Download MSKCC Guide By: Dominic C. Sia Last updated: 12/1/09 for any

MSKCC Guide
By: Dominic C. Sia
Last updated: 12/1/09
for any suggested changes, please email [email protected]
Before your rotation starts, download the packet available here and peruse them so you can
familiarize yourself with the system. If you have time, familiarize yourself with the
chemotherapeutic agents and their side effects.
MSKCC stands for Memorial Sloan Kettering Cancer Center. The building is located on the
southwest corner of York Ave. and 68th street. It is a 4 block walk from the Lexington
station at 68th street Hunter college (6 train) or you can take Bus 66 as you exit the station
which will take you to the corner of the hospital. The main floor where you will be working is
on the 9th floor, known as M9. Connected to this unit is also the POU (Pediatric Observation
Unit) and the PDH (Pediatric Day Hospital). Patients come to the PDH for regular outpatient
treatment and get admitted to the unit as necessary. POU is a stepdown unit where patients
who are post surgery or who are sick get transferred. For patients who require it, the ICU is
accross the street at Cornell.
There are 3 teams in the unit. Blue team is the oncology team who rounds on the blue team
sarcoma patients (mostly sicker kids). Pink team is the overflow team where patients are
followed up by the team. Patients here are usually post-op patients or overflow patients
from the green team. The Pink team usually has a maximum of 6 patients. The Green team
- where you will be working - has the most number of patients, most are stable, some are
sick, some are dying. You usually take care of 12-24 patients in the team. During the night
and on weekends, the green team person takes over the care of all the pink team patients
as well.
There are two charts for each patient - one is kept in a cubicle in the central area - this is
where the history progress notes are placed; and the other is at bedside where the vitals
and pain scales are written down. There is a central board on the nurses station listing all
the patients in the unit and accross is listed the MD and nurse taking care of the patient.
Only the orders and labs can be accessed through the computer system under HIS
(Healthcare Information Systems).
You are expected to be in the unit by 7 AM even on weekends. Dress code is long sleeved
shirt and tie for boys and dress for girls, lab coats are optional, it is not strictly enforced but
preferrable you should not wear jeans. Scrubs are ok to be worn if you are on call. Lunch is
provided and there is a pantry area behind the nurses station where you can get coffee, hot
chocolate, or juices anytime.
FIRST DAY
On your first day, look for the senior resident responsible for green team and introduce
yourself. They will be responsible to orienting you as you receive the sign-out for the
patients assigned to you. They will also begin your orientation on using the computer
system and what you job entails. Around 8 AM, the chief resident will arrive to give you a
more in-depth and formal orientation. She will also give you your pager and locator tag (a
tag you hand unto your body that gives your location in the unit), give you the card to get
the ID, your computer username and password for both the Compouter Information System
and the PACS (For radiology) and some handouts with the important phone numbers and
dosaging used in the unit.
Introduce yourself as well to the nurse practitioners of the green team - Mindy, Nikkie and
Rebecca.
When you get free time (usually in the early afternoon), go down to the security office to
get your ID. The office is on the ground floor past the escalators. Ask the guard at the
escalators as to how to get there. There are only select times that they allow you to get the
ID.
During your first couple of days, try to get the papers that will allow you to claim your
scrubs and lab coats. The form should be given by the chief resident. Bring the form to the
requisition area/room (way past the security office).
During your first days, when you have some free time, do the HIPAA course (which can only
be done in the unit), the chief resident will send you an email of where to go online to do it.
Try to concentrate on just the patients assigned to you on your 1st and maybe even 2nd
day. But once you are more comfortable, try to print out a patient list of all your patients
(see guide below on how to do this) so you can follow along in the discussion of the other
patients. This is most important on the day of your call as it is better if you know all the
patients.
USUAL COURSE OF THE DAY
Weekdays - You arrive in the unit by 7:00 AM to get sign-out from the person on call. You
usually keep the patients you are following, for those patients who are new or whose
resident is not available for the day, the senior of the team assigns the patients. Sign out is
a first come first served basis so if you can come early you get sign-out ahead. After sign
out, try to make sure to put your name on the board across your assigned patient's name in
the nurses station - this is so the nurses will know who to contact for the patient. You can
also check here as to which nurse was assigned to your patient. For the rest of the time
from 7:00-9:00, try to visit the patients in their rooms, take a look at the charts outside the
room for the weight, vitals, I&Os, pain level, and PCAs received. Talk to the patients and
their families about the specific issues each one has and of course don't forget to ask the
basics (feeding, pooping and peeing, activity level, pain, concerns). Examine the patients.
Try to research on the disease the patient has and the treatments he/she is receiving so you
can answer questions that the attending will ask during rounds. After you have gathered all
the information and if you still have time, start working on your progress notes and
discharge summaries while waiting for the rounds to start at 9:00am. You can put in any
preliminary plans. Do not print out your progress yet as the plans will change depending on
the rounds with the attending and fellow. Rounds go on from 9 AM to around lunchtime
(sometimes even past lunch). You go around to the various rooms and discuss each case.
For newly admitted patients, you are expected to present everything which would include
their HPI, Oncologic History, PMHx, PE, labs and Assessment and Plan (System-by-system).
For old patients, you present only the short oncologic description, then the current problems
of the patient, then go System-by-system review of events in the past 24 hrs including
discussion of most recent labs, PE, then assessment and plan (Again System-by-system). It
is expected that any new or modified order discussed during the rounds is being entered
already as you round. Make sure to inform you nurses of any significant changes so they are
up to speed. You are allowed to step out of the rounds intermittently to manage these
things, especially if you have presented all of your patients. While rounding, especially if the
case being discussed is not your patient, try to help in putting in the orders for any new
medications or medication changes. This is the job of the senior but you are expected to
help.
Around 11 AM, your senior resident or the fellow will receive a page for Radiology Rounds.
At this point, you stop rounding and head for the Conference room in the PDH. This is where
any studies done on the team's patients are discussed with the Radiologist. If your patient
had some studies done, you are expected to give a short introduction on the patient to the
Radiologist. Just mention the primary disease, any pertinent current problems and why the
study was done. After radiology rounds, you return to the unit to continue rounds.
After rounds, you get the time to eat lunch and start doing your discharge/progress notes.
Usually around 1:30 there is a lecture arranged by the chief resident. Most people have
their lunch during this time. After the lecture, continue working on your notes. Remember
to check on your patients and any pending labs, especially if they have acute problems.
Make sure you order all the labs due to be drawn for the next day.
Around 4:30 if Rebecca (The NP nurse) is working, she will sign out ahead, after that,
anyone else can sign out to the on-call person. Once you've signed out you're ok to leave.
Sign-out is done on a first-come first served basis.
On Fridays - On Fridays, you are also expected to prepare an off-service/discharge note for
all your patients, especially those who are possibly going home over the weekend. Make
sure all the prescriptions are printed out and submitted to the pharmacy. Also, order all the
labs for the weekend including Monday. Make sure to update the Hand-off tab of the patient
with the updated oncologic history and updates on the HPI.
Weekends -Again, you are expected to be in by 7:00 AM to get sign-out from the person on
call. You take care of all the patients on both green and pink teams. After sign-out, try to
change the name on the board so you name is reflected, although this is not as necessary
as the nurses know that only 1 person works in the weekends. From 7:00-9:00 AM, check
on the bedside vitals (which hopefully the post-call person had already done) and all the
pending labs, try to round on all the patients yourself (although it is understandable,
especially if there are a lot of patients that you cannot do them all). Official rounds start at
9:00-10:00 AM with the attending and the fellow and a short call person (if any). You are
expected to present all the patients you are taking care of. You are expected to know their
main oncologic problem and their current active problems (reason for admission) and the
updates on those problems. Rounds finish around 11:30-1:00 PM. You can then start to do
all the discharge summaries for patients for discharge and write all the progress notes on all
the patients for that day. Any admission coming into either the green or pink team are also
your responsibility in terms of the admission notes and entering orders. Don’t hesitate to
ask the short-call person (usually an NP or a senior resident) for help.
When on Call weekdays:
The day goes as normal. Around 4:30, your start getting sign-out. Initially from the NP and
then from the rest of the team, including the Pink team. The fellow on call also gets his or
her sign-out at this time. Introduce yourself and ask what time he/she wants to go on
rounds. The fellow on call usually goes on vitals rounds at around 11 PM - 12 MN. You do
not go to see the patients at this time, just check on the vitals and the orders and anything
pending. Through the night, the nurses will come to you for any orders they need to update
or for any concerns from the patients and their relatives. The best time to go on your own
rounds for vitals would be around 4-5 AM - the time when you are less bothered by the
nurses and also at this time, labs will be out already and you can check on them as well.
Around 7AM, people will start arriving for sign-out. The NPs come the latest around 7:30.
You can leave once you have signed out all the patients.
How notes have to be printed out
ADMISSION AND DISCHARGES
Admissions: Admission usually come from the PDH (Day Hospital). You can also get
transfers from the POU or PICU (from accross the street). For a chronic patient there are
already notes written before on the patient saved on the H drive of the computer. Look
under [H:\Notes_M9\M9_GREENTEAM_ONC\M9_GREENTEAM_ONC] and look in the folder of
the letter of the patient’s last name. For patients that are following up but have not yet
been admitted before or for new patients, you will have to start notes from scratch. Make a
folder under the appropriate letter for the patient. You can sometimes get copies of their
previous notes that have been scanned by going into their e-medical records. (in HIS, go to
[Tools] – [E-Medical Records]). For each admission, you are supposed to get a sign-out
from the physician/resident/NP taking care of the patient. You can ask them to provide you
a soft copy of their note so you can start from there (email, copy to a jumpdrive, etc...).
Once you know of a patient coming in you can ask the clerk to put in the name of the
patient into the system as an overflow chart so you can start entering in the orders for the
patient.
Discharges: Make sure to do prescriptions for the patients assigned to you a day or 2 before
they are set to go home. Make sure to update the discharge note for each patient regularly
(once or twice a week) so you do not have much problems when they do get discharged.
Once the decision is made to discharge the patient, prioritize the discharge orders (and the
discharge meds if you have not ordered them). You can update/write and print out the
discharge summary later, even if the patient has already left. Try to put in the discharge
orders early, even while rounding.
TELEPHONE NUMBERS
PICU 212-746-0308/646-837-4537
Interpreter Service 1-800-264-1545
CAFETERIA
Only for those on call, there are blue cafeteria tickets available in the drawer with the
pagers in the callroom. You can use one ticket for your call in the night to buy a meal up to
$6.
ORDERS:
There are Standard Order sets for admission and for discharge
Standard transfusion order is to transfuse pRBC for Hb<8 and platelets for platelets<10
Benadryl and Tylenol premedication is standard to be ordered for each patient prior to
transfusion – especially those who already have a history of reactions to transfusions.
SOPs (Standard Operating Procedures)
TPNs are not ordered by you. There are TPN nurses who do the orders. The team decides
whether TPN is to continue for each particular patient.
Admission and discharge guides on the corkboard
Cyclophosphamide - WOF SIADH and hematuria
Give Mesna when giving Cyclophosphamide. Take note that urine will come back positive for
ketones
For any fever, especially in a patient with neutropenia, the rule is to do blood cultures and
start the patient on antibiotics. The antibiotics choice will depend on the case (no standard).
But they like to give Cefepime, Amikacin, Ciprofloxacin, and/or Vancomycin (for possible
staph).
Remember that lines are color coded
how to know what lines your px has through the computer
Stem Cell Harvest - GCSF before and on day of harvest
PEG-Asparaginase - make sure to check Amylase and Lipase levels 1 week after
PEG-GCSF or PEG-Asparaginase - PEG means Pegylated
Vancomycin and Amikacin - make sure to order levels for peak and through for Amikacin
and through for Vancomycin
For patients who need to get tumor lysis monitoring, labs include: q6h UA, daily Uric Acid,
BMP, Mg, Phos. Don’t forget to give IV NaHCO3 and Amphogel
For patients with fever and neutopenia, you generally don't give Tylenol as this might mask
the fever.
PRESENTATION
You will be expected to give a presentation during your rotation, it's usually held during the
later half of your rotation. You are expected to choose a patient you are following.
MISCELLANEOUS TIPS
1) How to print out patient lists: In the system, go under the [Patient List] tab and choose
the patients that you want included in your list. Choose [Save Selected Patients] and either
choose to save as a new list, add to an existing list or overwrite an existing list. Once the
list is up, press [Select All Patients] and go to the [Hand Off] tab. Once there, press
[Reports], choose [No] when asked to submit pager. On the next window, you can change
the number of rows per patient on the list if you want more space (standard is 4 spaces).
Afterwards press [Print]. It is usually advisable to choose to print only the firs 4-5 pages of
the list just to get the blank sheets. The Hand Out sheets that contain the patients oncologic
and current history will print out as well and this is a waste of paper if you do not need it.
2) Be extra sensitive to the patients - don't wake them up when they are asleep. Most of
the patient are also very educated and know a lot about what is happening to their child.
Make sure to admit when you do not know the answer to their questions and tell them that
you will check with your fellow. Feel free to discuss the treatment with them but try not to
discuss the treatment if you do not have a full grasp of what is happening to the patient as
they will notice this and might call you out for not knowing.
3) It is very important to know what lines your patient has. They use a lot of different kinds
of indwelling lines in MSKCC and it is better if you are acquainted with them. You can check
out the document: Introduction to Lines for a discussion on this topic. There are several
ways to do this. You can ask the patient/parents of the nurse, or you can check the latest
blood cultures done (given that the lines have not been pulled out yet since then) which will
mention the number of cultures taken and this will give you an idea as to what line is used.
Be aware also that lines are color-identified/specific and when you get cultures, make sure
you get identify the color of the ports which you want the blood drawn from.
4) How to page: You can easily page by going to the main website and typing in the key
word for the people/service you are paging on the blank/input space. You can also dial 2000
on the phone to get the operator and tell them who you want to page.
5) Routine labs to order: Most patients will require a daily CBC and BMP (to include
Magnesium and Phosphorous). You are expected to order the labs for your patients for the
next day prior to leaving in the afternoon. On Fridays, you are expected to order all the labs
for the weekend including Monday AM. LFTs once a week.
6) Chemotherapy guidelines
7) The nurses - A lot have been said of the nurses in the unit. What is universally accepted
though is that they know a lot and usually have more experience than you do, especially
where the patients in the unit are concerned. So try to listen when they say something and
do not take their suggestions lightly. Most of the time, especially if you are new, just follow
their instructions. Most of the nurses and NAs in the unit have egos that need to be stroked.
8) The best thing to do to monitor the changes in the patient is to use the flag system of the
HIS. This is especially useful if you are on call and there are a lot of patients to keep track
of. Just double click on the [Flag New] column of each patient you are following and put na
X mark there. Each new lab will create a flag and you will be able to check on only the
newest lab and know which patient has new labs. Don’t hesitate to [Clear Flag] for those
labs you have already followed.
9) On Fridays, make sure to update the discharge/off service note for the patient just in
case the patient goes home over the weekend. Make sure to order the AM labs for Saturday,
Sunday and Monday. Prescribe discharge meds and give over to the pharmacy.
10) Keep the Hand-off page updated.
11) Insuflon is a temporary subcutaneous line developed for delivery of subcutaneous
medication that are to be given daily (i.e. GCSF)
FINALLY
Before the end of your rotations, try to make a sign out copy of the patients you are
following and send it to the next person in the rotation (at worse, get the admission note
and latest progress note of the patient). You are expected to be able to present your patient
from the first day and usually chronic patients are passed on to the resident from the same
institution. So it would help the person coming in if he/she already knows something about
the patients she will be following.
COMMON MEDS
Ativan (Lorazepam) – used for nausea
Avastin (Bevacizumab) - humanized monoclonal antibody that recognises and blocks
vascular endothelial growth factor (VEGF).VEGF is a chemical signal that stimulates
angiogenesis.
Compazine (Prochlorperazine) - nausea and vomiting
Dronabinol - the principal psychoactive substance found in Cannabis sativa (marijuana);
its mechanism of action as an antiemetic is not well defined, it probably inhibits the
vomiting center in the medulla oblongata; has complex effects on CNS including central
sympathomimetic activity
Lovenox (Enoxaparin) - being given for DVT or cardiac thrombi. Will require monitoring of
the anti-factor XA level*
Lupron - Continuous daily administration results in suppression of ovarian and testicular
steroidogenesis due to decreased levels of LH and FSH so that puberty and the pubertal
growth spurt are arrested; produces a “medical castration” in prostate cancer patients;
inhibits pituitary gonadotropin secretion
Lyrica (Pregabalin) – used for neuropathic pain
Mesnex (Mesna) - In the urinary bladder, mesna binds with and detoxifies acrolein and
other urotoxic metabolites of ifosfamide and cyclophosphamide via an active sulfhydryl
group on Mesna (2-MercaptoEthane Sulfonate sodium) – used as additional medication to counteract
the bladder effect of Cyclophasphamide whose metabolite acrolein can cause hemorrhagic cystitis.
Mesna inactivates acrolein
Neurontin (Gabapentin) – used for neuropathic pain
Olanzapine - a second generation thienobenzodiazepine antipsychotic which displays
potent antagonism of serotonin 5-HT2A and 5-HT2C, dopamine D1-4, histamine H1 and
alpha1-adrenergic receptors. Olanzapine shows moderate antagonism of 5-HT3 and
muscarinic M1-5 receptors, and weak binding to GABA-A, BZD, and beta-adrenergic
receptors. Although the precise mechanism of action in schizophrenia and bipolar disorder is
not known, the efficacy of olanzapine is thought to be mediated through combined
antagonism of dopamine and serotonin type 2 receptor sites.
Ovral - Combination hormonal contraceptives inhibit ovulation via a negative feedback
mechanism on the hypothalamus, which alters the normal pattern of gonadotropin secretion
of a follicle-stimulating hormone (FSH) and luteinizing hormone by the anterior pituitary.
The follicular phase FSH and midcycle surge of gonadotropins are inhibited. In addition,
combination hormonal contraceptives produce alterations in the genital tract, including
changes in the cervical mucus, rendering it unfavorable for sperm penetration even if
ovulation occurs. Changes in the endometrium may also occur, producing an unfavorable
environment for nidation. Combination hormonal contraceptive drugs may alter the tubal
transport of the ova through the fallopian tubes. Progestational agents may also alter sperm
fertility.
Rasburicase (brand names: Elitek in the US, and Fasturtec in Europe ) is a
recombinant version of a urate oxidase enzyme. Used for high uric acid.
Vistaril (Hydroxyzine) – used for nausea
*Daily Antifactor XA level - can only be done during the mornings of weekdays. Following is
the guide to titrating the dose:
Antifactor Xa
Dose Titration
Time to Repeat Antifactor Xa Level
Modified from Monagle P, Michelson AD, Bovill E, et al, “Antithrombotic Therapy in Children,”
Chest, 2001, 119:344S-70S.
<0.35 units/mL
Increase dose by 25%
4 h after next dose
0.35-0.49 units/mL
Increase dose by 10%
4 h after next dose
Next day, then 1 wk later, then monthly
0.5-1 unit/mL
Keep same dosage
(4 h after dose)
1.1-1.5 units/mL
Decrease dose by 20%
Before next dose
Hold dose for 3 h
Before next dose,
1.6-2 units/mL
and decrease dose by 30%
then 4 h after next dose
Hold all doses until
Before next dose and
>2 units/mL
antifactor Xa is 0.5 units/mL,
every 12 h until
then decrease dose by 40%
antifactor Xa <0.5 units/mL
Adults: Note: Consider lower doses for patients <45 kg
OTHER CHEMOTHERAPEUTIC AGENTS
3F8 – Monoclonal Murine antibody developed in MSKCC which has an affinity for the GD2
marker present in neuroendocrine tissue (Neuroblastoma). Can be used alone or tagged
with I-131 for “Hot 3F8” therapy. immediate reaction include pain and hives.
Imatinib (Gleevec) - good for GIST (Gastrointestinal Stromal Tumor), Ph(+) tumors
Cyclophosphamide (Cytoxin)
Thiotepa - alkylating agent. strong effect on skin and blood counts (frequent showering).
standard dose 600-900/m2
SPECIAL TERMS
Consolidation
Maintenance
Research Hurler's Disease
CVCs are color specific
Ronald McDonald house
What is a temp line ?
Clerk: Angie
Kerry Madden / Megan Behringer
Kloeniki Diamantis
d'Amore, Rebecca
Meds:
Suprax
Octreotide
Activated Charcoal
Actigall
Rasburicase - better than allopurinol
Amphogel - for phosphorous
Mesna - free radical scavenger
Zyprexa
Clonapine
Protonix - Pantoprazole
Oxybutinina Hydrochloride - Oxybutynin - used for the treatment of
MOPP (Mechlorethene, Oncovin, Procar, Pred)
ABVD (Adriamycin, Bleomycin, Vinblastine, Decarbazine, Etoposide)
COPP
COMP
OPPA
BEACOPP
BD Glucans – deep mycosis
Galactomanan – aspergillus
Ara-C – Cytarabine
Rasburicase (brand names: Elitek in the US, and Fasturtec in Europe ) is a recombinant
version of a urate oxidase enzyme
Memorial Sloan-Kettering Cancer Center
1275 York Avenue
New York, NY 10065