“The Rules of the Road”
A Guide for Pediatric Residents and Medical Students
on the Inpatient Hematology-Oncology Service
2006 - 2007 Academic Year
George R. Buchanan, M.D.
Jennifer Cox, M.D.
Table of Contents
General Description of Unit...................................................................4
Types of Patients Admitted to 4-B.........................................................6
Hematology-Oncology Medical Staff....................................................7
Who Does What?..................................................................................11
Weekend and Night Call......................................................................13
Resident and Medical Student Education..........................................14
Other Clinical Support Staff................................................................17
Interactions with Patients and their Families....................................22
Other Important Patient Care Issues..................................................23
Further Opportunities for Learning...................................................24
Daily Outpatient Clinic Schedule........................................................26
E-10 Phone List.....................................................................................27
Children’s Medical Center Phone List...............................................30
Please carefully review this material at the beginning of your rotation on E-10 at Children’s
Medical Center, the “home” of the inpatient hematology, oncology and stem cell transplant
components of the Center for Cancer and Blood Disorders (CCBD).
The guidelines outlined here will help clarify the roles of each participating team member
and, in particular, the faculty’s expectations of trainees while on E-10. Elective rotations for
second- and third-year residents and senior medical students in hematology-oncology are
offered in the outpatient clinic; information regarding these electives is available on request.
General Description of Unit:
• The E-10 inpatient unit has 22 beds (numbered E-10-401 to E-10-422), all private rooms.
Five rooms (E-10-412 through E-10-416) are used primarily for our bone marrow
transplant program, and are Hepa-filtered positive-flow rooms. Two other rooms (E-10-
404 and E-10-419) are negative-flow isolation rooms (used for children with chicken
pox, shingles, etc).
• The conference room is used by nursing staff and physicians for conferences and rounds.
Please try to keep it neat! Book bags and other materials should be stored on one of the
shelves or other area designated by the charge nurse, not on the floor. The cabinets on
the wall have shelves with notebooks containing copies of oncology protocols (C.O.G.
and institutional) and hematology protocols. Also available are standard reference
sources in pediatrics and hematology-oncology. A cart in the conference room holds the
patients’ shadow charts (green/blue charts). Additional protocol and reference books
are available on the sixth floor of the ambulatory (“C”) building in our outpatient unit
physicians’ work station and Peggy Sartain Library/Conference Room. None of these
materials should be removed from their respective areas.
• There are 2 HUC (Health Unit Coordinators) in the central area of E-10. The
Communication HUC is responsible for handling pages and phone calls, and the
Clinical HUC is responsible for order entry. At each HUC’s desk there is a list of
occupied room numbers, the nurse assigned to the patient, and the charge nurse for each
shift. The scheduled admissions for each day are listed on the white board at the
Clinical HUC desk.
• Behind the Communication HUC’s desk, there is a dictation/work area with several
computers and telephones, as well as work space for writing orders and notes. Blank
forms are located either on the racks or in the cabinets behind the Clinical HUC’s desk.
• Each patient area has a separate nurses station – one for Rooms E-10-401 to E-10-411
(Engine Area), one for Rooms E-10-412 to E-10-416 (Transplant Area) and one for
Rooms E-10-417 to E-10-422 (Caboose Area)
• There are 2 on-call sleeping rooms for housestaff – located near the “Train Elevators” –
Rooms E-10-369 and E-10-370. The HUC has a key or you may call security. Please
keep your belongings in the room.
• You may eat in the conference room, except between 0630 - 0730 and 1830 - 1930, as
these are shift change times. Neither eating nor drinking at the HUC stations or any
nurses station is permitted according to OSHA regulations. Please refrain from
consuming snacks from the nourishment areas, as these are for our patients. However,
you may help yourself to the coffee which can be found in the Nourishment Room near
each Nurses Station. In addition, vending machines are available near the Wagon
Floor Plan of E-10
1: Communication HUC
2: Clinical HUC
NS: Nursing Stations
Types of Patients Admitted to E-10
• Virtually all children admitted to E-10 have an oncologic or hematologic disease.
You should read about or otherwise become familiar with each of these disorders
during your stay on E-10. There will be educational lectures and materials provided
throughout the rotation, but it is expected that you will also take the time to learn
more about issues specific to the patients you are assigned to follow.
o Oncology Patients
The most common diagnoses are leukemia, brain tumors, lymphomas,
neuroblastoma, Wilms tumor, osteosarcoma, Ewing’s sarcoma, germ cell
tumors, rhabdomyosarcoma, hepatoblastoma, and histiocytic disorders.
Children with cancer are usually admitted to the hospital for one of four
reasons: (1) initial diagnostic evaluation, (2) complications of treatment,
(3) terminal care, and (4) administration of scheduled chemotherapy that
cannot be given in the outpatient arena. Most patients admitted for
chemotherapy treatment only will be admitted to the 6-bed chemotherapy
unit on E-8, and will be followed primarily by Pediatric Nurse
o Hematology Patients
The most common hematologic diagnoses are sickle cell disease, ITP,
hemophilia, aplastic anemia, and chronic neutropenia.
Children with sickle cell disease are most commonly admitted for (1)
management of painful episodes (crisis), (2) chest syndrome/pneumonia,
(3) aplastic or splenic sequestration crisis, or (4) elective surgery.
Hemophilia patients are admitted either for (1) unusually severe bleeding
events or (2) are receiving factor replacement because of a surgical
o Stem Cell Transplantation (SCT) Patients
There will usually be between 3 and 6 patients admitted to the stem cell
transplantation service at any given time – either for the transplant itself or
for post-transplant complications.
Transplant patients are followed by the pediatric housestaff. The senior
resident will be responsible for assigning these patients at the time of
admission to one of the PL-1’s, or, if the inpatient service is very busy, the
senior resident will follow up to 2 transplant patients. On weekends,
transplant patients followed by a PL-1 will continue to be followed by the
housestaff, but transplant patients followed by the PL-3 will be followed
by the fellow.
Hematology-Oncology Medical Staff
• The clinical care, teaching, and clinical research activities on E-10 are under the direction of
attending physicians of the Center for Cancer and Blood Disorders at Children’s who are
full-time faculty physicians at the University of Texas Southwestern Medical Center at
NAME OFFICE OFFICE
George Buchanan, M.D.
Director of Clinical Hematology
Naomi Winick, M.D.
Director of Clinical Oncology
UTSW: G3.210 648-2912 8696
Robert Bash, M.D.
Associate Medical Director
CMC: C06.677 456-2773 8645
Jennifer Cox, M.D.
Division Education Coordinator
CMC: E10:371.2 456-8062 8226
Patrick Leavey, M.D.
Director, Pediatric Hematology-Oncology
UTSW: G3.240 648-8062 9156
Victor Aquino, M.D. UTSW: G3.234 648-8800 9173
Jim Amatruda, M.D., Ph.D. UTSW: NB8.218B
Dan Bowers, M.D. UTSW: G3.238 648-8822 9280
Scott Cameron, M.D., Ph.D. UTSW: NA5.602A
Shelley Crary, M.D. CMC: A03.362 456-3194 9772
Janna Journeycake, M.D. CMC: A03.316 456-8556 9286
Matt Porteus, M.D., Ph.D. UTSW: F3.118B
Charles Quinn, M.D. UTSW: G3.106 648-9298 9157
Zora Rogers, M.D. UTSW: G3.224 648-6332 9328
• There are three distinct clinical services on E-10: oncology, hematology, and stem cell
transplantation. Each of them will have a designated attending physician. The rotations
of the attending physicians will be two weeks in duration. The beginning and ending of
the rotations will be synchronized with the four-week rotations of third-year medical
• Hematology-oncology fellows: Fellows in hematology-oncology are fully-trained
pediatricians who are taking an additional three to five years of training to become
board certified hematology-oncology specialists. As part of their training experience,
fellows have a series of rotations on E-10 during the day, and they provide night and
weekend coverage as well (see below). The hematology-oncology fellows (as well as
pager numbers) during the 2006-07 academic year are as follows:
FELLOW YEAR PAGER NUMBER
Cindy Neunert, M.D. 3rd
Tamra Slone, M.D. 3rd
Jennifer Wright, M.D. 3rd
Laura Klesse, M.D., Ph.D. 2nd
Jason Litten, M.D. 2nd
J. Allyson Niece, M.D. 2nd
Mark Hatley 1st
Tim McCavit 1st
Martha Stegner 1st
Cristina Tarango 1st
• Physician Consultants: As is expected with children who have complex medical issues, other
pediatric sub-specialists are frequently consulted to provide expertise in their fields. The most
commonly consulted services are Infectious Diseases, Endocrinology, Nephrology, Cardiology
and Gastroenterology. Housestaff are generally responsible for arranging these consults after
discussion with the Attending and/or Fellow covering the patient in question.
Two special cases are the Pediatric Surgeons and the PICU.
o Pediatric Surgery: As a general rule, we utilize the University Pediatric Surgery group
for the majority of our hematology/oncology patients – Drs. Guzzetta, Garcia, Hicks,
and Megison. Initial consultation with the surgeons is generally made by the
hematology-oncology Attending or Fellow directly contacting the Attending Pediatric
Surgeon or fellow.
o PICU: Given the serious nature of their illnesses and the intensity of their treatment, it is
not uncommon for hematology-oncology patients to become critically ill, and require
transfer to the Pediatric Intensive Care Unit. While in the PICU, these patients are
primarily cared for by the PICU team, with hematology-oncology consultation. Upon
their return to E-10, they are once again followed primarily by the hematology-oncology
team. Except under emergent conditions, the PICU should not be contacted by the
housestaff unless directed to do so by the Attending or Fellow on the service.
• Dr. Mulne: Some children with brain tumors (and occasionally other diagnoses) are
managed by two private physicians, Drs. Arlynn Mulne and Ammar Morad. They are
not members of the faculty or of the Center for Cancer and Blood Disorders. However,
as members of Children’s attending staff with privileges in hematology-oncology, they
admit their patients to E-10. These private patients of Drs. Mulne or Morad are cared
for by the housestaff and students but are not covered by the other staff physicians or
fellows. All questions regarding their patients should be directed to either Dr. Mulne or
• Housestaff: The housestaff assigned to E-10 is typically made up of a senior resident
(PL-3) and 2 or 3 first-year residents (PL-1’s). The hematology-oncology division is in
compliance with university and hospital guidelines regarding resident hours and patient
o Senior Resident: The Senior Resident is responsible for closely mentoring the
interns and students as they give care to the patients and overseeing all of the
general pediatrics issues, including I/O’s, antibiotic coverage, laboratory and
imaging tests, nutritional support, etc. This is particularly important for the more
seriously ill patients. During months where there is no fellow for one of the
inpatient services, the Senior Resident will be responsible for meeting with the
Attending on that service prior to Rounds to review any pertinent overnight
events and/or lab results.
o First-Year Residents: There will typically be either 2 or 3 first year residents
assigned to the inpatient hematology-oncology service. They will be responsible
for the day-to-day management of up to 10 patients each, including admissions
and transfers. Every patient needs a complete daily progress note and
documented physical exam – using the designated form. Interns are generally not
responsible for following children admitted for routine chemotherapy on E-8,
who are followed by an Oncology APN.
• Medical Students: Generally 2 or 3 third-year medical students (MS3) will be assigned to
the inpatient hematology-oncology service each month. MS3’s will typically follow 2 – 4
patients at any given time, and will be responsible for seeing those patients daily and
writing a detailed progress note each morning. It is expected that the MS3 will present
these patients to the Attending in rounds. Although it is generally expected that each
medical student will prepare at least one more detailed presentation over the course of
the month, specific requirements will be determined by the Senior Resident and the
Attending Physicians. Medical students are expected to attend all teaching sessions, as
well as general pediatric teaching sessions arranged by the senior resident.
On occasion, 1 or more fourth-year medical students (MS4) will do an elective rotation
on the inpatient Pediatric Hematology-Oncology service. These students will function
essentially as sub-interns, following their own patients, but closely supervised by the PL-
3 on the service.
Who Does What?
• Admission notes (histories, physicals, and admission orders): The housestaff and
students are responsible for workups on all admissions, except those patients admitted to
E-8 for chemotherapy who are followed by an oncology APN (Children with brain
tumors admitted for chemotherapy are followed by the housestaff, not the oncology
APN). The history, physical, and progress notes must be written by the housestaff,
even when medical students write notes.
• Orders: With the exception of preprinted orders and chemotherapy orders, it is expected
that the housestaff will write all orders, including admission orders and orders for
imaging and laboratory studies, transfusions, antibiotics, pain control, TPN, etc. PCA
(Patient Controlled Analgesia) forms must be filled out each time a dose is changed.
• Procedures: Bone marrow aspirates/biopsies and lumbar punctures, with or without
instillation of intrathecal chemotherapy, are generally performed by the APN or
fellow/faculty member. On occasion, house officers may learn to perform these
procedures under supervision. Simply let the fellow or attending know that you want to
learn procedures and an opportunity might be arranged if feasible. Conscious sedation
techniques are used to reduce or eliminate the child’s discomfort. Sedation flowsheets
and consent forms need to be completed by the housestaff prior to any patient being
sedated for a procedure. Parents are generally allowed to observe procedures, if they so
• Progress Notes: Daily progress notes are written for each patient by the house officers or
APN’s caring for the patients. Medical students and fellows may write notes as well in
addition to those by the housestaff and APN’s. The resident’s daily note should be
detailed, including interval history, physical findings, laboratory and imaging results,
and plan. Specially designed forms are to be used, and each section needs to be
completed daily (including PMH and ROS). Progress notes are also written daily by the
faculty member for purposes of continuity of care and billing documentation.
• Dictations/Discharge Summaries: The house officers are responsible for dictating a
complete discharge summary for all patients discharged from E-10.
• All chemotherapy, including steroids, for oncology patients is to be written by a
APN, fellow or attending ONLY. This includes discharge orders and discharge
prescriptions. When a child is being discharged, any prescriptions or discharge orders for
chemotherapy or steroids will be written by a APN, fellow or attending.
• The APN, fellow or attending writing the chemo portion of the discharge orders will
sign their name (not initial) to the side. If the patient is not to go home on any
chemotherapy or steroids, then the APN, fellow or attending will write “No home
chemo” on the discharge orders. They will again sign their name out to the side of the
order. Interns will continue to write and sign the remainder of the discharge orders
including all other medications. It will be the intern’s responsibility to make sure the
“oncology portions” are complete before signing the orders and submitting them for
• A nurse on the floor should not accept any orders or prescriptions that do not meet these
E-8 Chemotherapy Unit
• Up to 6 beds will be used for scheduled chemotherapy admissions on E-8. These beds
include E08-406 through E08-411. During the week the APN’s are in charge of these
patients just like they are currently on E-10. APN’s will cover these patients on
weekends. They have their schedules worked out and they will come in and round on
their patients and with the attending physician..
• If a patient of E-8 needs a procedure, the patient will go to E-10 for those procedures.
• During nights and weekends there will be no in house coverage. The Fellows are
responsible for each patient if there are questions or problems. The nurse will call the
Fellow. If the on-call Fellow feels that the patient needs to be seen immediately, the senior
resident covering E-10 will be called to evaluate the patient. If the patient requires on-going
management, the fellow will return to the hospital. There will be no formal coverage or
check out to the Resident.
• Staffing on Holidays: The inpatient APN will work on all holidays, with the exception of
Thursday-Sunday over Thanksgiving, and Christmas Eve and Christmas Day. If
Christmas falls on a Saturday, they will also have December 26 off. Fellows will be
expected to cover any inpatient chemotherapy inpatients who have been followed by the
APN’s on these days. On other holidays, APN’s will cover their chemotherapy inpatients
Weekend and Night Call
• Weekends: On most weekends one attending physician and one fellow will round on
the hematology and oncology patients combined, generally beginning at 9:00 a.m.
Rounds usually will last until 11:00 a.m.
• Evenings/Nights: The Children’s telephone operator and the E-10 nursing staff will be
aware of who is on first and second call at night. In general, a fellow will be on first call
for questions and problems occurring on E-10 that cannot be handled by the nursing
staff, first year residents and senior residents. The senior resident should covering the
unit should be consulted before the fellow is notified, except in an emergency. Faculty
attending physicians will be on second call.
Observation and Outpatients on E-10
• Observation bed status: Occasionally patients are admitted for 23-hour observation for a
blood transfusion, chemotherapy treatment, or other short-term assessment and therapy.
Admitting orders must indicate “admit for observation” when it is anticipated that the
patient will be there for < 23 hours. In the event that a patient is admitted under this
status and is approaching 23 hours, the HUC will contact you to re-evaluate whether the
patient will be discharged or needs to be admitted as a “full admission.”
• Outpatient Visits: Short-term care, lasting one to two hours, is provided on E-10 to some
outpatients during evenings and on weekends. These consist of brief chemotherapy
treatments, factor concentrate treatments, follow-up assessments, etc. and are taken care
of by hematology-oncology fellows and/or attendings.
Resident and Medical Student Education
Rounds with the attending physician(s) will be held daily on E-10. On week days, Monday
through Friday, rounds will generally begin at or shortly after 10:00 a.m. and will continue
until 12 noon. Rounds will always be completed in time for the noon conferences and
lectures. Rounds are usually of the “sit down” type in the E-10 conference room.
Occasionally walk rounds will be made on selected patients. Depending on the total
number of patients, new diagnoses, and problems on each of the three services (hematology,
oncology and stem cell transplant), the duration and order of each segment of rounds may
vary. It will be the responsibility of the attending physicians, working with the senior
residents, to make the first year residents and medical students aware of their expectations.
The attending physicians, often with a APN and a fellow, will make separate bedside
rounds each afternoon as well as early most mornings. Students and housestaff are
encouraged to see their individual patients with the attending and fellow when possible to
minimize disruptions to the family and to facilitate teaching. Discuss plan and discharge
plans daily during rounds.
Three afternoons each week (usually Monday, Wednesday and Thursday) between 2 and
3pm, “Teaching Rounds” for all residents and students on the service will be held in the E-
10 conference room. This schedule is based on the “Content Specifications” for “Disorders
of the Blood and Neoplastic Disorders” from the American Board of Pediatrics as well as
other topics felt to be of general importance by the hematology. The format for covering
these topics will vary from attending-to-attending, but may include lectures, case
presentations, walk-rounds, etc. The on-service attending may also assign fellows, residents
or students to prepare presentations on one or more of these topics.
Sickle Cell Disease
Principles of Chemotherapy
Stem Cell Transplantation
Late Effects of Childhood
Bone Marrow Failure
Not all of these topics may be covered during every 4-week period, but every effort will be
made to address those topics which are most important to the general pediatrician.
In addition, the medical students will meet approximately once a week with the Division
Education Coordinator, Dr. Jennifer Cox, to go over detailed patient presentations, review
interesting physical exam findings, and for more individualized educational opportunities.
Dr. Jennifer Cox is responsible for the evaluations for all residents and medical students on
the inpatient pediatric hematology-oncology service. Written evaluations are done by each
attending each week and provided to Dr. Cox. These evaluations form the basis for an
overall evaluation of the performance of each resident and student at the end of the rotation.
Dr. Cox will meet individually with each resident and medical student at least twice during
the rotation (once at or near the midway point of the rotation, and again at the end of the
Resident are evaluated on a 1-5 scale on a variety of areas, generally encompassing clinical
skills, interpersonal skills, professionalism and overall knowledge.
Medical Students are evaluated according to the RIME system.
• “Reporter” (C): the student can accurately gather and clearly communicate the
clinical facts on his/her own patients. The step requires the basic skill to do a history
and physical examination, and the basic knowledge to know what to look for. It
emphasizes day-to-day reliability, for instance, being on time, or checking a patient’s
test results. Implicit is the ability to recognize normal from abnormal, and the
confidence to identify a new problem. This step requires taking “ownership” in
patient care. These skills are often introduced to students in their preclinical years,
but now they must be mastered as a “passing” criterion.
• “Interpreter” (B): Making a transition from “reporter” to “interpreter” is an essential
step in the growth of a third year student, and often the most difficult. At a basic
level, the student must prioritize among problems identified. The next step is to offer
a differential diagnosis. Because students cannot be expected to have the “right
answer” all the time, we define success as offering at least three reasonable diagnostic
possibilities for new problems. Follow-up of tests provides another opportunity to
“interpret” the data (especially in the clinic setting). This step requires a higher level
of knowledge and more skill in selecting the clinical findings which support possible
diagnoses in specific patients. The student has to make the transition, emotionally,
from “bystander” to see himself/herself as an active participant in patient care.
• “Manager” (B+): This takes even more knowledge, more confidence and judgment
in deciding when action needs to be taken, and to propose options . Once again we
can’t require students to be “right” with each suggestion, so we ask them to include
at least three reasonable options in their diagnostic and therapeutic plan. A key
element is to tailor the plan to the particular patient’s circumstances and preferences.
• “Educator” (A): This means to go beyond the required basics of self-directed
learning, to read deeply, and to share new learning with others. Defining important
questions to explore in more depth takes insight. Having the drive to look for hard
evidence on which action can be based, and having the skill to know whether the
evidence will stand up to scrutiny, are qualities of an advanced trainee; sharing
leadership in educating others takes maturity.
Hematology-Oncology Nursing Staff
Nursing Director: Kaye Schmidt. The nursing director oversees the entire nursing
program of the CCBD, both inpatient and outpatient. She is responsible for
implementation of nursing policies within the division.
Pediatric Nurse Practitioner (PNP’s): The CCBD employs a number of pediatric nurse
practitioners to assist with patient care, teaching, and clinical research activities. Each of the
individuals focuses on a different group of patients (e.g., oncology, sickle cell, hemophilia, neuro-
oncology, etc.). They are valuable sources of information about specific patients and practical
Oncology PNP’s: Maria Bisceglia, Joe Don Cavender, Kelly Lautzenheiser. 1 or 2
of the PNP’s will be assigned to the inpatient service. One of the oncology PNP’s roles is
known as the “resident” role. This person will perform some of the procedures (bone
marrows, intrathecal injections, etc.) and serve as a “consultant” to the inpatient team to
maintain overall continuity of care, assisting with scheduling return visits to clinic, etc. This
role is not available every day. The other inpatient oncology PNP will follow all scheduled
chemotherapy patients admitted to the E8, and will occasionally follow scheduled
chemotherapy patients (maximum of 6 total) on E10. These PNP’s do not follow neuro-
oncology chemotherapy patients. The PNP’s will sign out the patients to the fellow on call
by 1500 on weekdays and by 1200 on weekends. The PNP’s will dictate discharge
summaries on their chemotherapy patients that they discharge.
Neuro-Oncology PNP: The Neuro-Oncology PNP works primarily in the outpatient
setting to coordinate the complex care of children with brain tumors. They will be familiar
with all brain tumor patients admitted to E10 for routine chemotherapy or complications of
their disease. Although the they do not provide coverage for neuro-oncology patients
admitted for chemotherapy, they are a valuable resource for arranging outpatient follow-up
with both the oncology and the neurosurgery services.
Sickle Cell PNP’s: Bonita Williams. One of the PNP’s will be assigned to the inpatient
service and will serve as a “consultant” to the inpatient team to maintain overall continuity
of care, assisting with scheduling clinic visits, etc.
Hemophilia PNP: Kim Miller. She acts as a coordinator of the hemophilia program at
CMC. She can provide comprehensive diagnostic and treatment information regarding the
care of patients with bleeding disorders, including hemophilia and von Willebrand’s Disease.
She is a valuable resource in the management of children with bleeding disorders in both the
inpatient and outpatient setting, and is very knowledgeable regarding the “state of the art” in
caring for children with inhibitors to coagulation factors.
ACE PNP: Debra Eshelman. The ACE (After the Cancer Experience) Program is a
unique program designed to provide long-term follow-up for survivors of childhood cancer.
This includes monitoring for late effects of cancer and cancer therapy, routine screening for
second malignancies, education targeted at reducing risk and promoting long-term health
and improved quality of life, referrals facilitated to appropriate subspecialties as indicated,
access to social services and child life specialists and other disciplines accessible in the
hospital setting. When a survivor reaches age 18 the patient transitions to the ACE Young
Adult Program at UT Southwestern. The annual visits at the ACE Young Adult Program
should continue through the patient’s adult life.
6-C Clinic Nursing Personnel: The outpatient hematology-oncology unit boasts a
highly trained core group of nurses. Each patient is assigned a primary clinic nurse who is
often the family’s main contact person in the division.
Clinical Manager: Jessica Reis
Oncology Nurses: Ceci Gladbach, Elizabeth Dressell, Pat Satterwhite,
Amanda Dean, Stephanie Hamilton, & Roxan Mars
Hematology Nurses: Debbie Boger & Rhonda Wooley
Hemophilia/Thrombophilia Nurse: Tina Costa & Kim Miller
Infusion Room Nurse: Brad Cook
Research Nurse: Tanja Hoffman
E-10 Inpatient Nursing Personnel: The hematology-oncology nurses on E-10 are a
dedicated and highly-skilled group of individuals devoted to the care of children with cancer
and serious hematologic disease. You will find them extremely helpful resources and are
advised to listen carefully to their suggestions and usually to act on them in a timely fashion.
During the week there is a team leader on the inpatient unit, who also functions as the
charge nurse. The team leader acts to facilitate communication and interactions between the
inpatient and outpatient units.
o Clinical Manager: Lisa Browne
o Team Leaders:
• Day: Virginia Bledsoe & Jessica Reis
• Night: Lydia Steele & Ignacio Vasquez
o Nurse Educators: Jillian Waterbury, Cindi Winkle, Claire Sartwell
o Discharge Coordinator: Cindy Flom x-7313, Beeper #18811.
Stem Cell Transplant Coordinator: Ceci Gladbach. Her main responsibility is to
coordinate the pre-transplant work-up on patients including donor searches, pre-transplant
education and recipient work-up. She also provides nursing support for patients being seen
in the clinic.
Other Clinical Support Staff
Social Work: Thresa Belcher (SCT, Leukemia. Lymphoma); Ethel Jernigan
(Hematology, Sickle Cell); Amanda Cabrerra (Hemophilia, Solid Tumors);
Jennifer Best (Neuro-Onc.). As part of our multi-disciplinary approach towards
caring for children with cancer and hematologic disorders, social work services are
extended to all patients and their families. A social worker is assigned to each family
from the time of initial diagnosis. The same worker follows each family through all
phases of treatment, both inpatient and outpatient. The social worker is the one
member of the team responsible for attending to the social and emotional needs and
practical concerns of not only the child, but the entire family. The demands on each
family are extraordinary, as parents cope with the needs of their sick child, their
other children, their jobs, and other responsibilities, as well as practical concerns
such as insurance, increased financial demands, and lengthy hospitalizations and
frequent clinic visits. The social worker can help each family handle their own
unique responses and circumstances to enable them to cope with the crisis of cancer.
There are a number of resources for children with life-threatening diseases, such as
cancer and many hematologic disorders, including the Ronald McDonald House
Make-A-Wish, and a variety of annual summer camps for children with hemophilia,
sickle cell disease and cancer.
Child Life: Shawnna Rogers (Monday-Friday), Ashley Reiken (Tuesday, Neuro-
Onc), Natalie Singer (T, W, Thursday). The Child life program is one of the
unique services offered to patients and families at Children's. Two full-time certified
child life specialists and one child life assistant are dedicated to the CCBD to provide
support to patients and families. These specialists help minimize the impact of illness
on the child's normal growth and development by helping increase their trust in
caregivers and their ability to understand and handle difficult situations. They help
children to better understand their illness and treatment by offering emotional
support, promoting positive coping, and facilitating procedure preparation, medical
and therapeutic play. Child Life Specialists also work with the child's school to
insure continued education and encourage peer support. Parents are provided with
information on the developmental and emotional effects of illness on their children
and how to support both the patient and siblings during a time of stress.
Child life specialists also facilitate several monthly support groups for patients and their
families. An exciting full-time play therapy/counseling program was established at
Children's four years ago. Weekly sessions are provided for children experiencing
extreme behavioral and emotional response to their illness or to the illness of a sibling.
Parent-Child Relationship Training classes provide weekly support groups for parents.
Clinical Nutrition: Hillary Underwood. The Clinical Nutrition Staff consist of
Registered Dietitians (RD) who are registered with the ADA Commission on Dietetic
Registry and are licensed by the State of Texas. Dietitians will provide comprehensive
assessment/counseling/education with documentation in Progress Notes,
Multidisciplinary Patient Form and/or EMTEC system for inpatient and outpatients.
Dietitians also provide Nutrition Support to patients treated with TPN and Enteral Tube
feedings. The dietitian On-Call after hours, weekends and holidays can be reached by
calling the hospital operator and requesting the On-Call dietitian be contacted
Pharmacy: Pharmacists: Stephanie Budsberg, Max Koepsell, Alan Lorenzen
Pharmacy Technician: Susann Deasy. The hematology-oncology service has a
dedicated “satellite” pharmacy which is operated by 4 Pharm. D.’s on a rotating
schedule, in which one covers the pharmacy and another attends work rounds and is
available for immediate consultation on medication-related issues. All 3 Pharm. D.’s
are specially trained in the preparation and dispensation of chemotherapeutic
Outreach Coordinator: Cristy Ecton The outreach coordinator, Cristy Ecton,
works with the hospital and medical school’s public relations and development
departments, CCBD donors, patient service organizations and the media. If anyone
from the media is in the CCBD areas of Children’s, they should be escorted by Cristy
if not a member of Children’s PR. If you are approached about any events, a
donation or media-related matter, please refer to or contact Cristy at 214-456-
2805/share page #23040. She also supervises new patient referrals.
New Patient Referral Coordinator: The new patient coordinator initiates the
paperwork for all new patient appointments and communicates with the on-call
physician taking referral consults during normal business hours. For referrals
received during off-hours, fellows/faculty are required to initiate the ‘new patient
referral form’ and hand off to this person to process.
If you don’t know “who’s who” or can’t place a name with a face, please consult the
photo display on the wall near the pharmacy as you enter the outpatient unit. There are
many important people who work within the Center for Cancer and Blood Disorders
(CCBD) “behind the scenes” – including front-office personnel and data managers. A
photograph of every person working in the Center for Cancer and Blood Disorders
(CCBD) is displayed.
Your major resources for the diagnosis and care of your patients will, of course, be the
patients themselves and their parents, hematology-oncology staff physicians and fellows,
and the nursing staff including a clinical educator. In addition, the following will be
• Hospital chart: Charts are located at the main desk in numbered slots. BMT charts are
kept in the bone marrow unit. Charts should be returned to the chart room when not
being used to allow easy access and prompt completion of orders.
• Shadow chart: A shadow chart (or “green chart”) is maintained on each established
oncology patient and will be brought to E-10 and placed on the cart in the conference
room upon the child’s admission. If the chart is not present, please ask for it to be
brought over from the chart room in the outpatient area. The shadow chart will contain
a great deal of useful information about the patient, including demographic data, the
protocol road map, recent outpatient visit notes, laboratory flowsheets, a summary of
correspondence about the patient, and pertinent laboratory reports. These charts are
never removed from the E-10 conference room or nursing station!
• Children’s Medical Center medical record. On patients with sickle cell disease and
miscellaneous hematologic problems, the Children’s Medical Center medical record will
usually contain the most up-to-date information about the patient. It should always be
requested from the Medical Records Department when patients with sickle cell disease
are admitted to the hospital in order for you to review the past history of painful
episodes, chest syndrome, and other complications.
• Sickle cell database: A detailed computerized database contains information on each of
the over 600 established sickle cell patients and is on-line in Citrix under its own ICON.
A copy of an up-to-date database is usually placed in each child’s chart.
• Preprinted order sheets: Preprinted order sheets are available for the most common
types of admissions encountered on E-10, including some scheduled chemotherapy,
fever and neutropenia, sickle cell pain crisis, etc. Interns and residents never write for
or sign chemotherapy orders.
• Protocols: Most oncology patients receiving chemotherapy are treated according to a
research protocol sponsored by the Children’s Oncology Group (C.O.G.) or an
institutional (in-house) protocol written by one of the program’s faculty members.
Copies of complete protocols (including background and rationale, which is often quite
informative) are in the protocol books in the conference room and outpatient unit
“command post”. Ask one of the fellows or faculty members to go over one or more of
these protocols with you to become familiar with the format. Protocols should NEVER
be removed from the notebooks in E-10.
Interactions with Patients and their Families
As the major referral center for children with blood disorders and cancer in North Texas, we
encounter and care for patients encompassing the entire spectrum of socioeconomic classes.
We view all of our patients as private patients and treat them with dignity and respect.
Please remember that parents are often under a great deal of psychological and financial
stress as a result of their child’s illness. As a result, certain considerations and courtesies are
• Always introduce yourself (by name and position or status) to patients and their parents
when you enter a child’s room for the first time (and subsequently if you feel that they
don’t recognize you). Always wear your identification badge. Many parents and
children are overwhelmed by the huge number of physicians and other personnel that
they meet. It is not always clear to them who is making decisions. Involve them as
much as possible and keep them informed of decisions in a timely manner.
• Never be afraid to say “I don’t know” when discussing any topic with parents on E-10.
You can always defer to the hematology-oncology fellow or attending physician. There
is no problem in saying “I don’t know, but I will check with Dr. __________”. Do not
answer if you are unsure.
• Families should not be awakened early in the morning without careful consideration of
activities, e.g., do all of your chart reviews, I/O’s, etc. prior to waking a sleeping family.
Avoid separate duplicative early morning assessments by students and housestaff – go
Other Important Patient Care Issues
• Discharge orders and prescriptions: Be certain that you review discharge orders and
prescriptions (including doses) with a APN, fellow, or faculty member during rounds. It
is quite easy to make an error when dispensing drugs with which you are unfamiliar.
Prescriptions for chemotherapy drugs (including steroids) must be written by a
member of the hematology-oncology staff, i.e., APN, fellow, or faculty member. All
efforts must be taken to avoid dosing errors (see Chemotherapy policy on Page 18).
• Appointments: Be sure that a follow-up appointment is made before the patient is
discharged. For oncology patients, please discuss this with the attending physician,
fellow, or APN. For sickle cell patients, the next regularly scheduled clinic visit is listed
in the sickle cell database. If you feel that a sickle cell patient needs to be seen sooner,
please call the APN or sickle cell office to make the appointment (extension 6102).
• Discharges early in the day: Whenever possible identify “expected” discharges the night
before so that any home care arrangements or patient education can be completed.
Discharge planning should be an ongoing part of each patient’s daily plan. There is a
section on the progress note form regarding discharge planning that should be completed
each day. Home care needs frequently take 48 - 72 hours to arrange so early planning is
essential. Try to write discharge and transfusion orders in the morning (before or during
rounds). Often the prescriptions are difficult to fill and should be written a day early to
allow for the drugs to be available at the time of discharge.
• Intake/output values: I & O’s are very important for hematology-oncology patients.
These values determine the safety of chemotherapy administration and allow for
monitoring organ function in the face of septicemia and/or tumor lysis syndrome. Per
policy, nursing staff will notify the appropriate housestaff if there is a discrepancy of ≥
• Prevention of infection: You will note that we rarely use reverse isolation techniques
just because patients are extremely neutropenic. The most important step that you can
take to reduce risk of nosocomial infection is to wash your hands and clean your
stethoscope with an alcohol prep pad before you examine each patient! There are no
exceptions to this hand washing rule. It is unacceptable for anyone on E-10 examining
patients to walk from room to room carrying pathogens on his or her unwashed hands.
Further Opportunities for Learning
The following conferences are always open to students and residents.
Monday Tuesday Wednesday Thursday Friday
Regularly Scheduled Conferences
Sign In Conf
8:00 – 9:00
11:30 – 12:15
1:00 – 2:00
PHO Res Conf
8:15 – 9:15
Dr Dining Rm
4:30 – 6:00
7:15 – 8:00
A03- Conf Rm
8:00 – 9:00
7:30 – 8:00
8:00 – 9:00
1:00 – 2:00PM
4:00 – 5:00PM
6:30 – 8:00PM
Every other 4th
12:00 – 4:00
The Peggy Sartain Library is located in the C-6 Clinic area.
The following conferences are presented by the Department of Pediatrics
Intake conference daily except Wednesday 9:15 – 9:45 a.m.: Doctor’s Dining Room.
The PL2s or PL3s only will meet with faculty in the dining room on Monday, Tuesday, and
Thursday. The PL 1s and the Medical Students will each have a conference on Tuesday and
Thursday and will meet with me, one of the Chief Residents, or a member of the faculty. On
Friday, all the residents and the medical students will meet together in the cafeteria.
Noon conference: Daily 12:15 – 1:00 p.m. Attendance is mandatory for all housestaff.
Doctor’s Dining Room
Pediatrics Grand Rounds: Wednesday at 8:00 a.m. in the CMC Auditorium
• Reading Materials:
In addition to the standard textbooks and protocols, you are encouraged to read about
specific differential diagnoses and diseases in reference books (including those available
in E-10 conference room and the Peggy Sartain Library in the outpatient unit) and
general and specialty journals. These reference books/journals should remain on E-10
on the floor. Access to a copier is available if needed to copy materials. Everyone’s
learning process is enhanced if you take the initiative and bring to rounds pertinent
articles about your patients. The faculty will try to provide, as time permits, review
articles and original publications.
• Outpatient Unit Activities:
You are welcome at any time to come over to our outpatient unit on C-6. The
outpatient unit is the “home” of our administrative area (which includes our work
station or chart room, data management operation, secretaries, nurses, etc.) Like most
areas of clinical medicine, the specialty of hematology-oncology is mainly practiced in
the outpatient arena. Activities on the inpatient service at E-10 do not accurately reflect
the overall picture of how we diagnose and treat children with these disorders. The most
common types of new patients encountered in pediatric hematology-oncology are not
those with cancer, but are children referred for consultation for anemia, bleeding
disorders, neutropenia, lymphadenopathy, etc. These problems are less commonly
encountered on the inpatient service. Increasingly, more of the care for most children
with cancer is given in the outpatient unit. Some patients successfully treated for cancer
are never admitted to the hospital following their initial brief hospitalization at time of
diagnosis. Many children coming for outpatient visits (for chemotherapy treatments,
procedures, or follow-up) are quite well, as are the many hundreds of children in our
long-term follow-up (After the Cancer Experience) program.
If you don’t have the time to experience outpatient hematology and oncology, consider
taking an elective rotation with us as a fourth-year medical student or second- or third-
year resident. You will find it a worthwhile experience!