“The Rules of the Road”

A Guide for Pediatric Residents and Medical Students

on the Inpatient Hematology-Oncology Service

2006 - 2007 Academic Year

Prepared By:George R. Buchanan, M.D.Jennifer Cox, M.D.

Revised 4/12/2023

Table of Contents

Introduction......................................................................3General Description of Unit..................................4Types of Patients Admitted to 4-B........................6Hematology-Oncology Medical Staff.....................7Who Does What?...............................................10Weekend and Night Call.....................................12Resident and Medical Student Education............13

Work Rounds............................................................................................13Teaching Rounds.....................................................................................13Evaluations:.............................................................................................14

Hematology-Oncology Nursing Staff...................15Other Clinical Support Staff................................16Resources.........................................................19Interactions with Patients and their Families......20Other Important Patient Care Issues...................21Further Opportunities for Learning.....................22Daily Outpatient Clinic Schedule.........................24E-10 Phone List.................................................25CCBD Phone List................................................26Children’s Medical Center Phone List..............................28

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Introduction

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.

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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

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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 elevators.

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Floor Plan of E-10

1: Communication HUC2: Clinical HUCNS: Nursing Stations

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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 Practitioners.

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 procedure.

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

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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 Dallas.

NAME OFFICE OFFICE #

(214)

PAGER #

(927) 206-

George Buchanan, M.D.Division ChiefDirector of Clinical Hematology

UTSW: G3.222CMC: A03.319

648-8594456-2379

9450

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 Fellowship Program

UTSW: G3.240 648-8062 9156

Victor Aquino, M.D. UTSW: G3.234 648-8800 9173

Jim Amatruda, M.D., Ph.D. UTSW: NB8.218BLab:NB8.218A

648-1645648-4023

or648-4920

(972) 451-2406

Dan Bowers, M.D. UTSW: G3.238 648-8822 9280

Scott Cameron, M.D., Ph.D. UTSW: NA5.602ALab:NA5.234/504

648-5152648-1855

9189

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: F3.118BLab: K3.108

648-7222648-9558

9062

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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 students.

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 972.206.9285

Tamra Slone, M.D. 3rd 972.206.9615

Jennifer Wright, M.D. 3rd 972.601.8666

Laura Klesse, M.D., Ph.D.

2nd 972.206.9712

Jason Litten, M.D. 2nd 972.451.1161

J. Allyson Niece, M.D. 2nd 972.206.8795

Mark Hatley 1st 972.451.1110

Tim McCavit 1st 972.451.1195

Martha Stegner 1st 972.206.8170

Cristina Tarango 1st 972.206.9266

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.

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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 Dr. Morad.

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 numbers.

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

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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.

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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 desire.

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.

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Chemotherapy

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 discharge.

A nurse on the floor should not accept any orders or prescriptions that do not meet these criteria.

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

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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 like weekends.

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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.

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Resident and Medical Student Education

Work Rounds:

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.

Teaching 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.

Normal HematologySickle Cell DiseaseNutritional AnemiasHemolytic AnemiasTransfusion MedicineHemostasis/ThrombosisPlatelet DisordersNeonatal Hematology

Principles of Chemotherapy Leukemias (ALL/AML)LymphomasBrain TumorsNeuroblastomaBone Tumors/SarcomasEmbryonal TumorsOncologic Emergencies

HistiocytosisStem Cell TransplantationLate Effects of Childhood CancerBone Marrow Failure SyndromesWBC DisordersImmunology

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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.

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Evaluations:

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 rotation).

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

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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.

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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 management issues.

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.

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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 Browneo 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.

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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

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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 medications.

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

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managers. A photograph of every person working in the Center for Cancer and Blood Disorders (CCBD) is displayed.

Resources:

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 helpful:

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

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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.

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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 required:

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 together.

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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 ≥ 20%.

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.

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Further Opportunities for Learning

Conferences :

The following conferences are always open to students and residents.

Monday Tuesday Wednesday

Thursday

Friday

Regularly Scheduled Conferences

Sign In ConfSartain Library8:00 – 9:00

Hemostasis ConferenceBlood Bank Lib11:30 – 12:15

Sickle Cell TeamA03-Conf Rm1:00 – 2:00

PHO Res ConfSartain Library8:15 – 9:15

Tumor BoardDr Dining Rm4:30 – 6:00

Fellows ConfSartain Library7:15 – 8:00

Hemophilia Team MtgA03- Conf Rm7:45-8:45

Neuro-Onc Tumor BoardAuditorium8:00 – 9:00

HematologyConsult ConfSartain Library7:30 – 8:00

Weekly Dept Staffing ConfSartain Library8:00 – 9:00

Occasional ConferencesBMT Core2nd TuesdaySartain Library1:00 – 2:00PM

Hgb Elect1st WednesdaySartain Library4:00 – 5:00PM

Journal Club2nd ThursdayFaculty Home6:30 – 8:00PM

COONC ClinicEvery other 4th Friday Sartain Library/C-6 Clinic12:00 – 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

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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

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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!

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Daily Outpatient Clinics: Fellow & Attending Physician Assignments

PEDIATRIC HEMATOLOGY-ONCOLOGY OUTPATIENT CLINIC SCHEDULE

EFFECTIVE JULY 2006

**Sickle cell patients only**Two weeks in each clinic each month

Monday TuesdayWednesday

Thursday

Friday

6th Floor Leavey Winick Tomlinson Aquino BashPorteus,Amatruda,or Cameron

BowersRogers* (pm)

Wickiser (pm)Cox (am)Quinn* (am)

Cox Wickiser

Bright Bldg.

Quinn (am)

Buchanan (am)

Rogers (am)

Buchanan (am)

Crary (am)**

Journeycake (am)

Crary (am)**

Fellows Slone Klesse Neunert Litten WrightNieceTarango Stegner Hatley McCavit

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E-10 Phone List

PERSON/ LOCATION PHONE BEEPERFront Desk X 7870

MANAGER    Lisa Browne 7188 18951

EDUCATORS    Jillian Waterbury 7196 18966

Cindi Winkle 7197 18928Claire Sartwell (Off-Shift) 5452 27828

TEAM LEADERS    Virginia Bledsoe (Day) 7312 19330

Jessica Reis (Day) 7312 27871Lydia Steele (Night) 7880 19225

Ignacio Vasquez (Night) 7880 27870DISCHARGE COORD.    

Cindy Flom 7313 18811STEM CELL TRANSPLANT    

Gevel Jackson (CRA) 7194  Susan McCollom (Coord.) 7193 25616

SECRETARY    Heather Smith 7191  

HUC's    Clinical HUC station 7266  Comm. HUC station 7870  

Work area behind Comm. HUC 7257 / 7259  Engine Side (Rooms 401 – 411)    

Nurse's Station 7332 / 7334  Med. Room 7314  

Caboose Side (Rooms 417 - 422 )    Nurse's Station 7880  

Med Room 7255  BMT (Rooms 412 - 416)    

Nurse's Station 7248  Med Room 7342  Playroom 7341  

Other    Conference Room 7278 / 7280  

Consult Room 7340  Playroom 7336  

Multipurpose Room 7339  Staff Lounge 7337  

Treatment Room 7256  Hoteling Space (E-10-C30) 7226 / 7227  

Call Rooms #1: 7199 #2: 7223

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Center for Cancer & Blood Disorders (CCBD) Phone List

NAME PHONE BEEPER WAYFINDING DEPARTMENT LISTING PHONE

Acevedo, Mayra 5849   C06-650 Admitting (1st Floor) 2191

Adix, Leah 2888 17864 A03-368 Appointment Line-CCBD 5167

Amatruda, Jim214-648-1645

972-451-2406

NB8.218A Lab Aston Center 214-648-6864

Anderson, Miriam 8588   C06-660. Audiology 6178

Aquino, Victor214-648-8800

972-206-9173 CO6-660.C

Bed Control Fax: 2197 2196

Barber, Sarah 2935   A03-320 Blood Bank (CMC) 7756

Bash, Robert 2773972-206-8645 CO6-677 Blood Bank - Parkland 214-590-8211

Beasley Genetta 6131   C06-660.L Blood Runner Pgr - 18381 Bisceglia, Maria 6317 27455 EO6-605     Bledsoe, Virginia 7188 27828   Central Sterile 3011 Boger, Debbie 6472 18254 A03-360.07 Chemistry Lab 2321

Bowers, Dan214-648-8822

972-206-9280 G3.238 UTSW Chemo HOTLINE 5452

Brown, Paula     C06-640 Command Rm2030/5403/5404/5405

Buchanan, George

214-648-8594

972-206-9450 G3.222 UTSW

Peggy Sartain/ Conf calls

4456 / 8026

Buck, Randy   19716 CO6-676 Copy Center 7230 Burton, Tiffany 2708   A03-360     Callicut, Jessica 2703 19446 CO6-660.E CT Scan 2304

Cameron, Scott214-648-5152

972-206-9189

NA5.234 UTSW Cytogenetics (UT Med) 214-645-7000

Cavender, Joe Don 2801 18303 EO6-605 Day Surgery 2022/2388 Cochran, Cindy 5061 17431 A03-306 Dental Clinic 6800/8800 Cook, Brad 5417 24976 CO6-660 Dermatology 2766 Costa, Tina 5402 17646 A03-319 Distribution 6161

Cox, Jennifer 8062972-206-8226 E10-371.2 E10 BMT Nurses Sta 7248

Crary, Shelley 3194972-206-9772 A03-362 E10 East Playroom 7336

Curtis, Lashunda 2946

Billing Coord A03-308.03 Echocardiogram 2327

Dale, Juanita 2341 10636 A03-360.03 EKG 3980

Davis, Bonnie 8060214-822-2594 A03-308.08 Endocrinology 5959

Davis, Mishel 6484   A03-304.01 Engineering 6988 de la Hoya, Myrna 2978   CO6-660.K Ear Nose Throat 2386 Dean, Amanda 2800 18963 C06-676 Emergency Room 2100 Deasy, Susann 2863   CO6-601 Eye Clinic 2383 DeMasi, James 7195 18360 E10-371.1 First Care 8700 Dezee, Genene 2806   CO6-660.M Flow Cytometry 214-645-7057 Dismuke, Corrina 7739 27902 CO6-672 Genetic Counseling 2357 Diver, Karen 5707   A03-308.04 GI Clinic/Fellow 8000/8032

Dressell, Liz 5738 18352 CO6-676 Guest Relations/Care Line 2273

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Ecker, Paula   18085 C06-676 Height & Weight Rm (A) 6159 / (B) 2021 Ecton, Cristy 2805 23040 A03-385.X Help/Info Service 4636 Ellis, Karen 5737   C06-677 Hematology Lab 3120/2320 Eshelman, Debra 8301 24259 A03-306 Housekeeping 2854 Evans, Jennifer 8138 25099 C06-652     Ewah, Obia 6525   A03-308.07 HR Customer Service 3900

Flom, Cindy 7313 18811 E10-359.1 HUC Clinical Station 10E 7266

Flores, Rosalba 6159   C06-650 HUC Communication 10th 7870

Gafford, Christy 7248 E10 / HUC    

Garcia, Nilda 6040214-822-4490

General Surgery ICU 2033

Gibbs, Sheron 8167   C06-660.H Infusion Room A / B 5417 / 6 008 Gladbach, Ceci 7193 25616 E10-371.1 Ketorolac Study Pager Pgr# 22631 Graul, Cynthia   A03-370     Hamilton, Stephanie 7892 19330 C06-676 Lab (6East Clinic) 5412

Hatley, Mark 2382972-451-1110 A03-365 Language Line 1-800-643-2255

Hawkins, Sharonna 2660 / 6159         Hermann, Darrell

972-991-5437  

Pediatric Surgery Mailbox Phone 2656

Heym, Jennie 8510 22637M4 Trailer N/Onc    

Hicks, Barry214-456-6040

214-822-8257

Pediatric Surgery

Med Records/ Charts Completion 2509/ 6396

Hoffman, Tanja 2726 27293 CO6-660.F Molecular Diagnostics 214-648-4075 Jackson, Gevel 7194 22916 E10-371 MRI 2135 Jancuska, Kathy 2804 18462 CO6-654 Neurology 2768 Jones, William 6167   C06-660.D Neuro Oncology 6139 Journeycake, Janna 8556

972-206-9286 A03-316 Nuclear Medicine 2815

Klesse, Laura 2382972-206-9712 A03-365 Orthopedics 7697

Koepsell, Max 2863 18916 CO6-601 Outpatient Phy Office 6306 Lautzenheiser, Kelly 5413 24492 E06-605 Parkland Main No. 214-590-8000

Leavey, Patrick214-648-8605

972-206-9156 G3.240 UTSW Pastoral Care 2822

Lee, Nancy 6226 27818 A03-803. Pathology 2322

Leija, Larry 6412  M4 Trailer N/Onc

Patient Financial Service 8224

Litten, Jason 2382972-451-1161 A03-365 Pedia Transport 2926

Lloyd, Michelle 7312   E10-324 Pharmacy - Oncology 2863

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Children’s Medical Center Phone List DEPARTMENT LISTING PHONE DEPARTMENT LISTING PHONE Admitting (1st Floor) 2191 Parkland Main No. 214-590-8000 Audiology 6178 Pastoral Care 2822 Bed Control 2196; Fax: 2197 Pathology 2322 Blood Bank (CMC) 7756 Patient Financial Service 8224 Blood Bank - Parkland 214-590-8211 Pedia Transport 2926 Blood Runner Beeper - 18381 Pharmacy – Inpatient 6209 Bone Marrow Unit 4541 Pharmacy – Outpatient 2879 Central Sterile 3011 Pharma Thera 972-641-3232 Chemistry Lab 2321 Physical Therapy 2778 Command Rm 2030/5403/5404/5405 Pulmonary Lab 2763 Conf Rm/Peggy Sartain 4456 Purchasing, Customer Ser 6161 Copy Center 7230 Radiology 2305 CT Scan 2304 Remote Building Charts 6356 Cytogenetics (UT Med) 214-645-7000 Respiratory On Call Beeper - 14298 Day Surgery 2022/2388 Respiratory 2762 Dental Clinic 6800/8800 Security 2889 Dermatology 2766 Special Coagulation 214-648-0204 Echocardiogram 2327 Special Procedures ARCH 6453 EKG 3980 Surgery 2766 Endocrinology 5959 Tissue Typing (UT Med) 214-648-2937 Ear Nose Throat 2386 Translation Service 6272 Emergency Room 2100 Ultrasound 4401 Eye Clinic 2383 Urology 2444 First Care 8700 Volunteer Services 6388 Flow Cytometry 214-648-4078 Waiting Room Hem/Onc 3071 Genetic Counseling 2357 CLINICAL CANCER GENETICS - UTSW GI Clinic/Fellow 8000/8032 Patterson, Annette 214-648-4051 Help/Info Service 4636 Robinson, Linda 214-648-1997 Hematology Lab 3120/2320 Shelby, Kristin 214-648-1919 Housekeeping 2854     HR Customer Service 3900 FAX NUMBERS Human Resources 1904 ACE Program 214-456-2095 ICU 2033 Bright Bldg. 214-456-6014 Infusion Room 5417 Clinical Research 214-456-6429 Kidney/Gynecology 2980 Hematology-Oncology 214-456-6133 Lab (6East Clinic) 5412 Sickle Cell 214-456-8469 Language Line 1-800-643-2255 Medical School 214-648-3122 Medical Records 2505 MEDICAL SCHOOL - UTSW Molecular Diagnostics 214-648-4075 Ellisor, Pat 214-648-3896 MRI 2135 Fillmore, Ann 214-648-3150 Neurology 2768 Adams, Michell 214-648-3074 Nuclear Medicine 2815 Clark, Laura 214-648-8594 Orthopedics 7697 TRANSLATORS Outpatient Phy Office 6306/6373 Dispatcher 6272 Orthopedics 7697

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