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?

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.

Across the Pond

Since I was a senior in college, I have wanted to spend time in London to conduct research. Sounds a bit odd I'm sure. Perhaps you thought I was going to say I wanted to spend time in London to watch football (that's soccer for you yanks) or to use it as a springboard to explore Europe. While I'll certainly be using my time in London to catch Arsenal matches and take advantage of cheap rail and airfare around Europe, my official reason for being in the UK is to conduct the research necessary to complete my master's thesis for the MTR program, one of the many dual-degree opportunities at Perelman.

From the south bank of the Thames River 

I am currently a visiting research fellow in the Department of Surgery and Cancer at Imperial College London's St. Mary's Hospital, where my work is supervised by Professor Ara Darzi and Dr. Rajesh Aggarwal (though in the UK, surgeons liked to be called "Mister"). My area of research is in surgical education and simulation, and the labs investigating surgical education and technology at Imperial College are some of the most prolific in the world, collectively publishing over a hundred papers every year.

The simulation facilities here are top-notch, though Penn's simulation center is just as impressive. St. Mary's boasts a virtual reality lab with multiple virtual reality laparoscopic and endoscopic trainers that allows trainees to receive highly detailed metrics of their operative performance. Furthermore, the simulation center is equipped with a cadaveric porcine lab to let trainees practice procedures on pig tissue, a fully simulated operating theatre, and a state-of-the-art simulated endovascular suite (the only one in the world). The inner tech geek in me, which I admit is actually the outer tech geek, nearly passed out when I was introduced to all of the equipment.

If med school doesn't pan out,
there's always Hogwarts

In August of 2011, I met Salaj, a medical student from King's College London through Perelman Med's Peer Hosting program. The Peer Hosting program connects visiting medical students from abroad with a current Penn medical student to help them get acquainted with Philadelphia. Salaj and I became quick friends during his time in Philly; and since I arrived in London, Salaj has been a wonderful host, showing me around London and introducing me other students at his medical school. I'm fortunate that Penn gave me not only the opportunity to come to London, but also provided the opportunity to make friends here before ever leaving the States.

I have much to look forward to in my remaining 8 months here: the Queen's Diamond Jubilee, Wimbledon, and the Summer Olympics. With over half a year to go, maybe I'll finally learn to look for cars driving on the left side of the road whenever I cross the street. My top priority, however, is picking up a posh British accent; I figure it is one of the most useful skills I can acquire before going back to the US. That being said, I don't think I'll ever learn to spell like a Brit. Dear Britain, it's spelled "esophagus" not "oesophagus."

I'm certain I'll have plenty more to write about London Town and British quirks that I find amusing. Until then, hope all is well in the colonies.

Olympic rings welcoming visitors to Kings Cross Station

Perhaps when I'm eventually an attending I can
get a suit from one of the famous tailors on Savile Row

Sir Alexander Fleming discovered penicillin at St. Mary's Hospital,
and the 2 million signs around the hospital won't let you forget it.
I guess it's the same as Penn's love of Benjamin Franklin...

Learning to Take in Order to Give

So this is it. I’m officially a real fake doctor now! I have just completed my first clinical rotation. Thus far, I spend 99% of  my time thinking “where am I?” and “am I annoying my resident/intern/attending by being in the way?” and the answers are usually “lost” and “yes.”

I am on neurology and one of our first patients of the morning was a middle-aged woman who had recently been diagnosed with ALS (Amyotrophic lateral sclerosis) a few months prior. ALS is a degenerative neurologic disease that is characterized by progressive loss of motor function. Patients end up losing the ability to move, talk, eat and eventually breathe. This patient had already lost the ability to talk and eat on her own.

My fellow medical student and I went to see her after rounds so that we could get a better idea about what a neurologic exam would look like in someone with ALS. When we got there the patient was in obvious pain and her daughter told us that she wanted morphine. The patient (who communicates now by writing) pointed to her pad where she had written “Ouch. Pain. Help.” Being lowly peons, we don’t yet know how to find a band-aid much less put in an order for narcotics so we quickly left to find the resident (who assured us that the order was being processed by the pharmacy). Given her level of discomfort, there was no way we’d ask her to undergo another exam so I just asked if there was anything else I could do to help. She got out her pad and started writing something.

“How can I help you?” she wrote in painstaking capital letters.

Here was a woman who had just been given a devastating prognosis. She had already lost the ability to speak and her disease will continue to progress, causing her to lose all motor function and die within a few years (median survival is 3 years from onset of weakness). She had been poked and prodded by the medical team, the neurology team and she had just undergone a serious procedure. On top of this she was in serious pain. Yet still she wanted to know how she could help me.

 “I….well…” I didn’t know what to say to this amazing woman. Sometimes medical school stinks. Plain and simple. We don’t have much to contribute at this point in our careers except time and enthusiasm. Our only job is to learn, which makes it feel like an inherently selfish process sometimes. Indeed, I have spent most of this week feeling in the way. Her small act of kindness nearly unbalanced me.

“You are already helping us,” I told her. “We are medical students and this is our first week ever working in the hospital.” She broke into a huge smile.

“We are trying to learn as much as we can from our patients. For example, even though I’ve read about it, you are the first patient I have seen with ALS and I will always remember you because of that. I am going to go home and read as much as I can about it so that some day I can take care of patients myself.” She broke into a huge smile, touched my arm warmly and gave me a thumbs up.

Throughout my first year and a half of medical school I have been blown away by the generosity of those who contribute to medical education:

• My LEAPP patient (a patient who we followed throughout our first 1 ½ years here) whose family let us sit in on her appointments, ask them countless questions and literally invited us to their home.
• Our course director for dermatology who came to speak to my interest group, personally showed me patients during dermatology grand rounds and then spoke about career paths with me for an hour.
• My MS3 “big sister” assigned to me by the Elizabeth Blackwell society who gave me invaluable advice about surviving my pre-clinical years and gave me all the books I needed for my clinical years.
• The MS4 who brought me on board with her project, helped me understand clinical research and is trusting me with presenting our work at a conference this spring.
• Our lecturers and small groups leader-physicians who volunteer their time in order to instruct us on everything from psoriasis to palliative care.
• The resident I worked with in Botswana who taught me how to think clinically about a patient this summer and then this fall coached me through writing a case report that she could easily have written herself.
• The countless patients who spoke movingly and openly to our class about living with cancer, mental illness or rare genetic disorders.
• And now - starting with this patient - all the patients who allow us as medical students to participate in their care.

I know that this is a cheesy story. I know that it’s not possible or advisable to get emotionally wrapped up in every patient you care for. I know that this outpouring of “touchy-feeliness” would earn me an eyeroll from more “seasoned” medical professionals. But I don’t care. And I know that I will remember this incredible woman. I am going to carry her with me throughout my rotations. Because she reminded me that every patient gives me a gift. They give me the gift of sharing their story and helping me learn. I may wear a white coat but for now all I can do is take. Take in the knowledge that is being shared: by the patients and by the physicians, nurses and staff who are helping me learn. One day hopefully I will be able to give something: care for my patients and, if I’m lucky, the ability to teach someone else. But first I need to figure out where the heck I am.

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!!

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

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!