Thursday, June 5, 2014

Inspiration and the Medical Student

My last post started with the idea of finding Inspiration, of the sort that drives one to create, to achieve, to question, to learn. The natural next question is what I plan to do with that Inspiration.
We’re told as children to dream big, that the world is ours for the taking. It’s no less true now—I’d be hard-pressed to find a better and richer environment in which to learn—but things have changed. As a high school or college student, I had the bandwidth to pursue those dreams. Sure, I still wanted to do more than I was able, but my internal checks and oft-waning interest for my latest obsession set up a sustainable way to balance my time against my passions. But as a medical student, it’s simply no longer possible to operate the same way. I realized this a few weeks ago as I found myself having ten conversations a day with my classmates commiserating about how 24 hours in a day is just too little, but it’s only starting to strike me now. 
I’ve certainly tried to do it all by going the extra mile to free up my time. But somehow, days blend into weeks, weeks to months, and I’m still sitting on that to-do list that’s gotten only marginally shorter. I want to be clear: I’m not saying that medical students don’t have the ability to pursue anything outside of their classes. Looking at the amazing things medical students are doing every day across the country would disabuse anyone of that notion. What I’m saying is that for very disparate career interests, even within the field of medicine, it’s exceedingly difficult to build solid skill sets as a student. For example, I have a strong interest in the innovation happening in the healthtech start-up world, I love writing and medical journalism, I’d like to pursue pharmaceuticals and drug engineering, and I want to do some academic research as well. These aren’t just passing interests; I would commit to doing all of these things as a career to better inform the way I care for patients and approach medicine.
To those reading, it would seem that I’m complaining about growing up. After all, it’s universally true that with adulthood come responsibilities and a narrowing of horizons. First with a college degree, then a focused graduate degree, and then often a more focused job.  I’m not presumptuous enough to think these issues are limited to medical students, or even students. But it’s a little different for us as medical students: we spend those formative 20s (and sometimes 30s), when much of our generation is exploring and trying and doing, in school and in training. Our capacity to extend and challenge ourselves becomes greatly diminished simply because our road consumes so many hours of our days and years of our lives. None of this is new, I realize. And none of this was new to me when I applied straight from college. I’m proud of my decision and excited for the future, but I need to have those difficult conversations with myself now. What do I want to do? Where do I want to make an impact? And as negative as it sounds, what doors am I willing to shut? Since I can’t both invent a device and revamp Medicare (I’m sure someone has, but c’mon, I have to play the odds), what next?  So I’m not complaining about growing up. Instead I’m realizing I can’t so easily take on the world anymore.
So to answer my first question: my Inspiration is being put to use leaving ajar as many doors and creating as many windows as I can. It’s far too easy to get bogged down by grades, and classes, and The Next Step. It’s even easier to shrug off goals because school is just too busy. To all my friends and peers with whom I’ve sympathized about running out of time, I get it. I don’t have the time either. But we have to make the time. We can’t sell ourselves short—the world is ours for the taking, remember?

To read more of my musings, follow my personal blog.

Wednesday, April 9, 2014

5 Reasons I'm Glad I'm a (Penn) Medical Student

1. I can find Inspiration on short notice

In the past few months, I've become increasingly focused on classes and getting through the day with the same routine. Exercise (sometimes), food, sleep, a semblance of a social life, studying, rinse, repeat. I was never someone who operated with such mental blinders on. In college I was the girl who had her mind in about a hundred places at once. I was the girl who wanted to blog, start some company, make new friends, find mentors, take more classes, invent a drug, and change the world all at the same time; I would lie awake at night thinking of everything I wanted to do and how I could make my mark on the people around me.

Since coming to medical school, it's admittedly been hard to find motivation within me, and that girl took a break. But a couple days ago, I realized I needed some big-time Inspiration. I looked up the events the school was having, and one of the events that evening was Penn Pearls, Penn Med's annual teaching awards ceremony. I went and listened to residents, fellows, and attendings impart their wisdom on the next crop of graduating medical students and my mind woke up from its hibernation. I could hardly wait to get home to start emailing, writing, thinking, and doing. It only took 30 minutes of being around the wonderful mentors at Penn Medicine to find the drive in me to start creating again. If I weren't here, that couldn't have happened.

2. People tell you to laugh (actual medical school-sanctioned advice)

This was by far my favorite Pearl from the ceremony I mentioned. Turns out, courtesy of Dr. Andrew Baum, laughter is a great medicine.

Things laughter can do for you (if a doctor tells you it must be true right?--there are actual studies, though)
  • Reduces stress (and may play a role in boosting your immunity)
  • Helps you with pain management because it releases endorphins
  • Plays a role in lowering your blood sugar
  • Improves your blood pressure
  • Acts as a burst of exercise for your body each time you laugh (and cleans up your respiration too!)
I might be speaking for Dr. Baum here, but I think his advice goes beyond the physical act of laughing or finding things funny. To me, reminding myself to laugh means reminding myself to be happy and to find joy in what I do. And in life, a school that reminds you to laugh is a good place to be.

3. Emailing anyone and getting a response

Definitely not to be taken for granted in a powerhouse like Penn. It gives me a warm, fuzzy feeling when I email the director of some big center here at Penn with a life question and they get back to me. It shows me that I'm valued as an individual and as an intellectual. On a larger level, it speaks to the philosophy of Penn Med. Lecturers have constantly told us that they love learning from medical students, and every lecturer we've had has welcomed shadowing. The flat structure of the medical school and the enthusiasm with which faculty here approach their jobs is rare and a great honor.

4. Penn really cares about its students

Nowhere else have I seen weekly meetings between students and curriculum directors. And it's not just empty promises. If the student body has a complaint, it gets implemented the next week. We all have to fill our course evaluations on every. single. professor. to get our grades. Annoying, at times, but that means the course directors get some hundreds of pages of student feedback every year. Right now I'm sitting on a focus group to revamp one of our classes. Our team (composed entirely of students) is responsible for sifting through those evaluations, polling our students, and presenting a huge report on our recommendations for the course next year. The best part? The faculty members implore us to participate in these groups because it really matters to them. Medical education has historically been based on the tradition of generations before. Our curriculum is so dynamic it changes every week based on our needs.

5. Respecting the human body

Something I've learned in medical school is that the human body is an awe-inspiring machine. The things it is capable of minute to minute astound me. I remember one day, while sitting in biochemistry, I was struck with the thought -- gosh, I'm so lucky more things aren't wrong with me. That feeling's only been compounded. We're now in neurology, and I'm seriously considering the social acceptability of walking around all the time wearing a helmet. In the midst of stress, studying, and lectures, it's hard to take care of myself. It's hard to eat well and sleep enough or pass on that last slice of free pizza. But one of the great privileges and powers of medicine and the holistic teaching at Penn Med is knowledge. And before I start caring for other people with that knowledge, I have to start with myself.

About me: I'm Sneha Kannan, a current MS1. I hail from Potomac, MD and graduated from MIT in 2013 with a degree in Bioengineering. The next question I'm often asked is, "so what do you want to go into?" (which, by the way, is just the grown-up-medical version of "what do you want to be when you grow up"). To be honest, I don't know. Every day I discover some new interest of mine and I'm loath to try and pare that down so soon. I know I can't do it all but a girl can dream, can't she? The really important things, though: I'm inspired by people around me, probably addicted to chocolate, love tennis, and spend quite a bit of my time reading, traveling, singing, and crossword puzzling.

Wednesday, April 17, 2013

10 Reasons to Come to Penn

Now that it's almost Penn Preview, here are 10 some-typical-and-some-slightly-more-atypical reasons why Penn is the best med school on the planet and Philly is a great place to live, in no particular order except #1 (at the end):

10. The city—it's pretty! This one is not because I'm running out of reasons already. This is what I see on my way home from school every day:
A little bit of extra happiness every day adds up to a lot over four (or eight) years!

9. The second anatomy exam. Which is the only way to take an anatomy exam, as far as I'm concerned. It's taken in learning teams, and each learning team dresses up to a theme.

We had a Pac-Man team,
Photo by Dr. Rubinstein

a Sesamoid (Sesame) Street team,
Photo by Dr. Rubinstein

and an Avengers team,
Photo by Dr. Rubinstein
among others.

Our team dressed up as Dr. Fisher! He's one of the anatomy professors, and he wears black scrubs and black gloves every day. He even took a picture with us :)
Photo by Dr. Rubinstein
(The rest of the pictures, taken by Dr. Rubinstein, the Mod I director, are here.)

8. Learning teams. I'll be really honest here: I don't think anyone starts out loving their learning team. Well, actually, maybe some people do, but I think for most people (myself included), there's an adjustment. When you randomly put seven people in a group, there will probably be some people who wouldn't normally interact much with each other. But, I also don't think there's anyone who doesn't end up loving their learning team, and that's the important part. 
Photo courtesy of Winnie Lin

7. Everyone in Suite 100 is super nice and wants to help you. Suite 100 also has everything from mailboxes to tissues to candy.

6. Every student gets an iPad. Because we can download lecture slides onto our iPads and take notes from there, (nearly) everything is electronic. I mean, seriously, you decide:

5. All the med buildings are connected, and mostly above ground—that means avoiding the elements when it’s raining/snowing/too hot/too cold, without giving up the benefit of sunlight. Here’s one indoor trip I took with Rebekah, who is on my learning team, with a detour to show off how pretty the buildings are (apologies if anyone gets dizzy/sick):

No sound, because played at 5x recording speed, we sound like chipmunks. Literally.

Here’s a rough map of where we went. Green rectangles are elevators.

4. SPOOF! Spoof happens every spring, and it is basically what it sounds like. It’s always hilarious, and also always includes a “first-year skit,” which is written, directed, and performed by first years. This year, the first-year skit was “Perelman Avengers.” This is Casey, one of our classmates, demonstrating Perelman Avenger Dr. White’s power stance (Dr. White teaches anatomy and writes the USMLE review book for anatomy, and is awesome!):

3. VC2000. I know I’ve written about this before, but it is really convenient if you ever need to miss class for anything, or just to review lectures afterward—for example, I’ve used VC to catch up when I missed class because I was shadowing at HUP, and Rebekah used VC to stay up-to-date with the lectures last time she was at a conference. Many people also VC because they just prefer to watch lectures at home. It has lots of useful features:

2. Three free classes in whatever you want. Mine this semester is ESE603, Simulation Modeling and Analysis, and I'm enjoying it, but there is definitely the option to take classes that probably sound more fun to everyone else. For example, my roommate took a Wharton class last semester, and one of my learning team-mates is taking a bioethics class. All of Penn is also on one continuous campus, which means getting to class isn’t a problem!

1. The students. This time last year, I was mostly choosing between two places. When I came to Preview, I had so much fun that I ended up missing my train back to school and booking a last-minute bus ticket on a friend's phone instead. I decided that was a pretty good indication that I should come here, and it's been one of the best decisions I've ever made. I guess what I learned is that some things, like the atmosphere at a school, are hard to quantify. But, it's those un-quantifiable things that make a decision which might seem whimsical at first the right one in the end.

Thursday, March 14, 2013

[Penn]WikiHow: How to Dissect an Eye

WE DISSECT EYES IN BRAIN AND BEHAVIOR!!! We also dissect brains, but I’m not sure if there are rules against taking pictures of them, whereas I’m pretty sure HIPAA doesn’t apply to cows’ eyes, so it seemed safer to skip the brains and go with the eyes for posting pictures on the Internet. I also didn’t want to get any of my camera-containing devices dripping in formaldehyde, since the brains are preserved.

Here’s how to dissect a cow’s eye in five easy steps, learning team-style:

Warning: This post is full of potentially graphic pictures.
Disclaimer/anti-warning: However, they were taken with my silly-phone (i.e., not smartphone), since I forgot to charge my iPad that day, so they might actually just be too blurry to see.
Plug for Penn, since it’s getting to be recruitment time: Every student gets an iPad! We take notes on them, instead of lugging huge stacks of paper around.
  1. Three eyes per learning team magically appear in the first-floor Stemmler lab rooms.
    Eyes in a bowl
  2. Find the optic nerve and the extra-ocular muscles (muscles around the eye that control eye movement), and cut off the muscles.
    Cleaning an eye
  3. Cut away the front part of the eye. Now you can see the lens (that round blob in the middle), and the vitreous humor behind it. The retina, which contains the photoreceptors that allow us to see, is in the wall around the vitreous humor.
    Inside of eye
  4. Play with the vitreous humor. It’s surprisingly jello-like—on a scale of 1 to 10 where 1 is water and 10 is jello, I’d probably give it a 6.5. If you look through the vitreous at the lens from the other side, you can see a shape exactly like the Mercedes-Benz logo on the back of the lens. Nature’s form of product placement?
  5. Look at the rest of the eye, without the vitreous humor. It’s blue in cows, which helps collect light that isn’t absorbed by the photoreceptors the first time around. That’s why they can see better in the dark than we can. However, it also means that their vision is kind of blurry. (Wikipedia has a better picture)

Ta-da! Basically, Brain and Behavior is super cool.

Wednesday, February 13, 2013

A VC Day

PennInTouch with a
slightly depressingly-
far-away graduation
Hi everyone! My name is Jessica, and I’m a first year MD-PhD student. I’m from Centreville, Virginia, which is about 20 minutes outside D.C. I did my undergrad at MIT, where I majored in bioengineering and minored in music, and just graduated in June 2012. I’m interested in a bunch of things, both on the research (tissue engineering, microfluidics, computational biology…) and medical (peds, cardiology, neurology…) sides, so I’m not quite (read: not at all) sure what I “want to do” yet, but my expected graduation date is apparently Spring 2020—see screen capture from PennInTouch—so I guess I still have plenty of time to figure it out. This is also my first blog post, so I’m kind of nervous, but here goes:

You may have heard that Penn has something called VC2000, which is like Reunion Hall CSPAN (Reunion Hall is where we have lecture). All of our lectures are recorded and put on VC, so that those who can't attend a lecture in person can watch them from home later. It’s pretty popular!

Anyway, I took advantage of VC recently too, but not to sleep in (although some do); instead, I shadowed at HUP’s electrophysiology lab! It was amazing. The backstory is that we have a project for our Mod 6 Doctoring class called ITAP (Interprofessional Team Assessment Project), where we’re supposed to observe a medical team in action and analyze how they work together. So Thursday morning, Russell (who is on my learning team) and I went up to the 9th floor of Founders in HUP to watch the electrophysiology team do their daily morning meeting. We watched how the team members interacted as they discussed the patients they’d be seeing that day, determined what procedures they’d be doing, and made some decisions as to how certain patients should be cared for. After we’d fulfilled the bulk of our ITAP responsibilities, we stuck around to talk to/do some short interviews with some of the team members (also for ITAP), and of course, to watch the procedures.

First, I went to see an ICD replacement, while Russell headed off to watch an atrial flutter ablation. ICDs (Implantable Cardioversion Defibrillators) are about half-cell-phone-sized, battery-powered generators that use electricity to effectively shock the heart back into normal rhythm when the patient has dangerous irregular heartbeats. Here’s a Youtube video of one in action: 

And here's the corresponding article in Sports Illustrated:

ICDs have a limited lifespan, though, so they need to be replaced every so often. The procedure for replacement was very different from what I expected—only a local anesthetic is used, the incision to take out the old ICD and put in the new one is just a few inches long, and the entire process took about half an hour. Only the generator—not the wires that connect it to the heart—get replaced, and a lot of double- and triple- and quadruple-checking goes on to make sure the wires are reconnected correctly. I didn’t understand much, and it didn’t seem like a good time to interrupt with a million questions, but it looked and sounded like each wire is color-coded, labeled with what part of the heart it’s coming from, and labeled with a serial number to make sure that it connects to the right place in the generator. The patient was actually awake until the very end, when the electrophysiologists induced an irregular rhythm in order to test the new device.

Since the ICD replacement went so smoothly and quickly, I went to find Russell, who was watching an atrial flutter ablation, after it was done. The setup for the atrial flutter ablation reminded me of an airport control tower. Since the ablation done by inserting a catheter into the femoral vein and guiding it up into the heart, X-rays are used for imaging throughout the process. In order to minimize X-ray exposure for the doctors who are doing these procedures every day, one of them is in the room with the patient doing the ablation while another one is in a “control room,” watching and guiding. Everyone inside the procedure room is wearing lead jackets to protect themselves from the X-rays, and the control and procedure rooms communicate via headset.

On every monitor in the control room, a large number of indecipherable squiggles were running across the screen. Luckily for us though, it turns out the ablation procedure includes a 30-minute wait, so during the waiting period the attending paused to explain these squiggles, and what on earth an atrial flutter ablation is anyway.

Image adapted from the National Heart, Lung
and Blood Institute. Original image here:
Heart muscles contract when they are stimulated by electricity, which is made in some special heart cells and is sent throughout the muscles. Normally, the electrical current passes through the atria in the upper part of the heart once, causing them to contract and pump blood into the ventricles, which then pump blood into the body. However, in atrial flutter, the electricity keeps on going around and around the atrium instead of disappearing. As a result, even though the atria contract more often, each contraction is less efficient, and this can cause all sorts of problems, including blood clots. To fix the problem, electrophysiologists can make a series of tiny burns in the wall of the atrium; this is called ablation. Then in the future, if the current tries to go around the atrium instead of stopping like it should, the electricity will get stuck where the burns were placed, and the atria will continue to contract normally.

When the half-hour wait was over, it was time to see whether the ablation had worked. To do this, the doctors stimulated the heart muscle with electricity in one location, and then measured how long it took to get to two other places in the atria. Based on which of these two places “felt” the electricity first, they could tell whether current was still passing through the area they had intended to ablate. To give an idea of the level of precision involved, they were looking at differences on the order of tens of milliseconds—for comparison, test your reaction time here: (average appears to be ~215ms. Guess I'm way below average!). Fortunately, the equipment being used could detect time differences that are much shorter than human reaction times, and they saw the stimulation pattern they expected, which meant that the procedure had worked.

After watching the ablation, we decided it was time to end our brief foray into real life after med school, and headed back to the biomed library to catch up on some rheumatology lectures. Shadowing was great, though; and we learned so much! I loved shadowing in the EP lab, but for those who aren’t as interested in cardiology, Penn also has many other shadowing opportunities, both at HUP and at CHOP—in fact, shadowing in the emergency departments at both hospitals is an established "thing" and is fairly common among our classmates. Some people also just set up shadowing times outside of the emergency departments, with small group preceptors, for example. Whatever your interests, shadowing opportunities are fairly easy to come by here, and definitely worth missing lecture for once in a while!

Wednesday, October 10, 2012

Perelman Students at the American College of Surgeons Clinical Congress in Chicago!

One of my favorite activities in medical school is attending academic meetings.  Conferences are a perfect opportunity to present your research and network with people from all over the world.  Perelman students are fortunate to receive departmental funding support for registration, travel, lodging, and food when our papers and abstracts are accepted for presentation at a conference.

Last week, I attended the 98th annual Clinical Congress of the American College of Surgeons (ACS) in Chicago. I presented my abstract entitled Construct Validity of Instrument Vibrations as a Measure of Robotic Surgical Skill in the Surgical Forum session on surgical education.  The abstract is a result of the work I've done in the The Haptics Group under the mentorship of Dr. Katherine J. Kuchenbecker.  My research would not be possible without the collaboration between Dr. Kuchenbecker's lab and many surgeons in the University of Pennsylvania Health System.  Since the Penn Engineering and Perelman campuses are less than three blocks apart, we are able to develop strong research partnerships more easily than most other medical schools.  This research was also made possible by the funding and support of Perelman's unique MD/MTR program, which I am currently completing.

A couple other students gave phenomenal presentations in the Surgical Forum. Rachel Yang, who is also President of the Agnew Surgical Society, presented her abstract entitled Characteristics of Ductal Carcinoma In Situ Found in BRCA1 and BRCA2 Mutation Carriers.  Third-year student Rashikh Choudhury presented Roux-En-Y Gastric Bypass Surgery Compared to Diet and Exercise Therapy for Morbidly Obese Patients Awaiting Renal Transplant: A Decision Analysis, an innovative work on the use of a hidden Markov model to predict patient outcomes.

At the Penn Surgery reception.  From left: Dr. Rachel Kelz, me, Daniel Hashimoto MS4,
Morgan Sellers MS4, Dr. Jon Morris, Dr. Noel Williams, Dr. Kristoffel Dumon, and Rachel Yang MS4
Every year at the ACS Clinical Congress, Penn's Department of Surgery hosts a reception for current and former Penn faculty, residents, and students.  This year was my third time attending the event, and it is always a fun opportunity to interact with faculty outside of the hospital.

Dr. James "Butch" Rosser, inventor of the Top Gun
competition, with this year's three finalists. 
I also had the opportunity to partake in the annual Top Gun Skills Competition, and I placed 2nd among 70 attendings, fellows, residents, and medical students.  This is the second consecutive year that a Perelman student has placed in the top 3, after my good friend Daniel Hashimoto became the first medical student to win the Top Gun competition last year.  This was also the first time in the history of Top Gun that competitors were required to perform both laparoscopic and robotic surgical tasks, which put me at a unique advantage since I have been mentored by Daniel and many of Penn's laparoscopic and robotic surgeons including Dr. Noel Williams, Dr. Kristoffel Dumon, Dr. Kenric Murayama, Dr. David I. Lee, Dr. Rajesh Aggarwal, Dr. Bert O'Malley, Jr., and Dr. Gregory Weinstein.  I was hoping to take home first place so that we can start a Perelman student dynasty in Top Gun, but I'll have to wait until April for one last chance to make it happen.

Science and competitions aside, I had a lot of fun and got to explore Chicago.  The city has beautiful architecture and an amazing jazz club scene.  I also made sure to get some authentic deep dish pizza.  I had an great time and would definitely visit again.

I'm a fan of Chicago's skyline
A big, shiny bean.
Students at dinner with Dr. and Mrs. Murayama and Dr. Dumon
Should aspiring surgeons be practicing Jenga?

Wednesday, April 4, 2012

The Drama of Trauma

I just finished my general surgery rotation with the trauma service at HUP, as well as the entire surgery block. I am astounded that we are done with a quarter of the core clinical year! Time flies when you’re having fun… and when you are really, really busy.

Trauma is consistently ranked as one of the best rotations by medical students at Penn. Besides the daily morning report that is chock-full of teaching points and the ability to play an integral part in the trauma resuscitation team, the sheer excitement of trauma is arguably unparalleled by anything else in the hospital.

All of the medical students are assigned to be the “primary surveyor” in the trauma team (see the picture above for the medical students on trauma for last month – I’m the nerdy looking one on the right). That means that when a trauma patient is rolled into the bay, the medical student is the one responsible for doing the exam and yelling out the results over all of the commotion so that the nurse can enter all of the findings into the record. The exam is shortened as ABCDE – A for airway (is the trachea midline? Is the patient moving air?), B for breathing (can you hear breath sounds on both sides?), C for circulation (check pulses, color, warmth), D for disability (what’s the patient’s neurological function?), and E for exposure, which entails exposing all parts of the patient’s body to look for injuries, deformities, abrasions, stab wounds, gunshot wounds, and whatever else might be present. Each patient receives a full exam, a bedside ultrasound exam to check for fluid in the abdominal cavity, a chest x-ray, IV access, monitoring, and then whatever other imaging or interventions is deemed necessary by the trauma team.

As the primary surveyor, what you find is essential to the decision-making in an acute way. For instance, if you don’t hear breath sounds on one side of the patient’s body, that person is getting an immediate needle decompression (ideally within seconds), followed by chest tube decompression. It is exciting as a medical student to be such an important part of the team and have an impact on emergent decisions.

Then there are the stories – the dramatic saves and the heart-wrenching losses – the types of narratives you would expect to see in movies or on Grey’s Anatomy. I will never forget a young Asian man who came in after being thrown from his car in a motor vehicle collision. He was unresponsive with a decreasing blood pressure, so we took him to the operating room immediately. The electrical activity in his heart went away while we were in the OR, and I found myself doing the most vigorous chest compressions I could at 4:30 AM after being up for almost 24 hours. His heart came back, and we proceeded with opening up his abdominal cavity to control his bleeding, but ultimately he passed away due to massive blood loss. He was the first person who I had seen die, and he looked exactly like my younger brother. As distraught as I was, I knew we had tried our best.

Only a few hours later, when I came back for my next shift, I was able to witness our senior surgical resident and a cardiac surgery fellow operate on a young man who’d been shot in the chest. The bullet had wounded his heart, two lobes of the lung, and the chest wall – generally considered a surefire way to die. Yet the surgeons had the swiftness and the skill to repair his injuries and miraculously save him. In one single day, I experienced death of a patient as well as the rescue of a patient back from the brink of death. These were just few of the memorable patients I encountered while on my trauma rotation.

Despite the long hours, the nonstop studying for shelf exams, and my own personal responsibilities at home caring for my 11-month-old son, experiences like these make me grateful for having the privilege of a medical education and the opportunity to work with an amazing team of care providers who are saving lives like this every day.