A kick in the kidneys

Today I want to write about the little things of med. Primarily because nothing huge has come along lately.

Some people say that it's a gathering collection of little losses that can lead to the unrelenting burden of sadness. Can this work the other way around? What is the effect of a life full of many of little joyful things?

Interestingly last year my life was filled with a thousand 'little joyful things'. Every couple of days before work I'd get a chai latte from my favourite cafe and walk around the beautiful old buildings and parklands of North Adelaide. Sometimes a koala would grace the gum tree at the bottom of our driveway. Kookaburras would gather in our backyard and blue wrens repeatedly fly into the back window. Friends and family were always around to go out for coffee or a dark chilli hot chocolate. I had a kitchen full of interesting food to cook with and an endless supply of colourful wool to knit with. I even had time to watch as much House as I wanted to (although it drove my family a little up the wall). Yet the unfulfilled longing to getting into medicine remained with me.

Often I now feel like my life is completely reversed, that I know have the one thing I've always really wanted, but at the expense of all my favourite little things. Of course this isn't completely true!! (I still knit and cook a little and I have some lovely friends here too) Yet medicine is worth the cost- overwhelmingly so. Everything we learn is INCREDIBLE (although sometimes I wish the biochemistry was a little easier). The constant hard study is like a an endless bush walk where it is always too hot or raining, but the scenery makes up for the pain. Beyond that though I love a fight, an adventure. Finally my life doesn't feel tame!

So then perhaps 'happiness' is deeply affected by 'little losses and joys' but it is driven by purpose. Crazily enough purpose is only fulfilling in the context of flourishing relationships. I, and so many of my med friends, find that they simply cannot study without taking time out to be with friends and family.

Just to convince myself that medicine also has some 'little joyful things' I'll list them:

• The one footed seagull that seems to meet me each day at uni
• The cozy place under the stairs in the med building that seems to act as a people magnet 
• Refusing to store my lab coat with any of my other belonging- cadaver smell is horrible
• Getting to hold pig kidneys
• Our tute room that smells of feet not matter what
• That it's so cold at home that the printer gives off steam
• That every organ is stunning from its gross anatomy right down to its biochemical functioning 
• That the content of med is like a never ending pit of treasure
• That I haven't tried to get off the wrong side of the train in two weeks and I stopped myself from applying highlighter (thinking it was lip balm) just in time
• That despite all odds it appears that my veggie patch will produce at least one eggplant
• Last week I got the state's medical journal in the post- reminding me afresh that I'm actually a med student!
• That I've learnt and probably know more in the first semester of my course than I learnt in my whole OT degree, and yet can't seem to remember what year it is. 
• That after a scary talk on the upcoming exams the lecturer felt the need to show us a powerpoint of cute animals to describe how we may be feeling. I love my 'warm fuzzy' uni!

I'll end really quickly on kidneys. I've never really known what dialysis is. It seems there are two main types: haemodialysis and peritoneal dialysis. Both are done because the kidneys aren't working well enough in managing the water, sodium, pH, toxin levels  etc of the blood. Until damaged kidneys have recovered their function (they are pretty awesome at regenerating from an acute injury) or a kidney transplant is performed dialysis will have to be done for life. 

In peritoneal dialysis the person has a permanent catheter into their abdomen (peritoneal cavity). Gravity is used to put up to 2.5 litres of fluid into this space. This cavity is rather cool in that it is separated from the rest of the body by the peritoneum. This membrane can act as a filter. The fluid that is pumped in matches the fluid content of the body except in the things that are usually eliminated by the kidneys, through the urine it produces. For example this may include urea and hydrogen ions. Using simple dispersion all the solutes (dissolved bits) all spread across the peritoneal membrane until there are equal concentrations in the fluid on each side. The fluid is then removed from the peritoneum 4 to 6 hours later- taking with it many of the toxins etc that crossed over the membrane. Brilliant. This can be done at home, without medical help. Sadly though bacteria love glass and plastic. One scientist figured out that bacteria and pass from one end of a 1 metre water filled glass tube to the other in 17 seconds! Inevitably the catheter will attract bacteria leading to an infection in the peritoneum. Infection can lead to scarring- if it happens too often the peritoneum membrane will be too scarred to let dialysis fluid pass through it. Most patients have to stop this form of dialysis after two years for this reason. 

Haemodialysis works on the same principle. This time though blood is pumped out of the body and through a machine that acts at the peritoneal space. Inside is a membrane. The blood passes on one side and on the other side of the membrane is the dialysis fluid. This procedure though is done in the hospital, so the poor patients have to disrupt their lives a bit more. Even though dialysis saves lives, it is never quite as good at filtering as the kidneys are. As a result patients tends to feel tired and nauseated a lot (due to the not quite right balance of chemicals in their blood). Also if they aren't urinating- they need to limited their fluid intake. Some fluid will always be lost through sweating and breathing, but without urinating the body's fluid content will swell in a disturbing way!

Enough for now- in a little over a month exams will have passed and hopefully so shall have I! So looking forward to a break:)

It's all in the genes

Today was a lovely day. In fact this last week (apart from a little hiccup in the stress department) has been lovely too.

Why this week has been lovely: 

Last time I wrote about how I was sick of the stressors that came along with medicine. I would like to finish that story. Burdened by the stressors of med I sadly chose to spend my money on printer ink rather than the upcoming med cocktail party. My friends somehow picked up on this and rushed over to give me a giant group hug. Secretly they then conspired to buy me a ticket to the party. I was so touched when I found out. My housemates lent me a dress and helped me do my hair. I felt like Cinderella who got to go to the ball after all. I wanted to include this little story to show that although med students can be grumpy (due to excessive amounts of stress), they'll do anything to help each other. I love my med family!

So what's been so lovely about today? Everything I wanted to get done- I did. It was a lovely sunny day. I got to study in the uni  courtyard, then by the beach and then inside my tute room. I studied when I got home- to Eva Cassidy and made some crochet flowers while watching Dr Who. A perfect day! 

After studying at the beach I went to my favourite lookout- where the cannon faces out  to sea. Earlier in my blog I talked about how passing medicine is like firing a cannon ball to a far off island and doing everything possible to make sure it makes it. Today I was struck by the cannon itself. It sits on runners and is chained so that when it fires the after shock doesn't make it shoot too far backwards. If I am so focussed on passing medicine, what will the aftershock be in me? In other words- how is medicine changing me? I know that I am far more decisive and confident. I also do a lot of stupid things and regularly have school kids mutter 'how embarrassing' about me. This doesn't bother me too much. What disturbs me though is my short fuse with people. In the past I only ever told treasured friends when I was upset with them- because I valued the friendship so much. Now it seems so easy to speak out my annoyance straight away. I don't want to become this person. I don't want med to make me become grumpy, overly vocal, quick to judge and basically always acting out in stress. What a horrible outcome!!! Particularly as studying occupational therapy taught me to be kind and to patiently search for the value in everyone. I do not want to lose these invaluable interpersonal skills. 

So perhaps I need to put runners and chains down for myself- so that I don't run off course. What though? How can I nurture my 'OT self' amid this high stress med world? Taking time to see friends, knit, crochet, run, cook etc will help. Insight into what is causing my short fuse and grumpiness will help. On top of that acknowledging my negative feelings, but choosing to act in a way that I'm proud of will help too. To keep a marker of who I want to be I'll continue to read stories of people I aspire to be like. It may seem trivial to focus so much on my character, as well as medicine, but I'm hoping it'll be worth it. Who wants a proud, short tempered, judgemental doctor anyway??!!! Not me. 

Now for something awesomely cool and medical. Well I can't really do that this week- we've been studying cancer and it's quite difficult to understand. Biochemistry drives me insane. Someday I'll conquer it. As well as that cancer seems to affect most families and evoke feelings of fear and grief. Here are some very very basic facts about cancer.

1. It's genetic. There are genetic mutations that take place in the DNA. These revolve around the genes that regulate cell growth. The genes that pause cell growth to allow any damage to be repaired are decreased. The genes that encourage cells growth are increased. 

2. The genes can be mutated due to all sorts of things ( we don't fully understand this yet) such as radiation. Also people may have a genetic predisposition too. For example they may have one healthy gene and one bad one (genes come in pairs, and the good one often compensates for the bad one). This person then requires only one mutation in the healthy gene to get cancer, instead of one in each gene.

3. The cancerous cells therefore have a genetic mutation and grow heaps, dividing and dividing making lots more cancerous cells. They grow so quickly that they don't have time to differentiate. This means choose what they want to be. For example the white blood cells will only grow enough to exist, but not to carry out their immune function. 

4. They don't have the normal 'time is up gene' that tells them to die at the appropriate time. Most cells in the body have this and die, thus removing old damaged cells from the body. Therefore cancer cells can be immortal. 

5. They are able to make blood vessels grow near them. This way a cancerous lump can get enough nutrients to survive. 

6. Most cancer cells are killed by our immune system. Only the really tricky ones escape. These ones are far more similar to the normal cells and this means the immune system treats them as such- not realising how dangerous the impostors really are. Radiation therapy aims to create further mutations in the cancer cells so that they are less about to hide and thus can get knocked off by the immune system, or simple be so badly damaged that they cease to be immortal and die. 

7. One in three people will get cancer. One in five will die from it. This is scary.

To sum up, cancer is quite clever, horrible to study, yet there is hope now and in the future due to our growing understanding of it.

Bye for now- so much study to do!!!!

ps. here's a photo of my beloved textbooks and some flowers that I've crocheted recently.

Iron deficient

Gah medicine. I mean really- sometimes I hate all the baggage that medicine brings with it.

I wish that medicine was simply- medicine. The wonderfully fascinating science that can be used to extend the quality and quantity of life.

It's not though. No matter how much I try, some of the baggage will haunt me- tempting me to carry the stress of that too. I know the metaphor is becoming a little hard to follow- so I'll try and explain.

At least 70% of people in my course are struggling financially to get by. Some of these people astound me with their ability to hold down jobs on top of the mammoth task of studying medicine. 100% of us don't keep in contact with our friends and families like we did in our past lives. The list goes on. Perhaps what I dislike the most is being so vulnerable all time. It is so strange to go from competently holding down a job and looking after others to need constant support from those around me. Should a 25 year old still be calling home for help? Should a 25 year old burst into tears in front of strangers? Should a 25 year old need care in much the same way as a toddler learning how to walk does? It is embarrassing.

Yet I wonder if this humbling time has value? I know a lot of my med friends are going through the same thing. In hospitals patients are often seen by doctors during their most fragile moments. For example to go from working one day to lying in bed being catheterised the next- must be a horrible adjustment to the person's identity. Perhaps like me they need help, but also long to be seen as the competent  happy person they normally are. So then how should I treat these patients? Should I get them well as quickly as possible? Yes. Should I acknowledge their pain? Yes. Should I acknowledge who they 'normally are'? Yes.

I want to thank my family for putting up with my many phone calls. I want to thank my friends for loving me just the same- even though I write letters far less than should. I want to thank my housemates for encouraging me daily. I want to thank my housemate's family for having me over during Easter.

Enough of that deep thinking for today. Two weeks ago I went to suturing night at uni- we lacerated and sewed up pig trotters. It was pretty incredible. I loved it. Being a surgeon must be exhilarating. Soon I'm going to be part of the Teddy Bear hospital and pretend to treat school kid's teddies- how fun! I've finally given in to Ugg boots. All my life I've hated them- they are so ugly. However they turn out to be vital for studying in my cold house. My friend's wedding was stunning and it was so refreshing to be home for it.


Cool medical fact for the week- we can get iron through eating it, but it's a lot harder to get rid of. Our body cells take up what they need and store a little extra. Some protein (transferrin) carries it around our blood stream allow the iron to reach cells all over the body. If the cells don't need anymore iron the body seems to know to not absorb any from the intestines. Yet why do we keep needing to eat iron- if the body doesn't get rid of iron once it's been absorbed from the intestines? Simply because we lose cells every day. Hair falls out. Dead skin rubs off. We fall over and a bit of blood oozes out. This is the lost iron that we need to replace. Pretty cool hey?!

I shall leave you with a picture of my room. The angel reminds me to pray. The picture by my brother reminds me to hope. The skeleton makes me laugh.

Deadly words

Oh my dearie dear me. I have not written for two weeks. How completely dreadful.

My excuse is that I had an essay due and I'm heading home this weekend for a beautiful friend's wedding. Somehow I had to study extremely hard so that I could do absolutely NO study for those few days at home.

Over these two weeks I've thought a lot about the power of words. Does saying something negative really make it happen? To me this has always been a ridiculous belief. Yet, I now wonder otherwise. I have a veggie patch- that I nurtured from seed. The soil in Perth is basically sand and yet some zucchinis and a pumpkin were beginning to grow. Every morning I'd eat my breakfast by my garden and lovingly water it. It was one of the best times of the day.

I suppose love is blind. What I thought was beautiful, was scorned. My housemate's friends would come over and they would stand in front of my garden and laugh. Every day it seemed, someone would give me some more advice on how to improve my ridiculous garden. This upset me. My beloved garden was now a laughing stock. I no longer ate my breakfast by it and hence forgot to water it.

Over  the week I got upset enough to forbid my housemates from paying it out. However by the end of the week most of it died through lack of watering. Only the basil and eggplants continued to thrive. If only people hadn't paid out my garden. If only I hadn't let their words destroy my enjoyment of my garden. If only... then my garden would not have mostly died. Quickly I just want to say that I'm not blaming my housemates (Australians basically pay out anything thing that they can). Still I think this is a part of our culture that we ought to lose.

So words killed my garden... sort of.

Applying this principle to my studies intrigues me. Each day I plug away at what I need to learn. Yet I regularly feel completely inadequate. I am vulnerable to attack. Imagine if I believed that it was no use and that I should not bother. Imagine if in my vulnerability, people began talking and saying that I didn't have what it takes and laughed at my poor grasp of medicine. Would I study harder to prove them wrong? Or would I slowly lose motivation to study and believe that it's no use anyway?

Normally I would be resilient and prove them overwhelmingly wrong. Yet now I am pushing myself to the extreme. I am tired. I am stressed. My brain is working harder than it ever has. I am away from home. My defences in other words are down. Therefore I've come to the conclusion that as med students we should encourage and support each other. All pushing each other to believe that we can in fact pass and that yes.. all the study is worth it.

Enough deep(ish) thinking. This week has been full of med brain instances. I poured cereal into my coffee mug. I tried to pay for my printing with my transport card. I boiled the kettle with the lid off. Despite this med is still wonderful. I love it how our lecture went 30 minutes overtime tonight, but it was so engrossing that no one told the lecturer. I love it that as many of us chat on the train ride home (7:30pm) after a day of lectures, we laugh and share our favourite parts of what we've learnt. I love it that we love med.

I'm way too tired to describe something medical in detail to finish this post off tonight. Instead I'll leave you with this cool fact. Some people don't like big scars. This poses a problem when surgeons want to remove something big like a kidney. So they make a tiny cut to slip the scalpel in and detach the kidney... but how to pull the kidney out through that tiny hole? Well they make a cut into the colon and put the kidney in there and then suture up the colon and abdominal wall. What... so they leave the kidney in there??!! Yes! The person then wakes up and excretes it like they normally would with anything else in the colon, ie faeces. Now that is gross, but awesome.

This is a giardia cake that I baked for my tute group.

My favourite new things... (mentioned in the blog below)

Gut instinct

Have you ever listened to someone's story of woe and instead of feeling sorry for them, have felt jealous of them? Or at least wanted to shake them and say 'Dude you have no right to complain, your life is 1 000 000 times easier than mine'?

This week this has happened an awful lot. So far I have managed to listen, nod my head sympathetically. Yet what is going on inside my head is a different story. 

We were warned right at the beginning of our degree that this would happen. That when when we graduate and work as doctors we'd come home and our families would complain about their days and we'd snap and say 'here's 50 cents, go call someone who cares'. 

I know that I'm not a doctor yet who cares for others all day. However I have to study A LOT and therefore have very little time for myself. Last weekend I studied from 8:30 am to 10pm on Saturday and Sunday and then followed this by a week of lectures from 8:30am to 6pm with extra study when I get home. All with the added stress of still being behind and not knowing enough. On top of all of this I am meant to cook, clean and wash my clothes, oh and sleep. 

So when people complain about their busyness and I know that they at least have time to see their friends most days and certainly don't study on their weekends I have to restrain myself from saying something horrible. To me it's like they have a splinter in their thumb and I have had a whole arm chopped off- their pain seems negligible. 

BUT... I do not want to become this person, the sort of person who only has compassion for other doctors (single parents probably also work as hard or harder). Pain is still pain. There are also different types of pain. My pain is grief for my free time, my friends and family back home and all my nice pretty things that simply won't fit on a plane. Yet perhaps my pain is not that bad, I CHOSE this life and I although the cost is dear, I GAIN medicine and a whole lot of new friends. 

The lecturer who warned us of this horrible attitude, that we may develop towards others, gave a lovely solution. Instead of saying 'I'm such a mean person' and feeding our self pity even more he suggested that we must find time to CARE for ourselves too. No one can give and give and give without receiving. Far out even Jesus took time out early in the morning away from everyone who wanted his help. 

So this week I've done two things. I've bought lots of brightly coloured stationary to make study more fun (back in high school aqua and purple highlighters did not exist). I've also decided that I don't care how far behind I am, I AM going to take Friday night off to watch a movie, eat yummy food and crochet. 

When I had my interview to get into medicine they asked one final question- 'Do you have any other achievements you'd like us to know about'? This freaked me out. I mean I've done nothing amazing. I was sure that all the other applicants would be amazing athletes, volunteered in orphanages overseas or at least won the nobel peace prize. All I could scramble together was my passion for knitting and crocheting. Weirdly enough this got an overwhelming response from the three interviewers. For 5 minutes they drummed it home to me that no matter what I must maintain this passion- that it was vital. The doctor on the panel was particularly adamant. I wonder now if this was because he knew, that without it medicine would take over everything and I'd become the bitter person I described above. 

Do I have a cool medical fact for this week? YES. This week has been all about the gastrointestinal tract. I seriously think this is my favourite part of the body- it just makes sense. 

Helicobactor pylori is a bacteria that can survive the acid of the stomach and it has a few tails (flagella) to help it swim to the mucus wall. There it uses spikes (frimbrae) to attach to the wall (so that the intense muscle contractions of the stomach don't knock it off). It the secretes urase  (enzyme) which helps to break down urea in the stomach to carbon dioxide and ammonia. The ammonia makes the area around it more alkaline (protects it from the acid that it can survive in, but not thrive in) and the CO2 is absorbed through the mucus, into the blood and is finally breathed out through the lungs. It also releases toxins that destroy the mucus layer of the stomach wall. This means that the acid can now destroy the stomach wall and an ulcer forms.  The only way to heal the ulcer is to kill the h. pylori with antibiotics and to slow down the acid secretion in the stomach. 

An Australian from University of Western Australia discovered this bug and is now a hero. I can't count the number of times we've heard about him and the person who helped him. Before him the world thought that ulcers were stress related. So now patients no longer are blamed for their ulcers and treatment is pretty non invasive. The poor surgeons get less work though.

Okay so that is all rather specky. However what I really love is one of the key diagnostic tests done to detect h. pylori. The Urase breath test. The patient swallows a tablet of urea which is made of ammonia and an isotope of carbon. (isotope means it is difference to the normal carbon breathed out in CO2). If the h.pylori is in the gut it'll break it down and with 30 minutes a sample of the patient's breath is taken to see if the isotope is in it. This is AWESOME. Finally I get to use a little bit of physics. 

The other cool thing I learnt was about faecal transplants. Now I understand that most people are squeamish. However if you're not, google this! It's exactly what you think it is. If you were dying from gastro you may let this be done to you. Maybe. 

Duckling

Ask any med student what could be harder than studying medicine. I think most would say- 'not studying medicine'.

It sounds silly, but it's true. 

So many times over the last two months I've wanted to throw it all in and go home... and yet I couldn't. There is nothing else that I'd rather do. 

Being an occupational therapist I would say this is because people in life are the most fulfilled when their lives centre around activities (occupations) that are suited to their abilities and are profoundly meaningful to that person. 

The whole selection process to get into med hopefully means that we all possess the ability to be good doctors! 

However what makes medicine so meaningful that people stick at it- even when it seems to take all they have and more?

My peers have given a variety of responses from: it's a challenge, my parents want me to, it was the next logical step etc. Most though, would say that apart from wanting to help people- they find medicine the most fascinating thing they've come across. It's a passion that bubbles up from deep within us. 

Personally I have two reasons for studying medicine. Firstly I have loved 'blood and guts' for as long as I can remember. For example as a little girl I came home to find my cat had cut open her abdomen while jumping over a fence. Carefully I laid her down and gently probed her stomach fully absorbed in viewing the exposed muscle. This is not a normal response. Later I did cry and dream about her for months when she died a day later. Everything we have studied so far in medicine absorbs me in this way. It's as though every week I fall move deeply in love with medicine. 

My second reason is what gives me the motivation to study when my eyelids are twitching with tiredness  and the sun is calling me out to play. It's the deep set feeling that this is what I was created to do. I remember looking down at my hands in grade four thinking that they were made to heal. In year eight I would sit next to one of my oldest friends and we would joke that there are some very vulnerable people out there that needed our help- without us they would surely die. We would imagine these people as ducklings with a crocodile following them eating them up one by one. I have no idea what made me think that I too wouldn't be eaten (maybe I was in a boat)! 

Over the years this metaphor grew to illustrate people in developing countries who were living restricted lives or simply dying prematurely because they didn't have access to world class health care. Desperately I wanted to go there and provide them with that care. Sometimes I would catch glimpses of myself in the future doing this. I saw a clinic, made out of dried mud, with kids running in and out laughing and one of them held flowers for me. I stood in the door, full of joy, with a stethoscope around my neck. Glimpses such as these would be painful when I thought that I'd never get into medicine. Now however they are a source of inspiration. I am not studying simply for myself. The more I learn, the more I will be able to help my future patients. It is an act of love for those I do not yet know. What a romantic notion! Who does not want to be a hero, who overcomes many obstacles to rescue people?! I wonder if others have their own 'ducklings'?

The friend who used to sit next to me in year eight gave me a plastic duckling that sits next to my laptop. I've included a photo just for fun. 

Usually I finish each post with my favourite medical fact for the week. I'll be brief this time. T cells (are good at killing germs) are white blood cells that are made in the bone marrow and then are sent off to T cell school in the thymus. Here they go through rigorous training and testing- for 2 to 3 weeks. Of these cells only 3% pass their exams and are allowed to leave the thymus and go to live in the lymph system (eg lymph nodes  and the spleen). The rest are cruelly forced to kill themselves. We are all (hopefully) born with a thymus which continues to grow until we reach puberty. After this it slowly shrivels and changes into a heap of useless fat, going from 40g to 12g by the age of 50. Why? Well, hopefully by this stage our bodies have been exposed to most germs and therefore have enough memory T cells specific to these germs. As we get older and the thymus starts falling apart, some T cells manage to escape some of the tests in the thymus, which would normally have resulted in their demise. Occasionally these T cells are unfortunately untrained and dangerous- they don't recognise some of the body's own cells and start killing them- hence causing an autoimmune disease.  Please med students (if you read this) say if this is incorrect! 

So please honour and help us med students who are giving up so much to study such a great discipline, and delight with us that we have the reciporacle honour of studying something so absolutely wonderful.