Considering applying for a BMT Unit, questions

[srleslie]

I never found myself wanting to be an oncology nurse per say, but I'm burned out on regular med/surg and I am looking for something different. There is a position open on the BMT unit at a tertiary academic medical center that I would like to work at. The little I've read about BMT units sounds fascinating. I do have some questions:

1. How is BMT different from an oncology floor? Do they overlap? Are BMT patients frequently getting chemo while on the BMT unit?

2. How much classroom/training/orientation does it take? Is there a large learning curve? Would coming from a heavy surgery floor where many patients have had cancer surgically removed help? I'm already accustomed to interacting with oncologists and familiar with many types of cancer.

3. Can you describe the typical BMT patient? Is the job very physically intensive? Are these patients mostly self sufficient or do they need lots of help? Compared to your typical med/surg population. I want to get an idea of what to expect with these patients before I consider applying.

Thanks for your responses!

[tokebi]

I'm still learning about BMT myself, but here goes...

1. There are some overlap with oncology sure, but BMT patients won't be getting chemo to treat cancer -- remission must be achieved before they can be transplanted. You still give a lot of chemo -- as conditioning regimen before the transplant.

2. I received two-day classroom instruction before I could take BMT patients. I'm not sure if it's the norm or how different in other hospitals. I do think there is a steep learning curve, both in book-learning and hands-on skills.

For example, BMT nurse must be familiar with extremely wide variety of medications -- antibiotics, immunosuppressants, prophylactic antivirals and antifungals, on top of the usual chemo drugs and immunologic agents. You must know how to monitor various labs and correlate with the effects of those meds. Of course any med-surg nursing does this too, but there are so much more to monitor with BMT patients.

You must be also proficient and fast with many hands-on skills -- drawing blood (thank god all BMT patients have PICCs! We draw so much blood!), hanging blood, repleting lytes, accessing ports, etc.

3. There's a typical autologous HSCT patient and then there's a typical allogeneic HSCT patient. Autos are relatively easy and smooth. They stay about two weeks after the transplant and get discharged as soon as neutropenia resolves. Allos, on the other hand, are the ones we watch holding our breaths. Not only do they take longer to engraft, they will also develop GVHD (graft-vs-host disease). With severe cases, they can stay in the unit for many months.

Most BMT patients are self-sufficient, but we still have a lot of fall precaution due to severe thrombocytopenia. And then there are those with severe GVHD and require almost total care.

To give you an idea how busy an allo patient can be, let's say you have a patient with severe GVHD of the gut, and so he's on TPN, running to the bathroom every hour with diarrhea. He'll be on PCA for mucositis pain. He has to get transfusion daily, his Mg, phos and K need to be repleted almost daily. He has a continuous tacrolimus drip. He's on several antibiotics. The prophylactic antifungal and antivirals are all IVPB as well because he cannot tolerate PO. As you can see, even with triple lumen PICC, juggling the lines become a nightmare.

Thankfully, our typical ratio is 3:1, sometimes 4:1. But I don't think that's universal in all BMT units. Honestly, I couldn't care for BMT patients with a typical med-surg ratio.

I don't think I'm doing a good job of giving you a comprehensive picture, but I hope this helps. It's physically, intellectually and emotionally draining, but I think you will find BMT nursing to be very rewarding. Compared to med-surg, you get to know your patients very well, and they are very appreciative and sincere.

I hope this helps, and post away if you have more questions!

[annaotis]

I'm still learning about BMT myself, but here goes...

1. There are some overlap with oncology sure, but BMT patients won't be getting chemo to treat cancer -- remission must be achieved before they can be transplanted. You still give a lot of chemo -- as conditioning regimen before the transplant.

2. I received two-day classroom instruction before I could take BMT patients. I'm not sure if it's the norm or how different in other hospitals. I do think there is a steep learning curve, both in book-learning and hands-on skills.

For example, BMT nurse must be familiar with extremely wide variety of medications -- antibiotics, immunosuppressants, prophylactic antivirals and antifungals, on top of the usual chemo drugs and immunologic agents. You must know how to monitor various labs and correlate with the effects of those meds. Of course any med-surg nursing does this too, but there are so much more to monitor with BMT patients.

You must be also proficient and fast with many hands-on skills -- drawing blood (thank god all BMT patients have PICCs! We draw so much blood!), hanging blood, repleting lytes, accessing ports, etc.

3. There's a typical autologous HSCT patient and then there's a typical allogeneic HSCT patient. Autos are relatively easy and smooth. They stay about two weeks after the transplant and get discharged as soon as neutropenia resolves. Allos, on the other hand, are the ones we watch holding our breaths. Not only do they take longer to engraft, they will also develop GVHD (graft-vs-host disease). With severe cases, they can stay in the unit for many months.

Most BMT patients are self-sufficient, but we still have a lot of fall precaution due to severe thrombocytopenia. And then there are those with severe GVHD and require almost total care.

To give you an idea how busy an allo patient can be, let's say you have a patient with severe GVHD of the gut, and so he's on TPN, running to the bathroom every hour with diarrhea. He'll be on PCA for mucositis pain. He has to get transfusion daily, his Mg, phos and K need to be repleted almost daily. He has a continuous tacrolimus drip. He's on several antibiotics. The prophylactic antifungal and antivirals are all IVPB as well because he cannot tolerate PO. As you can see, even with triple lumen PICC, juggling the lines become a nightmare.

Thankfully, our typical ratio is 3:1, sometimes 4:1. But I don't think that's universal in all BMT units. Honestly, I couldn't care for BMT patients with a typical med-surg ratio.

I don't think I'm doing a good job of giving you a comprehensive picture, but I hope this helps. It's physically, intellectually and emotionally draining, but I think you will find BMT nursing to be very rewarding. Compared to med-surg, you get to know your patients very well, and they are very appreciative and sincere.

I hope this helps, and post away if you have more questions!

As a former BMT nurse, you gave a very accurate explanation of a "day in the life" of a BMT nurse.

[Amistad, RN]

Srleslie,

I LOVED working in BMT, and also knew very little about it before taking the job there. On my unit, our nurse-patient ratio was typically 3:1 or 4:1.

Like Tokebi I am still learning, but this is my general understanding of BMT:

1. Bone Marrow Transplant is a subset of oncology. These patients typically are being treated for blood malignancies such as leukemia where their bone marrow over-produces immature white blood cells. Patients usually are in remission from previous chemotherapy treatments when they come to transplant and come to transplant because they are at high risk for relapse. First-time admit patients will come to the unit, receive a preparative chemotherapy regimen to “ablate” the bone marrow, and receive a bone marrow stem cell infusion through a central line into their peripheral circulation. The stem cells eventually find their way to the bone marrow and “engraft.” You will be giving a lot of chemo in BMT, and many of your patients will also receive radiation.

2. Many facilities vary in their orientation process. I went through 10 weeks of precepted training with interspersed classes regarding oncology, BMT, and chemo administration. BMT is quite complicated and is always changing, so you will be learning constantly.

3. As others have described, there are two main types of transplants: allogeneic and autologous. Allogeneic transplants are from a donor, either a pt’s sibling or unrelated. Autologous transplants are the patient’s own stem cells. Allogeneic transplant patients have a lot more complications such as Graft-Versus Host Disease (GVHD). However, all transplant patients are at high risk for infection and relapse. In addition, patients can have serious complications related to chemotherapy such as cardiac and hepatotoxicity. BMT can be physically intensive at times. Patients who become very sick can become debilitated and require frequent lifting. In addition, these patients take A TON of medications- some may be getting multiple IV medications every hour so you will get used to managing multiple lines and checking compatibilities.

Hopefully this was helpful! Tokebi did a great job of describing BMT as well.

Just a side note, I found that almost every BMT patient was a fall risk and that should never be underestimated.

[Amistad, RN]

Let us know if you made your decision and are working in BMT!

[srleslie]

Thank you all for your comments. I knew I wanted to leave med/surg and was exploring my options. Today, I was offered my dream job: psych. I'm looking forward to this opportunity!