Two weeks in the life of a transplant doctor

I recently finished my first 2 weeks of attending on the BMT service this year. Although I admit that I wasn’t paged through the nights while on service, the anticipation of possible problems — and rumination over ongoing issues in the unit — kept me waking up periodically for most of the 14 nights.

The first few days on service were adrenaline-inducing but manageable, and of course wholly different as an attending than as a fellow. Walking through the double doors to the unit on my first morning as the medical team leader was the first symbol of an entirely new level of responsibility. Nonetheless, all of the patients were handed off to me with clear plans and most of the ongoing medical decisions already made.

I was nervous, but I was able to keep a steady hand on the wheel during the first part of the week. The intensity level began to slowly rise as I admitted several new patients and conducted initial family conferences. I discussed toxicities of treatment and code status with each patient, but these were mostly imagined problems and not yet real.

William Wood

Our patients are often pleasantly surprised during the first few days of their hospitalization. Although they suffer indignities they may or may not have known before, such as frequent night-time awakenings for labs and vital signs, the first few days of conditioning seem planned, expected, and tolerable. Many greeted me during the first few mornings on rounds with a mixture of happiness that they were still feeling reasonably well, and anticipation that something yet unknown might be about to start.

Problems and patient resilience

And then, the kinds of problems one expects to see on a BMT unit began to appear. One patient 6 months out from her initial transplant was readmitted with a large pericardial effusion and tamponade physiology, requiring a liter of fluid to be drained. Another patient, this one in the midst of his post-conditioning neutropenia, developed high spiking fevers and gram negative bacteremia. A third patient evolved grade 4 mucositis and began to look increasingly tenuous.

Peripheral blood counts dropped. Fatigue and malaise began to set in. Unexpected toxicities of one form or another — mucositis, nausea, diarrhea, febrile neutropenia, hypoxemia, or worse — evolved. In confronting these events, my patients displayed a resilience that they may not have known they had. Although they might not have been able to eat, they smiled bravely at me each morning. Encouraged to get out of bed, many mustered the strength to walk a few laps around the unit. These patients knew that the counts would rise, and the aches and pains would eventually improve.

By now, I was into the rhythm of the unit. I met all of the 2 weeks’ challenges with humility and self-doubt, and periodic consultations with my colleagues. Although my patients caused me to lie awake late at night, I was in the middle of a marathon at that point, and knew that by focusing on each mile marker in front of me I would make it through to the end.

The unit became my home away from home — with remote desktop access, I had a virtual office in the physician workroom — and even when I was at my actual home in the late evenings, I was still frequently checking vitals and lab results. The 2 weeks ended, finally, and I spent the next few days in a mental haze, trying to sort through everything that had just happened.

Revisiting patients

My patients, of course, went through similar growth experiences up on the unit, albeit more intensely, with significantly higher stakes. One of my patients told me that his initial experience walking through the unit’s double doors at the beginning of his transplant hospitalization left a profound impression upon him. He had been counseled extensively about the transplant process as an outpatient, but he knew once he walked through the doors that something very big was about to happen.

Not all patients experienced rough hospitalizations, but all, I would guess, emerged changed in one form or another. When I see patients I had known in the hospital or in the hallways of the outpatient clinic, I can see something different in their expressions and mannerisms from the way they were when I first met them. They seem to have a new sense of self-awareness, and a realization that living after transplant represents another a new “normal.”

A few days later I went back up to the unit to visit the patients who I had come to know so well, all of whom were now my friends. One actually was renewing his marriage vows with his wife in the midst of his hospitalization, celebrating 43 years together with her. He insisted that I have a seat on the couch with his extended family and stay for the ceremony.

I know in reflecting on my first 2 weeks that my growth as a transplant doctor is trivial in comparison to the life-threatening and life-changing circumstances that our transplant patients experience. This is humbling. It is easy for all of us to get caught up in the trials and tribulations of life as a fellow, junior faculty or even senior faculty member. At the end of the day, we are doing this for our patients — and this is why I think a clear orientation towards the patient experience is so important for us to have.

William Wood, MD, is assistant professor of medicine, division of hematology/oncology, at the University of North Carolina Chapel Hill. Dr. Wood may be reached at william_wood@med.unc.edu.

This evocative description of doctor/patient bonding in the particularly-horrendous clinical endeavor of bone marrow transplantation raises a troublesome question. Are not brief, two-week roations of transplant attendings a formula for separation anxities in patients who are already emotionally fragile?

– Harry S. Jacob, MD, FRCPath(Hon)

Chief Medical Editor