Peds Heme-Onc nursing- question/advice

mcstanton1505 · Nov 21, 2014

I work in a peds hem-onc-BMT clinic/day hospital but I thought I would pitch in anyway because we see the same population.

I can't help you with ratios since I'm outpatient and personally see anywhere from 3-16 patients a day depending on how intensive each one is (I have three rooms at any given time). We do anything from simply draw labs, to infusing chemo and blood products, to running fever-neutropenia/near-code cases. We access ports, CVCs, PICCs, and perform venipuncture every day. We do a little of everything, which is unique to outpatient but that's because we do, as you said, see the sickest patients.

No other population would be allowed to leave the hospital with the counts our kids have. When I transferred here from the emergency room I routinely panicked over lab results that the other nurses would barely glance at before replying "Oh that's normal for them" or even "Those look great! Their counts are really improving!"

Yes, they are some of the sickest patients, but most of the time you wouldn't know it. I've never taken care of a more inspiring population. Kids are so resilient and you don't see it better anywhere else. One pre-teen girl has so embraced her baldness: she has the largest collection of embellished headbands any of us have ever seen and she ROCKS a new one daily; she is so sassy, I love her! I have many pre-school age patients who handle their port accesses with amazing stoicism. And the families are amazing with their patience and overall outlook on life, even if they have already lost one or more children to the same disease.

Coming from PICU you are no doubt accustomed to bonding with patients and families and then experiencing their loss, but it will get worse if you move to hem-onc because you won't just know them for days or weeks or months but years. You will see them be declared disease-free just to see them come back a month or a year later, relapsed. You will sing and dance and celebrate with them when they go into remission even though you know the probability that it will not last. You will be them when they are diagnosed with things like DIPG which are literally death sentences -- no cure in sight -- and watch them decide to participate in trials that provide no hope for them but may one day give us a cure for someone else. You will repeatedly poke them to draw labs that are only for the benefit of others as they grow weaker and weaker. But it will be worth it because of who they are. Because they are the weakest and strongest people in the world.

So depending on why exactly PICU is no longer for you, hem-onc could be an excellent or horrible switch. I got burnt out in the ED from the constant rush and the feeling that I wasn't making the most of my time with the non-urgent cases that came through and only took my current position in hem-onc because it was the only one available but I have fallen in love with it. The people who tend to work hem-onc are also a special breed of caring loving and supportive nurses who treat their coworkers as well as they treat their patients.

Good luck!

PublicHealth · Nov 21, 2014

Thank you SO much for all of that advice and information! It sounds like such an amazing speciality to work in.

The main reason that I do not like PICU is because I get almost no patient interaction. 90% of my patients are sedated/intubated, or chronic vent/gtube dependent kids. Also, I do not like the constant feeling of an impending emergency, and always having to constantly plan for the worst case scenario. I am a new grad, and trying to figure out if/how I can make the switch to a heme-onc floor sooner rather than later. Thank you so much for your reply!

mcstanton1505 · Nov 21, 2014

Well at least in my hospital, patient interaction in our hem-onc dept is a high priority. They've recognized that hem-onc burnout among nurses happens when they don't get to know their patients and also we need to keep an eye on the families emotional state etc. They are often at their outpatient appointments for several hours so even the outpatient nurses really get to know them.

As an adrenalin junkie (EMT for 2 years, ER RN for 4), we don't have enough "impending emergencies" for my taste, but everything else about the specialty makes up for it. The goal is definitely to avoid impending emergencies, especially among admitted patients (in outpatient you can't avoid the fever-neutropenia patients coming from home. It happens) Your ICU experience will definitely be helpful in identifying potential emergencies and getting them assistance or transferred to the PICU promptly.

KelRN215, BSN, RN · Nov 22, 2014

Thank you SO much for all of that advice and information! It sounds like such an amazing speciality to work in.
The main reason that I do not like PICU is because I get almost no patient interaction. 90% of my patients are sedated/intubated, or chronic vent/gtube dependent kids. Also, I do not like the constant feeling of an impending emergency, and always having to constantly plan for the worst case scenario. I am a new grad, and trying to figure out if/how I can make the switch to a heme-onc floor sooner rather than later. Thank you so much for your reply!

The impending emergencies are definitely still there in oncology. Your kid can go from fine to septic to dead very quickly if he's neutropenic...

USNavygirl · Nov 24, 2014

I work in a large pediatric hospital on a Heme/Onc unit. I would agree with much of what was said above regarding the population and how awesome they are (for the most part! :) ). For all of the patients who are wonderful and amazing, there are plenty who are mean and moody (especially on steroids), and I have definitely had a patient spit in my face over a blood pressure. They're not all strong and stoic like we would like to imagine them to be. The parents are much the same. Many are amazing, and it's as though their pains are our pains. We get calls when their children pass at home, attend memorials, and visit families if they passed in one of our ICUs. Parents will bring us dinner or donuts and send Christmas cards. But of course there are some where you just wonder why they even come stay, because they either ignore their kid or are actively unpleasant. I'm assuming that much is like the rest of the hospital where there are chronically ill children.

Other than that, our ratios are 2-3:1, depending on acuity. Our kids also tend to stay a little longer than other floors, so there aren't a ton of admissions and discharges per day. We run a lot of blood products, chemo, etc., as was previously mentioned. Sometimes we also go to NICU to give chemo, or ED to access ports, etc. but we generally don't like to leave! It becomes all you know after a while.

As far as being "sicker", it's true and not true. They have the potential to be very sick, but a lot of times they come in for chemo, hang out for count recovery, and are on their merry way. But yes, we obviously do see a lot of more complicated cases, hence the hospitalization (since many heme/onc patients never really need to be hospitalized are in seen outpatient for chemo and blood products). We get various complications related to drug toxicities, neutropenia, infections and the like. Many of the kids we see frequently inpatient relapse, and it can get very sad. It always seems like the sweetest kids, with the most fabulous parents, are the ones that have it the worst. But we have great staff support here, and it's like a second family.

It's a great place to be! Just don't come with expectations that it will be like The Red Band Society or The Fault in Our Stars, and you'll be just fine

PublicHealth · Nov 25, 2014

Thanks so much! That was so helpful and informative. I want to be on a unit where I have more interaction/continuity of care for patients and families. I am finding the ICU environment to be aggressive and intense, with little patient interaction.

I truly appreciate the information and advice!!