Dr. M. Margaret “Peggy” Knudson

I asked Dr. Knudson to introduce herself, and I quickly found out she is quite the storyteller! She brought me through her college years, where she conducted wet-lab experiments in a cardiology lab and aspired to pursue a PhD to become a research scientist. But a late-night lab session made her rethink this career trajectory…

Halfway through my last year in college, I'm in the laboratory and the experiment is finally working. It's late at night, and I'm in the engineering school where I put the little cardiac muscle on the machine, and I put the antibody on it, and it stopped working. And there was nobody around to talk to about this.

I thought, ‘Is this really what I want do with my life? To be in a lab [for] three years to get the experiment to work, and there's nobody around to appreciate it?’

So I talked to my professor and I said, “I think I should go to medical school.”

After scrambling to take the last MCAT and a swerve from PhD to MD, then-college-aged Peggy was accepted with a scholarship to the University of Michigan Medical School.

After graduating medical school, Dr. Knudson stayed at U Mich for her general surgery residency, then completed a pediatric surgery residency fellowship at Stanford. She knew from her rotations that she was most interested in trauma care.

I knew that the real leaders in trauma were at UCSF. They were the people writing the only textbooks that were in trauma…I used to come up on Wednesdays to rounds at San Francisco General and learn from guys [like] William Blaisdell and Don Trunkey and Frank Lewis. They were the gods of trauma in our area. I used to sneak up there on Wednesdays and listen to the presentations and chart reviews…

Eventually, they invited me to join the faculty. I consider myself really lucky to have gotten into San Francisco General, and I was there for 33 years.

Dr. Knudson was a prolific researcher. One patient’s tragic outcome motivated her to research pulmonary embolism in trauma patients.

I did a lot of work on clotting disorders. One of my first patients at Stanford was a gentleman who was a school teacher at the local college. He got in a big crash, and his diaphragm was ruptured, and his liver was in his chest. He was really, really sick for a long time, and we took care of him. We were so proud of ourselves. We were able to fix him up and he had a terrible lung injury and he slowly got better.

The first day he got out of bed, he had a massive pulmonary embolism and died right in front of us.

I was devastated…I went to the literature to see what we are supposed to give to trauma patients to prevent [the pulmonary embolism] and there was really nothing [in the literature].

There was a little brochure from the NIH –– a tiny little brochure. I kept it because it was just a handbook [that] said, ‘trauma patients are at high risk but we don't know what to give them and we don't know what works.’ And so I started my research in that area.

Through her research, Dr. Knudson refined anticoagulant treatment and clinical protocols for trauma patients with pulmonary embolism and thromboembolic complications. Most recently, she worked with the National Institutes of Health studying COVID patients, who “look a lot like trauma patients” who are at risk of developing clotting issues.

Aside from a woman surgeon she worked with in Detroit, Dr. Knudson felt a lack of role models to guide her career. However, she was certainly a trailblazer in her own right:

I wanted to show you something. I gave one of the major speeches at the American College [of Surgeons] a couple of years ago. The woman who introduced me gave me this [see image above]... Instead of a crack in the ceiling… it says, “She shattered the glass ceiling.”

I love it. It's a little paperweight but it reflects the stuff you have to do to be able to move forward. You just gotta keep pushing because there was definitely a lot of pushback for the women at the time.

I can clearly say that UCSF was very different. They're very fair. I never felt that I was being held back because I was a woman. And I give them a lot of credit for that… UCSF has always been very fair… So I can say that's why I stayed there for all those years. It's a great place to work.

Much of our conversation revolved around her work in the military. Dr. Knudson expresses that “the relationship that I've been able to have [with the military] for the last 20 years, in my mind, is more important than my grants or my professorship.”

Dr. Knudson designed courses in ultrasound with the American College of Surgeons. One day in 2003, a military representative from the Uniformed Services University asked Dr. Knudson to teach an ultrasound course at the Travis Air Force Base…

This is 2003, when [Americans] were just beginning to invade Iraq. [The military representative] said, “These guys are getting deployed. There's going to be a war, and they need to know how to do this, because they're not going to have any CT scans. We don't even know if they’ll have X-ray. Go teach the Air Force physicians how to use [ultrasound].”

Shortly after teaching at the Travis Air Force Base, she taught at the Naval Base San Diego, and then at the Landstuhl Army Base in Germany. Her affiliation as a civilian doctor with the military continued to deepen.

We [civilian physicians] would go [to Landstuhl] for two to three weeks at a time as a volunteer and help with the patients that were coming out of Iraq and Afghanistan and –– oh man –– those guys were so badly injured. Just horrible injuries.

We were there supposedly to help, but I think we actually learned more than we could teach. We’d help in the operating room, we would help in the ICU, we would make rounds. Over a course of seven years, we sent 200 surgeons over there. [They were] trauma surgeons, vascular surgeons, orthopedic surgeons –– all civilians –– who were willing to give up their vacations and go over there.

I went over seven times. I went over every year. I learned so much, and I had just so much respect for the doctors that were there. And the patients [service members], they wanted to just turn around and go back [to combat].

So that was my introduction to the military.

Dr. Knudson recounts the ten days she spent learning military medicine with the Air Force in 2008 in Balad, Iraq –– an active combat zone.

[Balad Air Base] was very active at the time and I just learned so much from them. I learned how to put in a little vascular shunt so that you could keep the leg alive while you did other things. I learned so much just by being there, and then you could come back and translate some of that into the civilian world.

I wasn't afraid. They got mortared every day. When you're there, you would hear the sirens go off. But I never felt afraid. I was just so much in awe of what I was learning and watching that I didn’t really feel like I was to be worried.

Bringing our attention back to the civilian world, Dr. Knudson recounts working as an attending and Chief of Surgery at the SFGH on July 6, 2013 –– the day of the Asiana Airlines Flight 214 Crash. Her experience alongside the military helped her efficiently manage and treat the barrage of critically injured victims.

I was on call when the airplane crashed in San Francisco in 2013 –– the Asiana aircraft. It was a Saturday of Fourth of July weekend, so we had all new interns and residents… We had just made rounds and we had two ORs already going. We had two trauma codes already going. I went back to my office and put my feet up and got a cup of coffee, and I got a phone call from the emergency room. They said, “There's a small airplane crash. We think it's a delivery [plane]... You probably won't hear anything. We’re just letting you know.”

And then 5 minutes later, all the ambulances came. We got twelve critical patients all at once, and we hadn't set up. We didn't have a decontamination tent set up.

We didn’t have anything. We didn't have any triage. We had nothing, because we weren’t ready. I went down to the emergency room, and I really thought I was going to be sick. I just thought, ‘oh my god, [those are] really sick people –– just one after the other.’ I was almost paralyzed, thinking I wasn't going to be able to handle this.

And then I remembered what I had seen when I went into Iraq with the Air Force. I had seen how they managed mass casualties. The chief surgeon didn't even go in next to the bedside. They would have this team go, this team go, and this team go –– small little teams with every one of the patients. But you [the chief surgeon] stood out and directed the traffic and figured out who needed to go to the OR.

And so I remembered that and I did that. I had one of our nurse practitioners take that kid and [another] go for this [patient]. And I was in and out of the rooms.

But I tried to keep to myself so I could think and say, ‘This person needs to go to the OR right now, and this person needs to go to CT, and we need blood over here.’

We didn't lose anybody, and we had really, really sick patients, particularly the two flight attendants that were in the back of the plane and got knocked out and dragged on the runway. We didn't lose anybody, but that was a lesson.

And then the intern goes to me, “Dr. Knudson, is it always like this here?” I said, “Oh God, no. We'd all be quitting.”

Dr. Knudson’s more recent work involves creating educational modules for military surgeons to counteract something called the “Walker Dip.” This term refers to the cycle of learning (and re-learning) and forgetting (and re-forgetting) the principles of military medicine/surgery as conflicts come and go. During wartime, care of Soldiers improves as physicians relearn and redevelop military medical knowledge to best treat service members on the battlefield. However, when the conflict is over, military medical knowledge is “forgotten.” This cycle of learning and relearning is cumbersome and can make military medicine a “discontinuous” specialty.

Dr. Knudson describes how she took action in her role as Medical Director of the Military Health System Strategic Partnership American College of Surgeons (MHSSPACS) to address this discontinuity.

We're trying really hard at the national level to keep [military medicine] front and center by having educational courses. We set up an entire curriculum for military surgeons. We just finished it.

It has 42 modules. I call it kind of “TikTok-y” because they're very short. [In] 15 minutes, you can get through respiratory distress or how to do a fasciotomy. It has some videos in it, and has some quizzes in it. I’m really proud of it.

It took us four years to do it with multiple authors, and we used a company to help us put it together.

We've just finished that, and we have a hands-on course for doing different kinds of surgeries that you need in a trauma setting. Then there's some simulators that we've added for things that you don't see very often in your garrison practice but that you might see when you're deployed, like having to do a C-section, for instance, [or] how to take care of an injured child, having to fix a fracture, or how to put on the X-fix [external fixation]. We're trying to keep that so every three years, surgeons in the military have to go back and do these courses.

Additionally, Dr. Knudson describes Mission Zero, which helps military physicians stay prepared –– even in peacetime –– to treat war-wounded trauma patients.

We finally got funding for this program called Mission Zero. There are now about 25 military–civilian partnerships at level 1 trauma centers throughout the country where [military medical professionals] are rotating. That's another way of keeping them ready to do trauma should they get deployed. And as you know what's going on right now in the world, deployment could happen anytime.

Dr. Knudson identifies what made trauma surgery so rewarding for her.

Technical stuff in the operating room –– that's fun. But, for me, it was really about the patients. I just really like taking care of really sick patients. I love the ICU work. That's the stuff that kept me happy –– taking care of somebody that you've operated on and then seeing them get better. To me, that was the satisfaction.

Finally, Dr. Knudson provides words of wisdom and encouragement to women who aspire to become surgeons.

She explains how she has balanced demands on her professional life and personal life to prioritize what is most important.

I have twin daughters, and when I came to San Francisco General, my twins were three years old. I took call every third night in the house when I came up there. But when I was off, I was off. I really was protecting my time.

When they were young, I didn't take national positions even though I was offered them. For instance, the American Board of Surgeons wanted to make me part of the board. And I just said, “30 days away a year? No, I'm not doing it.”

I was very selfish with my time. I have this rule called the “Post-It Rule” –– my to-do list can only fit on a Post-It. If it’s not on my Post-It, you’re not getting done…

I was very selfish with my time that I didn't take national jobs that required me to travel very much when my twins were young. Later on in my career, I became more active on the national level, but not when my kids were little. You have to do that. Your family is important.

[At UCSF], we have a lot of women in trauma surgery. We have more women than men. In fact, during my last years there, there were two men, and all the rest of us on the faculty were women [see the picture above from Zuckerberg SFGH].

I was the second woman to work at San Francisco General as a surgeon. Trauma’s a nice specialty for women because it's a little bit [more] controlled. You have your shift and then, you still have work to do, but your shift work is controlled.

You're there for 12 hours, and then you're off. So it's a little bit easier to plan your life around it.

Dr. Knudson identifies what she would do differently knowing what she knows now:

I didn't really have a mentor –– nobody that was steering my career, and you really have to have somebody to help you navigate through and give you advice on what part of surgery would be best for you and how do you get there and what papers do you need to write, and I didn't have anybody to do that. I think that it's so important to have a mentor –– somebody to help you, direct you to go to this meeting, and introduce you to important people who might be able to help you shape your career.