the kidneys, so knowing those systems are important. Knowing all the systems is important...and signs those symptoms are shutting down. Managing, pain, fevers, nausea (look up antiemetics), fatigue, mucositis, GI issues/weight loss, emotional support, the process of being in isolation for weeks to months..."those walls can close in fast"

Review general heme/onc w/ a focus on blood diseases (leukemias, sickle cell). We also transplant SCIDS babies (born without immune systems to start) and some others...what you'll see really depends on the hospital.

Review the process for transfusing blood products (probably won't be able to touch blood or chemos while your precepting, but you'll see plenty) also managing transfusion reactions. Know your antibiotics, antivirals, antifungals. Research working with severely neutropenic populations & practicing impeccable hygiene/precautions. Learn about mucositis, pain interventions, all pain narcotics. You'll learn a of critical care. We are categorized as an ICU but we don't do vents. Review signs of sepsis, infection, signs of bleeding problems (read up on hemophilia), topical skin lotions (some of the chemos burn/irritate the skin and it can peel right off), incredible wound care, working with CVCs & Ports.

I remember being intimidated by the amount of lines to manage. We frequently have kids on PN + Lipids + Heparin + Dilaudid or Morphine PCA, sometimes lasix or insulin drips...then add on their antibiotics, or blood products, and various IV meds -- and you have to double and triple check what's IV compatible with what...that can be quite a juggle! But you do get used to it.

While you are there, you will have great opportunity to practice your head-to-toe assessment and monitoring vitals signs. I'm sure you've heard throughout nursing school how important these two skills are. On BMT these two skills are SOOO important. Sometimes the slightest change in your baseline assessment can indicate a serious change in condition and these patients can crunk out fast. We've had kids who were up talking & playing and within 30 minutes were going septic! There's an art to getting reliable temps and BPs on our patients. Even changes in weights or abdominal girth can indicate big issues. Look up Veno-oclusive disease & hemorrhagic cystitis.

Some of what I love about BMT is there is a big emphasis on "team nursing" -- so much of what we do has to be double checked by other RNs at the bedside (Chemos/Blood Products/Drip Changes/Narcotic PCAs) so everyone works together a lot. You also work with patients for such an extended period of time that you really get to know them well. I love the psycho-social support aspect, personally, and with the kiddos we do so much to keep things fun and interesting and developmentally appropriate. I love the critical care aspect also (nerd alert!) and really do a lot of review and education regularly.

I also like that most of our patients can still talk and interact (no vents!) and most of them have central lines so we aren't doing a lot of poking (alas, I have zero IV skills working on BMT). I also like that there is so much teaching involved. You really have to enjoy developing relationships with people and being creative in educating them about their "new normal" post-transplant

What I don't like about it is sometimes all the interventions in the world don't seem to ease the suffering and I go home some nights feeling like I didn't provide any relief despite throwing my entire orificenal of interventions at them. Sometimes patients really break down psychologically, and if they react to medications they can hallucinate, or they don't make it through treatment...dealing with grief, and the dying process is also important to review -- and therapeutic listening/communication. Losing patients is so, so challenging and you have to learn really good coping and self-care methods to avoid burnout.

Remember to take care of yourself. Set healthy emotional boundaries. I find working with this patient population makes me recognize how magical every day is, and to not to take anything in life for granted. I really give thanks on a regular basis, and take full advantage of my days off!

That's probably more than enough...

At the end of the day, just try to soak up as much as you can! Ask questions, keep a notebook handy, and look up everything. I hope you have an enjoyable experience. It can be incredibly difficult work, but also deeply rewarding.

And I forgot the mention: BMT nurses are a super unique kind of wonderful -- often a bit type A, but extremely compassionate and fantastic colleagues.

You're going to learn so much! Enjoy the process & good luck!!!

brithoover · Apr 1, 2013

Hey there! Huge Congrats!
I did my senior practicum in BMT too & LOVED it. It's not for everyone, but it was definitely for me. I remember it being a steep learning curve because, as you mentioned, we really hadn't learned much about BMT during nursing school.
Now I work as a Pediatric BMT RN. We usually have no more than two patients, sometimes we share 1.5:1, 1:1 (and in really serious cases 2:1!) but on adult units it can be 3:1, and on mixed BMT/Heme/Onc it might be closer to 4:1 or 5:1 (but I think 5 is too much if blended with a BMT patient!)
Here's a taste:
Folks get super sick on BMT -- we "condition" them with very high-dose chemotherapy (Imagine the equivalent of 1 years worth of chemo given over 6 days) that ablates the bone marrow, then we infuse them with either donor stem cells (allogeneic) or their own cells (autologous, sometimes called a "rescue") -- then we manage the symptoms of the high dose chemos et al while they grow their new marrow/immune system back. Those who receive cells from a donor source take a lot longer, and require immunosuppressive drugs for life so they don't reject the transplant.
It's an incredible process, and very hard on the patients. During my senior practicum, my preceptor told me "we basically bring them to the edge of death and back again..."
With no WBC counts, they are prone to infection, their bone marrow is essentially non-existent so they need multiple platelet and blood transfusion (or FFP, Albumin...) until their counts are back up. Antibiotics/Antivirals/Antifungals are the norm. The chemo can be cardiotoxic, hepatotoxic, and can fry the kidneys, so knowing those systems are important. Knowing all the systems is important...and signs those symptoms are shutting down. Managing, pain, fevers, nausea (look up antiemetics), fatigue, mucositis, GI issues/weight loss, emotional support, the process of being in isolation for weeks to months..."those walls can close in fast"
Review general heme/onc w/ a focus on blood diseases (leukemias, sickle cell). We also transplant SCIDS babies (born without immune systems to start) and some others...what you'll see really depends on the hospital.
Review the process for transfusing blood products (probably won't be able to touch blood or chemos while your precepting, but you'll see plenty) also managing transfusion reactions. Know your antibiotics, antivirals, antifungals. Research working with severely neutropenic populations & practicing impeccable hygiene/precautions. Learn about mucositis, pain interventions, all pain narcotics. You'll learn a of critical care. We are categorized as an ICU but we don't do vents. Review signs of sepsis, infection, signs of bleeding problems (read up on hemophilia), topical skin lotions (some of the chemos burn/irritate the skin and it can peel right off), incredible wound care, working with CVCs & Ports.
I remember being intimidated by the amount of lines to manage. We frequently have kids on PN + Lipids + Heparin + Dilaudid or Morphine PCA, sometimes lasix or insulin drips...then add on their antibiotics, or blood products, and various IV meds -- and you have to double and triple check what's IV compatible with what...that can be quite a juggle! But you do get used to it.
While you are there, you will have great opportunity to practice your head-to-toe assessment and monitoring vitals signs. I'm sure you've heard throughout nursing school how important these two skills are. On BMT these two skills are SOOO important. Sometimes the slightest change in your baseline assessment can indicate a serious change in condition and these patients can crunk out fast. We've had kids who were up talking & playing and within 30 minutes were going septic! There's an art to getting reliable temps and BPs on our patients. Even changes in weights or abdominal girth can indicate big issues. Look up Veno-oclusive disease & hemorrhagic cystitis.
Some of what I love about BMT is there is a big emphasis on "team nursing" -- so much of what we do has to be double checked by other RNs at the bedside (Chemos/Blood Products/Drip Changes/Narcotic PCAs) so everyone works together a lot. You also work with patients for such an extended period of time that you really get to know them well. I love the psycho-social support aspect, personally, and with the kiddos we do so much to keep things fun and interesting and developmentally appropriate. I love the critical care aspect also (nerd alert!) and really do a lot of review and education regularly.
I also like that most of our patients can still talk and interact (no vents!) and most of them have central lines so we aren't doing a lot of poking (alas, I have zero IV skills working on BMT). I also like that there is so much teaching involved. You really have to enjoy developing relationships with people and being creative in educating them about their "new normal" post-transplant
What I don't like about it is sometimes all the interventions in the world don't seem to ease the suffering and I go home some nights feeling like I didn't provide any relief despite throwing my entire orificenal of interventions at them. Sometimes patients really break down psychologically, and if they react to medications they can hallucinate, or they don't make it through treatment...dealing with grief, and the dying process is also important to review -- and therapeutic listening/communication. Losing patients is so, so challenging and you have to learn really good coping and self-care methods to avoid burnout.
Remember to take care of yourself. Set healthy emotional boundaries. I find working with this patient population makes me recognize how magical every day is, and to not to take anything in life for granted. I really give thanks on a regular basis, and take full advantage of my days off!
That's probably more than enough...
At the end of the day, just try to soak up as much as you can! Ask questions, keep a notebook handy, and look up everything. I hope you have an enjoyable experience. It can be incredibly difficult work, but also deeply rewarding.
And I forgot the mention: BMT nurses are a super unique kind of wonderful -- often a bit type A, but extremely compassionate and fantastic colleagues.
You're going to learn so much! Enjoy the process & good luck!!!

You could not have describes BMT any better!

danceyrun · Apr 2, 2013

Wow, thank you all SO MUCH for your informative replies! All of this information is great to have in advance. The hospital where I am a PCT does not have a BMT unit so I really didn't know what to expect. I will definitely be referring to this thread in preparation for my externship. So is the actual transplant/infusion process much like how you infuse blood? What is the average LOS for each pt? Thank you all soooo much again

brithoover · Apr 2, 2013

Not sure what LOS is but yes, a transplant is like infusing blood

danceyrun · Apr 3, 2013

Length of stay. Thanks

KelRN215, BSN, RN · Apr 4, 2013

This is based on my experience of having some of my home care patients go through it. For auto transplants, I've seen as short as 3 weeks and as long as 6-8 weeks. Allo transplants are typically in for longer. I had a patient who went in for an allo transplant who was in for more than 2 months. It seems that most patients end up on TPN, PCAs and numerous IV antibiotics post-transplant.

tippeny · Apr 8, 2013

I'm doing a summer residency on a BMT as well. I'm a little nervous, not really knowing what to expect either, but super excited! I can't wait to get started and see what is involved. Good luck in your program!

edimo · Apr 9, 2013

LaRoseRN summed it up pretty nicely and was very thorough. As for length of stays; I've seen auto transplants stay for an average of 3-4 weeks and allo transplants for at least a month...but allos specifically are sooo difficult to predict since I've seen length of stays as long as nine months due to complication after complication after complication...specifically dealing with graft vs host disease and hemorrhagic cystitis. But I will say this; you learn a hell of a lot about time management and critical thinking since there are multiple IV meds, TPN, lipids and immunosuppressants that you get to juggle with

danceyrun · Apr 25, 2013

Tippeny, good luck with your residency! I found this upon googling and found it really interesting and wanted to share with you:

http://stanfordhospital.org/PDF/NurseMagSpring08.pdf

I also have another question, are there many codes run on a bone marrow transplant unit?