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Emergency Care for Cancer Patientsby Sunni Hosemann Triage: A patient calls to report that she began to feel feverish about a half hour ago and has a temperature of 100.8°F. She is currently undergoing chemotherapy treatment for breast cancer. Should she
For most people, fever is not an emergency, and there would be no need for immediate care. But for patients with cancer, who often have compromised immune systems, it’s a much different story. Neutropenic fever can signal the development of a serious and fast-acting bacterial or fungal infection that requires immediate and aggressive treatment. The patient in this example should go to the nearest emergency room. “In fact, even if this were one of our patients, she would be instructed to go to the nearest emergency room if she was more than 30 minutes away, rather than drive farther to come here,” said Cecil Brewer, clinical administrative director of the Emergency Department at The University of Texas M. D. Anderson Cancer Center. And while he concedes that most cancer patients would prefer to be treated where their cancer and cancer treatment are known, that’s not always possible. Reasons for emergency room visits Many cancer patients need some type of emergency care during the course of their illness and treatment. Neutropenic fever is one of the most common reasons, but there are a number of others as well. Oncologic emergencies are usually either compressive or obstructive, metabolic, or cytopenic in nature.
About 19,000 patients were treated in M. D. Anderson Cancer Center’s Emergency Center (EC) last year. Most were M. D. Anderson patients. About 86% of them presented with urgent or emergent conditions. Not all conditions were directly related to cancer; the focus of this facility is not limited to “oncologic emergencies” but rather to any urgent care needs of cancer patients.
“Cancer patients are not immune to the things that send other people to emergency rooms, too; incidents arising from co-morbidities, such as heart disease or diabetes, are common. In these cases, cancer may be a complicating backdrop, increasing the complexity of the situation,” said Margaret B. Row, M.D., who is medical director of the EC and section chief of Emergency Care at M. D. Anderson. Uniquely, the EC in this cancer center is staffed by non-oncologists like Dr. Row—physicians whose first specialties are internal or emergency medicine but who now specialize in the emergency care of cancer patients. Dr. Row notes that one of the professional rewards of this unique subspecialty of emergency medicine is that the staff develops long-term relationships with patients, which is not usually the case for emergency personnel. A specialized EC Compared with a conventional emergency room, the EC has other differences: no burns, obstetrics, or trauma, of course. Few cases can be processed quickly. Quite often, for example, a patient presenting to a conventional emergency room (ER) with a fracture can be transferred directly to an orthopedic department for an x-ray and cast, followed by an immediate discharge. A cancer patient with a fracture—possibly a pathologic fracture—is a different story. The work-up and evaluation is not a fast process in this setting, and patients are admitted to inpatient care from the EC—including the ICU—more often than they are from a conventional ER. The care given in the cancer center EC is more holistic than single problem–oriented and is thus labor and resource intensive. But the cancer center EC makes sense for cancer patients, who often feel more secure about treatment—even for other conditions—in a facility where their cancer is understood. It is unique, and the demand for its services is growing. “We are seeing increasing numbers of patients, and as treatments become more aggressive, we often see sicker patients,” noted Mr. Brewer. To better meet the growing needs, construction of a new EC facility is underway at M. D. Anderson; it will have increased space and bed capacity, special procedure rooms, a unit designed for fast-track cases, and a unit for 24-hour observation, and it will be located in convenient proximity to imaging and other important services. There will be easy access for automobiles and ambulances, and there will be a 24-hour dedicated pharmacy and diagnostic imaging and laboratory services. “Concurrently, we’re implementing high-tech patient tracking and other workflow efficiencies,” said Mr. Brewer, noting that medical and nursing staff have been very involved in the design of the new unit. “It will be one-of-a-kind,” he said. Starting with, “What would the perfect ER setting be?” Dr. Row said that medical and nursing staff worked with designers and architects on the plan and made site visits to other facilities. The new facility will be uniquely tailored not just for emergency medical care but also for the unique needs of cancer patients: the new plan involves patient advocacy, case management, and food services; the single rooms are designed to provide privacy and comfort for patients and their families as well as protection from infection. Resource for local physicians But not all cancer patients who need emergency care will be treated at a facility like this. M. D. Anderson and Memorial Sloan-Kettering are the only comprehensive cancer centers in the United States that offer this highly specialized service. Most cancer patients who need emergency care will receive it in their local emergency department, so the EC staff at M. D. Anderson is also committed to helping support their colleagues elsewhere. Towards that end, M. D. Anderson recently hosted the second annual oncologic emergencies conference for community health care providers in internal and emergency medicine as well as oncology. An additional resource is Oncologic Emergencies (B.C. Decker, 2002) by M. D. Anderson physicians Sai-Ching Jim Yeung, M.D., Ph.D., and Carmen P. Escalante, M.D., a book written for community physicians and emergency physicians who may not see oncology patients on a regular basis. Finally, M. D. Anderson’s EC staff consults with physicians at other facilities by telephone about a cancer patient’s care. “We are often a resource for the emergency physician elsewhere who must cover a much broader range of conditions and is now confronted with a cancer emergency,” said Mr. Brewer. “Sometimes,” added Dr. Row, “that is just a medical discussion, but there are other times it may mean helping colleagues in other ways, such as assisting them with difficult conversations with families or offering the kinds of emotional support we have found that cancer patients need in these situations.”For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789. Other articles in OncoLog, February 2006 issue:
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