Exploring the Intersection of Emergency Medicine and Oncology With Joseph Oropeza, PharmD, BCCP, and Joseph Kalis, PharmD, BCOP

In this interview, Joseph Kalis, PharmD, BCOP, introduces Joseph Oropeza, PharmD, BCCP, one of the newest Editorial Board members of Oncology Data Advisor. Dr. Oropeza shares what he does as an Emergency Medicine Pharmacist, the intersections of oncology and the emergency department, the steps he takes to manages oncologic emergencies, and the importance of communication and collaboration between disciplines to ensure optimal outcomes for patients.

Joseph Kalis, PharmD, BCOP: Thank you for joining us here at Oncology Data Advisor. My name is Joe Kalis. I’m an Ambulatory Oncology Pharmacist with UC Health in Colorado Springs, Colorado.

I wanted to hop on a call today so that I can introduce one of our newest board members for Oncology Data Advisor, have a conversation with him, and let him tell us a little bit about what he does. He’s got some unique perspectives on oncology and supportive care, especially coming from a different specialty. Without further ado, I’d like to introduce the viewers to Dr. Joseph Oropeza.

Joseph Oropeza, PharmD, BCCP: Thanks, Joe, for the introduction. Like Joe said, my name is Joe Oropeza. I’m an Emergency Medicine Pharmacist here at UC Health Memorial Central Hospital. Originally, I was trained in critical care and was board-certified in critical care pharmacy, but over the past couple years I’ve moved my career and passions more towards emergency medicine. I’m super happy to be involved with this and learn more about the oncology realm from you guys, so thank you for having me.

Dr. Kalis: We’re very excited to have you. We’ve got physicians, fellows, pharmacists—quite a variety of people, but oncology can really touch so many disciplines and so many health specialties. Before we dig into that and how your role in the emergency department plays into it, I was hoping you could spend a couple minutes and tell us—what got you interested in critical care and emergency medicine pharmacy?

Dr. Oropeza: Sure. That’s a tough question. I feel it’s somewhat akin to “What’s your favorite food?” or “What’s your favorite song?” There are a lot of things that really interested me originally in critical care. I think, particularly, it’s because I am somewhat impatient and like to see the instant gratification. If we have somebody who is critically ill and needs immediate treatment, with a lot of those treatments, you’re going to see the effect of that treatment within seconds of starting it. That allows us to titrate, and not to nerd out too much on all the drips over here, but it gives me a sense of gratification to see that instant fix with a lot of those very critically ill patients.

And why emergency medicine? It’s certainly an interesting question, because I did start my career in critical care, and they can seem at times to be on very polar opposite ends of that career stick. However, throughout my residency training, I had many experiences in the emergency department (ED), both during my post-graduate year (PGY)-1 and PGY-2 years. I would say that throughout those experiences, I found myself attracted to, as I call it, the high-paced organized chaos that is the emergency department.

Now, as you know, Joe, I’m a very high-energy person. I like to be moving around for most of my day. I think that the ED provides pharmacists, at least in my opinion, with a unique practice environment. Since we are often collaborating with the medical team at the bedside and roping in the critical care component, we do get to see a lot of critically ill patients that come through the emergency department. When I had the chance to mix my passion for critical care with everything else that is the ED, I found myself very interested in moving my career towards emergency medicine pharmacy, and I have been there ever since.

Dr. Kalis: Ever since. Well, thank you. And for the viewers out there, Joe and I are colleagues at the same institution and pretty good friends outside of work, so if there seems an extra air of familiarity, that’s the reason behind it.

It’s interesting that you bring up the drips. I know we’ve had offline conversations where you joke about being able to fix everything with the drip, and I joke about being able to fix everything with a monoclonal antibody. For any viewers out there who might be unfamiliar or just need a refresher on some of the pharmacy pathways, PGY-1 is post-graduate year one after you earn your Doctor of Pharmacy. It often focuses more on internal medicine and general pharmacotherapy. Then if the individual wishes to specialize in something—oncology for me, critical care and emergency medicine for Joe—you can choose to do a second year. He and I have each completed those board trainings in different avenues and specialties. I joke that I like to be able to talk to my patients, and Joe likes to be able to put them on drips and sedate them, so you’ve got both ends of the spectrum covered here.

But I think really what makes Joe such an asset to the Oncology Data Advisor Board is a lot of the oncologic emergencies out there. We think of things like febrile neutropenia or hypercalcemia of malignancy. As we get into the T-cell and redirection therapies like chimeric antigen receptor (CAR) T cells and bispecific antibodies, there could be things like cytokine release syndrome as these agents are given more in the outpatient setting. Joe and his colleagues in the emergency department are going to be that first line of defense. They might call the clinic first and then get directed there, but I kind of see it as we’re all still partners. Health care is still a team sport, and we really need to have everybody on the same page.

From the emergency medicine standpoint, let’s say a patient walks in, they’re in the oncology clinic, they’re being treated on active chemotherapy, and they’ve got a fever. Can you walk us through some of that emergency department thought process for how you would work up a patient with febrile neutropenia, and then what information from an oncologist might be most helpful for you?

Dr. Oropeza: Of course. Like you said, this is one of the categories where we intersect with oncology as a cancer-related emergency. The biggest thing with neutropenic fever that we’re going to be concerned about is making sure that we’re providing adequate coverage right on the front end. Things that I’m looking for right on the front end include—are they actually febrile, or is this a subjective fever that they’re coming in with? Do we have recent blood counts? How quickly can we get those blood counts to determine if they are neutropenic at this point? What was their last chemotherapy regimen?

You can talk more in detail about this than I can, but depending on which chemotherapy regimen they’re on, that could potentially be associated with a greater risk of developing a neutropenic fever as compared to other regimens. If they’re on a high-risk regimen, maybe we’ll empirically start treatment now, given the temporal aspect of their last regimen, their expected nadir, and their clinical presentation with us right now. Maybe we’ll start it prior to getting the counts just to be safe. We do know that when folks without cancer come in with septic shock, every hour of delay of appropriate antibiotic therapy can increase mortality by about 7.2% up through the first six hours. How much more is that with somebody who has a disease that is as complicated as cancer?

There is a sense of true medical emergency to make sure that we’re providing adequate care for these folks. It can be very complicated, because we don’t want to over-treat them, since they’re also at risk for treatment-related side effects associated with antibiotics. We have to be very diligent in making sure we’re evaluating them appropriately and starting them on appropriate therapy.

Dr. Kalis: You brought up some good points about what regimen they’re on and mentioning the nadirs, the cell counts being at their lowest point. For listeners, say they’re calling over a report to the emergency department. “I’ve got Mrs. Smith, she’s on such-and-such regimen.” Would it be helpful then for the emergency department to know when the last treatment was in order to assess some of that nadir information and then the risk of febrile neutropenia?

Dr. Oropeza: It definitely would be. From my perspective—it’s hard for me to speak for all of emergency medicine, particularly because I’m just one small little facet of it—but throughout my relatively short career, I have noticed one thing that is challenging, particularly with this population, and that is the documentation component. A lot of times when these folks come in, we have very little information, and sometimes we don’t even have access to the records. We’re very fortunate here at Memorial Central that our primary cancer clinic in town is attached to our hospital, so we do share medical records with you guys. We’re very fortunate from that aspect.

As you probably know, in the ED, we’re often making treatment decisions on very, very little information. As new information comes in, those treatment decisions can change literally from moment to moment. The more information we can have on the front end, the better, whether it’s from a peer-to-peer conversation or it’s in the medical records. Where is their cancer? What type of treatment are they on? Is it immunologic, is it chemotherapy, et cetera? When was their last dose given? Was it today? Maybe I wouldn’t expect them to be as neutropenic if they’re coming directly from the infusion clinic versus if it’s been seven to 10 days since their chemotherapy, and now they’re coming in. A lot of that information really helps build that acute care type of clinical picture. That is certainly helpful.

Dr. Kalis: The more information you can get, the better, especially if they’ve been treated at a different health system. We’ve got a number of patients here that live several hours away from a hospital, and maybe they’ve received local care at a more critical access or more rural treatment facility. Any information and records you can get are helpful. I think too, some chemotherapies and cancer treatment drugs have a risk of tumor fever or even drug-induced fever as a side effect. I think of gemcitabine as an example. If you spike a fever within 12 hours of getting your dose, it’s most likely from the drug; however, we still need to work it up and make sure that this is in fact the case. I like that you brought up the point about time directly affecting mortality, especially with the risk of infection.

That brings to mind another oncologic emergency, hypercalcemia of malignancy. I remember giving talks on this particular condition. There’s a statistic that if a patient is hypercalcemic and it’s due to their cancer, there’s a 50% chance of mortality within 30 days. It’s relying more on just the underlying malignancy being progressive. I think that just underscores the need for everybody to remain collaborative. Somebody’s in emergency medicine, and somebody else is in oncology, but again, we’re all still on that same team.

You also brought up the great point of the immunologic therapies being on the cutting edge right now. Let’s say a hypothetical patient comes into the emergency department, and they are on a checkpoint inhibitor. How does that affect some of the differential workup? I imagine it would still be helpful to have as much information as you can, but I think about the immune checkpoint inhibitors and even some of the T-cell agents now being a little bit vaguer if a patient just presents at the ED.

Dr. Oropeza: Absolutely, I don’t think you can overstate that. It can be very hard, particularly with the new T-cell therapies. A lot of times, those patients can present with symptoms that mimic septic shock, and the treatment is very different for septic shock than it is for some of the T-cell–related toxicities. In one case, we’re essentially giving mild immunosuppressants, and in the other, we want to try to bolster that immune response as much as we can and give them heavy antibiotics and pressors. It can be very, very difficult. Again, being able to understand where they’re at in their disease process and where they’re at in their treatment really helps guide the differential, in my understanding.

Now, I don’t do too much of the differential diagnosis side of things, but as far as deciding what treatments, what doses, and how to approach their care, I work very closely with those providers to collaborate on making those decisions. Having that information upfront can be helpful because then we’re not just thinking, “Oh, this is a generic sepsis alert that comes in.” We’re thinking, “Okay, this is a sepsis alert in a cancer patient. Is this treatment-related? Is this directly related to their cancer?” It expands that initial clinical approach.

This is probably a poor word, but I hate to “algorithmize” patient care, because I think each patient needs to be looked at exactly as they are. I think that is particularly true with our oncology population. I would say that it does add a degree of complexity when we have folks that come in who are on the immunologic agents, because they can present with multiple “-itises.” That can present as a whole host of different management strategies depending on where the “-itis” is. If it’s in their liver versus their gastrointestinal (GI) tract, we have both a differential diagnosis tactic and a different management tactic. If we knew that they were on an immune checkpoint inhibitor, then that could quickly change how we’re thinking about approaching the management for that patient.

Dr. Kalis: Like you mentioned earlier, you’re shifting the plan within minutes of getting new information. An analogy popped into my head—I remember growing up, and even still when I have spare time now, playing a PC-based strategy game called Age of Empires. For anybody in the audience who’s not familiar, you start off with a small village, but the rest of the map is black, and you have to go explore to see what else is out there. I’m seeing a lot of parallels with the emergency department. A patient comes in, and all you know is what’s right in front of you, unless there’s information that’s come in from an outside source.

I think you really hit the nail on the head. You could be giving somebody pressors and antibiotics, or if you knew that they’d been on one of the programmed cell death protein-1 (PD-1) checkpoint inhibitors, you could be looking at high-dose steroids. If they’re on CAR T-cell therapy, maybe you’re looking at tocilizumab. It’s a very drastic divide in terms of treating what might present as a very similar symptom.

Dr. Oropeza: Absolutely.

Dr. Kalis: I think with those things said, we’ve covered a fair bit of ground in terms of how you started in pharmacy to now working in the emergency department and seeing cancer patients. If there was any one thing you would like to leave with our audience—and again, we’ve got physicians in training, we’ve got full-fledged providers, we’ve got wide variety of people out there—but if there’s any one thing you would like them to know about the emergency department as it relates to cancer care, what might that be?

Dr. Oropeza: That is a tough question. Again, I’m not sure I’m qualified to speak on behalf of all of emergency care here, but we’ve talked a lot about the information aspect of things that is super important. Again, I can’t overstate that. I think if I had to choose anything else, it would maybe be the importance of reaching out for those conversations. If you’re going to be sending somebody into the ED, you can reach out and have those peer-to-peer conversations on the front end as opposed to having an ambiguous patient show up and say, “Oh, I was told to come here.” Taking those extra steps can be some important. A lot of times, emergency medicine is very broad. I hate to use the word “general,” but oncology is very specific. If a patient comes in and they’re on some new study drug, chances are that even I, as the medication expert, haven’t heard of that drug yet. Particularly if they’re on an experimental treatment, taking that little bit of the extra time to provide some very brief, basic education during that handoff could potentially change the course of care for that patient and the course of their outcome. I think that would be the one thing I would like to experience more often.

Dr. Kalis: Well, Dr. Oropeza, sir, thank you for your time and for joining us on the interview here for the Board. I look forward to many happy years of working together in the future.

Dr. Oropeza: Absolutely. Thank you, and I do as well. I appreciate it.

About Dr. Oropeza and Dr. Kalis

Joseph Oropeza, PharmD, BCCCP, is an Emergency Medicine and Critical Care Pharmacy Clinical Specialist at the University of Colorado Health. With a strong commitment to evidence-based care, he collaborates directly with providers and nurses to ensure the best possible outcomes for patients. Dr. Oropeza’s focus revolves around applying pharmaceutical expertise in emergency situations to deliver optimal care. He enjoys fostering two-way learning by not only contributing expertise but also engaging in continuous learning from colleagues and experiences. He takes pride in teaching and mentoring future learners and emphasizing critical thinking, problem-solving skills, and the importance of shared decision making in clinical scenarios.

Joseph Kalis, PharmD, BCOP, is an Ambulatory Oncology Clinical Pharmacy Specialist at the University of Colorado Health. In this position, he educates patients about their chemotherapy and immunotherapy treatments, reviews treatment plans and dose adjustments, and assists with supportive care. Dr. Kalis’ professional interests include multiple myeloma and hematologic malignancies. He enjoys teaching learners from all walks of life. Dr. Kalis has spoken extensively for continuing education programs, along with various peer-reviewed papers on oncology and pharmacy.

Transcript edited for clarity. Any views expressed above are the speakers’ own and do not necessarily reflect those of Oncology Data Advisor. 

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