Harbor-UCLA Pediatrics

Harbor-UCLA Pediatrics Interviews Nathan Kuppermann, MD, MPH
This is the third interview in our series on alumni of the Harbor-UCLA Pediatric Residency Program.

Nate Kuppermann, MD, MPH is a Professor in the Departments of Emergency Medicine and Pediatrics, and the Bo Tomas Brofeldt Endowed Chair of the Department of Emergency Medicine at UC Davis School of Medicine. He was a resident at Harbor-UCLA in Pediatrics and was Chief Resident, before completing his fellowship in Pediatric Emergency Medicine at the Children’s Hospital Boston (affiliated with the Harvard Medical School). He is both a pediatric emergency physician and clinical epidemiologist. Dr. Kuppermann has been a federally-funded investigator for many years, and has particular interests in the clinical efficiency and utility of laboratory testing in the setting of the Pediatric Emergency Department. Specific foci of his research include the laboratory evaluation of young febrile children, evaluation of children at risk of diabetic ketoacidosis-related cerebral edema and the laboratory and radiographic evaluation of the pediatric trauma patient.

Dr. Kuppermann served as Chair of the Steering Committee of the Pediatric Emergency Care Applied Research Network (PECARN) since its inception in 2001 until late in 2008. This network is funded by HRSA/MCHB and EMSC and consists of 22 geographically and demographically diverse hospital pediatric emergency departments which evaluate ~ 900,000 children annually. Most recently, he completed a 25-center study of 45,000 head injured children in PECARN to create and validate a decision rule for emergent neuroimaging of these children.

How did you get interested in pediatric emergency medicine (PEM)?
I was always interested in caring for acutely ill and injured children, and was greatly influenced by both Stan Inkelis and Jim Seidel. How I truly ended up in PEM, however, was the result of some serious serendipity. In the middle of my pediatric residency at Harbor (after my second year there), I spent most of a year working in Southeast Asia, with my most important work in a refugee clinic serving the Tibetan population in Katmandu, Nepal. I had completed my second year of residency at Harbor at the time, and had already applied for and been accepted in a pediatric critical care fellowship at Children’s Hospital of Boston. Before I finished my residency, however, I really wanted to “get out there and save the world” and didn’t want to wait any longer (i.e. until residency was finished). Somehow I was worried that if I waited any longer, I would lose the opportunity (i.e. the impatience of youth). I remember my spirits being lifted and feeling more determined to go by the encouraging words of Dr. Emmanouilides, who as a child lived through harrowing times during the Bulgarian occupation of Greece in World War II and later in the Greek civil war.

While I was working at the clinic in Nepal, I was very stimulated and very much enjoyed caring for a needy and sick population of children, as the only Western pediatrician in the Katmandu valley (treated every form of TB know to humans!). Part of what I enjoyed was working with very limited technology, using my hands and clinical skills learned at Harbor, as the clinic was stocked only with the basic supplies left by trekkers or donated by religious or other groups. As fortune had it, one day while at the clinic I received a telegram (OK folks, the 1980’s version of a tweet) from the PICU director at Children’s of Boston, saying that the PICU group there was moving en masse to Seattle Children’s. The PICU director recommended that I no longer do the PICU fellowship in Boston, but rather wait until the PICU fellowship in Seattle “matured”, and that they would take me as a fellow there. This gave me the opportunity to reconsider my options. At that point, I loved what I was doing in Nepal, and was already considering the field of PEM, particularly for its flexibility, and its utility in the setting of international medicine and disaster relief environments. So after I returned to Harbor, I finished my third and Chief years of residency (while Carol Berkowitz was Chair), and accepted a position as a PEM fellow at ... Children’s of Boston. I have not regretted it. Sure is strange how life works ....

What led you to choose epidemiological research?
I have always been moved to broaden my impact on the care of acutely ill and injured children - first as a resident clinician honing my clinical skills, then as a Chief resident working on my teaching skills. To improve the evidence base on which we care for acutely ill and injured children, and have a broader and more influential impact on my field, however, I realized that I needed to learn how to perform large-scale epidemiological research, clinical trials, etc. This has been my career focus of the past 15 years. It is all about how one feels one can most impact the care of children.

Why did you select Harbor for your training?
I selected Harbor as my training location over many different children’s hospitals for a few main reasons: 1) the quality of the faculty, 2) the underserved nature of the patient population, and 3) the soulfulness of the institution and department of pediatrics. Need I say more?

Did your experience at Harbor prepare you for your career, and if so, how?
My training at Harbor formed the basis of what I am now as an academic physician. I learned to think critically at Harbor (no mushy thinking allowed there!), and I was guided by great mentors (in no particular order - Alan Jobe, Bud Anthony, Stan Inkelis, Jim Seidel, Carol Berkowitz, George Emmanouilides, Larry Shapiro, Sudhi Anand, Usha Raj, Dan Cooper, Jim Padbury – holy smokes, what a group of superstars). Finally, I was encouraged to push my knowledge and academic skills to their limit and to not shy away from big projects and leadership positions.

Any especially memorable stories from your time at Harbor?
So many memories and stories – wow. I do have a few particularly powerful clinical and personal moments
Clinical memories:
1) “Running” the ED and PICU as a junior resident without fellows or attendings around. Now that was an experience of trial by fire!
2) I trained at Harbor during the middle of a horrific outbreak of meningococcal disease (which turned out to be one of the main foci of my research for the first decade of my career. I cared for many children with purpura fulminans, and saw many die or lose limbs. I remember being the “senior” in the PICU as a second-year resident when a critically-ill child with purpura fulminans arrived. No fellows or attendings in house those days! I remember being scared like the dickens and called in one of my neonatology fellow friends to help me place a central line and radial arterial catheter (that was the spirit of collaboration and friendship at Harbor). The child survived, with minimal digit loss on the side of the arterial catheter (in which heparin was dripping to keep the line patent). There began my first investigation regarding death and loss of limb in children with meningococcal disease (keep your eyes open!).
2) Harbor was a place where one could care for children with routine pediatric illnesses, as well as exotic infectious diseases. I remember two cases on the latter particularly vividly:
a). I remember caring for a child who had recently arrived from the Philippines, who presented to the ED septic appearing. I had recently returned from working in Nepal (see above), and had cared for many children with Typhoid. I diagnosed and treated the child in the ED with Typhoid, and was rewarded with all sorts of kudos and good vibes at Friday case conference. However, this particular case was pretty bread-and-butter for me after my clinical experience in Nepal – one of the other benefits of exotic travel!
b). As a chief resident, I remember passing through the ED one day where a school-aged girl was having an apparent seizure, and the resident asked me for help. On closer evaluation, however, she was having tetanic spasms, and on further questioning, she was an unimmunized girl who had punctured her elbow on a tree branch 3 days earlier. I recognized her tetanus, because I had cared for a ward full of children with tetanus in the Northeast of Brazil as a 4th-year medical student. She was intubated, treated with antibiotics and antitoxin, and did well. Once again – only figured it out based on my international health experience!

Personal memories:
I remember Harbor as such a soulful place, where great friendships were made and the esprit du corps was particularly high. In the Department of Pediatrics, there was great camaraderie not only among residents, but between residents and faculty. I forged strong friendships with many people who are still there, including Stan Inkelis, Sudhi Anand, Monica Sifuentes, Carol Berkowitz, and others. In addition, I fondly remember my close friendships with Jim Seidel, Marvin Weil, Alan Jobe and Dan Cooper. I am still in touch with several of the faculty members, and some of my residency mates.

You have managed to collaborate with diverse groups of investigators to conduct large-scale, important, landmark studies. Any advice for the rest of us on how to do that?
Start small, but think big. Life is short, and we all want meaning, from both our personal and professional lives. For me (in my professional life), that means doing research that will improve the clinical practice of medicine. My large collaborations have resulted from a sequence of events starting with small studies with few collaborators. However, early in my career I realized that in order to really change clinical practice, one needed to conduct large-scale studies which were powerful (i.e. narrow confidence intervals around the results) and generalizable. So I kept my eyes open, and sought collaborators from different disciplines, who were dedicated, collaborative, and had some passion burning in their bellies which were aligned with mine. My advice to junior investigators is to seek collaborators outside of your immediate circle. If you are a clinical researcher, seek collaborators who do bench work, and vice versa. The potential synergies are powerful. In addition, seek collaborators who share your passion, who are fun to work with, and who will pull their weight! Also seek mentorship “teams”, including individuals with different skills from outside of your immediate discipline.

What is the hardest part of your work?
Keeping the balance between work life and home life. I have a lovely wife (Nicole) who is my best friend and research collaborator, and three great children, (the last recently adopted from Guatemala). I advise my academic mentees that the “triple threat” has to include your personal/private life first, then you get to pick 2 of the 4 academic pursuits (clinical, teaching, research, administration/policy). That is the realistic triple threat. I try to stick with what I advise.

Any comments on the current health policy debate?
I can only see one solution: the single payer. How is it possible that so many other developed countries could be wrong and only us be right? I don’t think so. To quote the Supreme Court Justice Oliver Wendell Holmes: “Taxation is the price one pays to live in a civilized society.” To me, universal health care is an attribute of a civilized society.

What advice would you give a new pediatric resident starting out at Harbor?
1. Start small, but think big.
2. Focus on the fundamentals of clinical medicine first.
3. Do what burns in your soul.
4. Keep your eyes open for things that stimulate you in your immediate environment.
5. Treat people well – from your colleagues to the cafeteria personnel to the service workers. You never know when that comes around to help you.
6. Don’t let internship get you down – it is the start of something big.
7. Remember the realistic triple threat – it starts with having a good personal and home life.
8. Fight for what is right for your patients.