Yes, I Mix The Chemo Too...

So what exactly does a pediatric oncologist do anyway? 

Well, we take care of children with cancer. Our role is to coordinate their care with surgeons, radiation oncologists, pathologists, and to manage their chemotherapy. We are charged with choosing the correct treatment plan for the child, ensuring that they receive therapy on time, and writing lots of orders for chemotherapy. 

Sometimes we are asked to do a little more. 

In the developing setting, particularly where I am currently, I do a little more than order chemotherapy and coordinate the care of each child as I learned on the first day I wrote chemotherapy orders back in September 2007. 

I turned to the nurse and said, “Now what?” 

She said, “well now you must mix the chemo and give it.” 

What? Did she just say I have to be a pharmacist and a nurse as well? “Well, you’ll give the chemo right?” I asked. 

“Sorry. No we do not know how to give it, you must give it.” 

Oh. Sure no problem. These are not tasks that we are trained for mind you. At Texas Children’s Cancer and Hematology Center, or really any cancer center in the States, preparing chemo is what a chemopharmacist will do, and giving it is what a pediatric oncology nurse will do. So I took myself to the back room, opened a box of doxorubicin and read through the entire package insert. Truly I must admit, I don’t think I have ever perused a package insert so intently and with such a fine-tooth comb. They say a lot as it turns out! 

Another little nuance of import. Back in the States, 2 doctors sign the chemo orders, a nurse reviews and signs off on them, 2 pharmacists check them, the chemo is made, and then 2 nurses check the chemo before it gets into a patient. 

How many different people was that again?

That’s right — 7. I’m finishing reading an insert when it occurred to me, I’m all of those 7 people… After checking my math 7 times and reading and re-reading the package insert I got to it. Three medications prepared in about 90 minutes… I was just a little stressed about making a mistake. After all, this is chemo people not a multivitamin, a mistake could result in death! I marched over to give the chemo. 

Turns out giving multiple medicines simultaneously is not really something one can do in our resource-limited setting. So, stop the fluids, run the chemo, restart the fluids to provide a flush, start the next medication, finish, and restart the fluids that need to continue 'til tomorrow’s dose. Two infusions took an hour for each one. So if we do some more math, 30 minutes to order the chemo and check an re-check the doses, 90 minutes to prepare the medications, and 2.5 hours to give three medications (one was an IV push medication). 

That means 4.5 hours to give one kid chemo. 

This was clearly not going to work unless I had only a patient per day! Obviously I have not done it this way for 3 years or else I’d have gone mad.