Friday, January 27, 2012

Learning in Action

A few months ago I was in a CVS in center city when a man came charging through door, shouting “I need an AED!!”

The pharmacy employees looked back and forth at each other but no one made any actions. The man became angrily impatient, crying out “Come on, there’s a guy dying out there!!”

Before I had really processed what was going on I had set down my basket and my feet were carrying me out the door. I knew that administering CPR can become very tiring very quickly, and having just completed my Advanced Cardiac Life Support course I was as qualified as anyone to lend a hand.

Out on the street I immediately saw a group of people crowding over a man collapsed on the sidewalk. As I got closer I could tell CPR was underway but it wasn’t until I was standing directly over them that I felt a jolt of fear. Though in the past I had seen patients who were very sick and patients who were already deceased, somehow I had made it through three years of medical school without witnessing someone actively dying. The purple color of his skin was frightening.

He was receiving quality CPR from an incredibly fortuitous group of bystanders: A nurse at a local center city hospital and a soon-to-be internal medicine intern were trading off on chest compressions, while coincidentally one of my classmates, Mike Hoaglin, was keeping his airway open and performing pulse checks. I was impressed with how perfectly coordinated the nurse and (almost) intern’s handoffs were- the chest compressions were flawlessly continuous so that any positive pressure build-up in his circulation was not lost as they traded turns. Despite all this it was very clear that he was dying.

Just then the man who had burst into the CVS ran over to us. Out of breath, he managed to report that he had looked everywhere, and asked all the local restaurants and pharmacies, and he couldn’t find an AED. The ambulance had of course been called first thing, but we couldn’t yet hear sirens, and the purple tone of his skin was becoming a sickening gray.

Suddenly a picture flashed in my head of the wall in the mail room of my apartment building nearby. I knew where there was an AED! I jumped up and sprinted down the street, flew into my building, grabbed the AED off the wall, shouted something to the confused doormen, and returned to the scene.

As I crouched down again and opened the AED box I said, “I’ve never done this ‘for real’ before”. No one else had either. Luckily, it was exactly like it had been in ACLS training, and there were very, very simple instructions so that even if I hadn’t been to class I could have easily done it on my own.

With the power button pressed the box immediately spoke to us. ‘Analyzing rhythm, continue CPR’. It was reassuring to hear its automated voice providing instructions.

A few moments later, it spoke again:

“Shock advised. Stand clear”.

The shock sent a jolt through his entire body with enough force to raise his head and send it falling back down onto the concrete sidewalk with a thud. I winced but the AED was unperturbed.

“Continue CPR two minutes”.

Chest compressions were resumed, and before the two minutes had elapsed when it would have been time for another shock, if necessary, the ambulance came screeching down the street. As the paramedics loaded the man into the van Mike said he may have felt a faint pulse after the first shock. I wasn’t so sure.

I headed home knowing we had done our best, and wondering if I would ever find out how the man had fared…

The paramedics contacted Mike the day after to thank us for performing excellent bystander CPR, but they didn’t know the condition of the patient, so it was of little satisfaction.

However, a few weeks later, I received a letter in the mail. It was from the man. He had survived, and had asked his emergency room doctor for our contact information from the paramedics. The letter was three pages long and told me about his family, his job, and his hobbies. It talked about what it was like for him to wake up in the emergency room, and how he has memories of being ‘zapped’ and of people yelling at him to stay awake. It talked about his plans for the next few years and how he can’t believe his luck to still be alive. He also included a $100 check, which I didn’t cash, but plan to hold on to forever.

This story had the best possible outcome, and I really believe it was the AED that made the difference. Despite getting the highest quality CPR I think that early shock was crucial. So, I’m ending this blog post with a shameless plug:

This week Penn launches an amazing new phone application and they are kicking it off with a competition. Using your cell phone, you take a picture of each AED you see around the city. The grand prize for the most AEDs photographed is $10,000!!!!!! But even better, all the pictures you take will be used to create an application that will map the location of AEDs all over the city. Then the next time someone needs to find one, they won’t waste time checking pharmacies and restaurants that don’t have them- they can take out their phone and go directly to the nearest place. What a great idea!!

Wednesday, January 4, 2012

The Beginning is Near!

I'm a firm believer the world won't end in 2012, but I guess we'll find out soon enough.

This is not a regular Christmas for me. The end of this year symbolizes a small (but important) transformation in my life. Just yesterday, I started "working" in the hospital for my clinical rotations. Gone (mostly) are the lecture halls and didactics that have been my home for more than a decade. Now, I start my on-the-job training.

I've mentioned this a couple of times before - the clinics are something I've looked forward to for a long time, something I've worked towards for many years. But it also creates a lot of anxiety. I feel woefully inadequate to take care of patients. But people reassure me that the training I've received so far is much more comprehensive than I realize. That I am more prepared than i realize. That small consolation goes a long way.

Then again, I guess this kind of anxiety is a good thing. A little bit of stress does improve performance... but more importantly, it harkens back to an important lesson from my differential diagnosis class - don't assume you know everything about the current situation. This is the cornerstone for a good differential diagnosis: you always keep your mind open to other possibilities, and you force yourself to think of counter examples - what else could it be?

By walking into clinics assuming I know less than I do, I'll force myself to keep my eyes and ears open. It forces me to be on my toes just a bit more. At a personal level, this means I'm hungrier to learn more. But the more important (and bigger) effect it'll have will be for my patients: I'll be taking second, third and even fourth looks over their plans, histories, results... the works! I'm hoping this second guessing will make me a better student now, and (eventually) a better doctor.

So here's to the end of a beginning and the start of a new phase in my education. On the job training isn't something new to me - I worked in the corporate world for 5 years before coming to medical school. But this is a very different animal. Sappy as it sounds: lives are on the line.

There will be many more "ends of beginnings" to come, I have no doubt of that. But I believe recognizing and respecting milestones (like this one, even though it's a small one) is crucial to the learning process.

This is a bit tangential (and if this is your first time reading my blog, you'll realize that I almost always have tangents in each post), but times like this remind me of what it takes to be a good doctor. For some reason, whenever I think of that, I'm taken back to a scene from Scrubs (one of my favorite shows).

This is one of the most powerful scenes from the show and it has stuck with me for many, many years. A great doctor is someone who is very invested in his patients... but knows the importance of staying objective. Walking the line and keeping tragedies from debilitating your work is not the easiest thing to do, but I believe it is an important lesson to learn. Here's hoping I learn it.

Enjoy the New Year!

- Karthik

Tuesday, January 3, 2012

A Very Special Christmas

This year marks a particularly special holiday season for me. Not only have I finished the preclinical years of med school (and apparently the last full-time classroom work of my life!), but this is also my first Christmas as a mother. In addition to my role as a medical student, I am also married to another medical student and a mom to an adorable and chubby 8-month-old boy named Raymond.

As an undergrad, I was accustomed to juggling multiple responsibilities, having been a pre-med student at Duke while also a varsity pole vaulter and a lab researcher on the side. I would be constantly switching gears between the classroom, lab, track, in addition to a myriad of other extracurricular activities I had taken on.

This past year, the juggling act was a bit more hectic, to say the least. I gave birth in late April and powered through the rest of my first-year courses until the end of June. Penn's administration graciously allowed me to Skype in for small group sessions right after I delivered so that I could stay home with my newborn and keep up with school at the same time. In the fall, I came back to class in person again and fell into a nice routine - when I was at school, I tried to study at maximum efficiency so that when I went home, I could put schoolwork aside and be fully present for my family. Even with class and a four-hour roundtrip commute (more on that in a second), we managed to cook and have dinner together pretty much every night, as well as go to our fair share of happy hours at neighborhood establishments (baby-friendly, of course). The commute I mentioned is the 100-mile trek I do Monday through Friday between Baltimore and Philly on the Amtrak because my husband is at Hopkins, and we wanted to stay close to my in-laws in the DC area. Sometimes I love it (protected study time can be wonderful), and sometimes I hate it (is it really going to take over 2 hours to get home?!). But I'm happy that there's a way to make everything work. All in all, starting a family while in medical school has actually been really fun.

Right now, my husband, son and I are spending time with my parents in San Diego. We are enjoying the 70 degree weather and sunny, clear skies. Though we both love med school, it is really nice to have a break from lectures and studying and just hang out and relax. It is also really special for me to have more time with my baby boy. Usually I leave before he wakes up and once I'm home, we only have a few hours together before he goes to bed for the night, so it's really great just to be able to sit and play with him for hours and hours on end. He has grown so much this year, and it seems like's he's just getting cuter with each passing day (but I'm biased of course!).

Another reason I'm really relishing this break is that I know it's about to get truly crazy soon. My clinical rotations start in just a matter of days, and I'm starting on the surgery block. The hours are going to be substantially longer than what I've been used to for the past semester. And Ray will be getting older, becoming more interactive and wanting to play more. I have a feeling this whole juggling act is going to become even more complex. However, I am truly excited for the clinical rotations as well, and even with a husband and baby at home, I trust that somehow it will all work out. I'm looking forward to blogging more about my experiences as the year progresses, but for the time being, I'm going to enjoy my last few days of freedom!