Life in the transplant unit

On the fourth floor of the St. Jude Children’s Research Hospital Patient Care Center, a soft, but frequent chime rings overhead. To the causal listener, it easily blends into the background noise with its singsong flow, but for Ramelle Wheeler, a registered nurse in the Division of Bone Marrow Transplantation (BMT), a story is told in each variation of its length and tone.

On this morning, early into her 12-hour shift, Wheeler works on patient charts. At the chime’s prompt, she pauses and listens to its instruction. Today she is taking care of two patients, and the bell has called for a platelet transfusion for one of them. Throughout the day, Wheeler will check on this patient every 15 minutes. The other will need attention every half hour.

“It’s a balancing act,” she says. “There are a lot of medicines, blood products and procedures to fit in a day. We’re constantly checking out the patients from head to toe.”

Intense monitoring and treatment is all part of the job for Wheeler and her colleagues in the St. Jude BMT division. Before and immediately following transplants, patients’ immune systems are significantly weakened, putting them at a higher risk for infection and complications. During their recovery, which lasts an average of six weeks, transplant patients are restricted to the hospital’s fourth floor, where staff members keep a constant vigil against infection.

“Our kids’ counts drop so low and stay low for so long that everything—from the air they breathe to the food they eat to the number of times a day they brush their teeth—is about infection control,” Wheeler says.

The battle against infection begins with creating a sterile environment. In addition to the protection the hospital’s air filtration system offers, each of the unit’s 14 patient beds is located under an additional HEPA air filter. The rooms are designed to circulate air according to need.

“The air is constantly recycled here, so if a patient has the flu or something else contagious, the air in the room stays in the room,” Wheeler explains. “If we have a patient with an exceptionally low immune system such as a baby with SCID (severe combined immunodeficiency), the air is circulated so that none of the air in the hall goes in the room.”

In cases of patient isolation such as these, the BMT staff must take precautions. “For a patient with the flu, we’ll wear one gown, one pair of gloves and a mask in the room and take it all off before leaving the room,” she explains. “It protects us from picking up anything and bringing it out of the room.”

With every trip to a patient’s room, staff and visitors must wash their hands upon entering and exiting. Hand washing is a hospital-wide practice, but Wheeler, who is often called to a patient’s room every half hour, says, “I can’t count how many times a day I wash my hands.”

In addition to the staff’s personal precautions, all patient rooms are cleaned twice a day, and the bed linen is changed once. The unit, as a whole, is cleaned daily as well.

Managing a sterile environment also means managing who comes into the BMT unit. Access to the fourth floor is limited, and guests must pass a health screen administered by a nurse before visiting a patient.

These strict measures allow patients added mobility during their confinement. “It’s a long time to be in one place,” explains Gregory Hale, MD, interim chief and clinical director of Bone Marrow Transplantation. “St. Jude is different because at many centers you can’t get outside of your own room, but here patients are offered protection outside of the room.”

The change of scenery, albeit slight, is important.

“It can change their outlook,” says Wheeler, pointing to the “teen link” Web cam as an example. The Teen Room activity areas on the hospital’s first and fourth floors are wired together so that patients, separated by these floors, can interact. “Many times, the teens don’t feel like coming out of their rooms, but sometimes you’ll catch them in there having a good time,” Wheeler says.

The BMT unit is designed to motivate and invigorate patients, especially since their physical therapy is limited to that area. A floor-to-ceiling mural, spanning the length of the unit, radiates energy with soccer players chasing a ball down the field, ballerinas pirouetting and basketball players scrambling for a slam dunk.

“It draws them out of their rooms,” Hale explains. “It’s important because physical activity prevents loss of muscle strength and muscle tone during five-to-seven-week hospitalizations.”

While the fourth-floor restriction may limit outlets for patients in some ways, it benefits them in others. The nurse-to-patient ratio is one-to-two, allowing concentrated care. “The nurses provide continuity,” Hale says. “They get to know the physical, physiological and social needs of the patients.”

“The long-term relationship that forms with the kids is my favorite part of working in BMT,” Wheeler says. “It is certainly one of the most rewarding reasons to work here.”

Reprinted from Corridors magazine, winter 2007.


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