fluidity.

“What goes in... must go out.”

Dr. R Alonso

The domain of fluids, electrolytes, and complex countercurrent mechanisms has always been a feared and daunting one, the undisputed Achilles heel of medical school. Time and again, we have continually persevered and grappled with its intricate theories and mechanisms, poring over mammoth books in vain and groaning in frustration over seemingly incomprehensible concepts. There’s supporting evidence to boot: Just recently, it has been pointed out in a survey that renal topics were the ones deemed most important by medical faculty and students alike, yet ironically were also the ones considered most mind-boggling and difficult to deal with.

I guess that perhaps, part of its notoriety stems from the fact that Nephrology shuns the straightforward scheme of things and painstakingly pursues our unseen inner workings, stripping us bare to our most fundamental functional elements – fluids, molecules, and the myriad physiological and biochemical interactions that govern them. In time, I found myself growing a soft spot for its web of challenges, lack of candor, and rush of adrenaline that overwhelms you as you carefully tip the scales and juggle cations, anions, and their ilk in an effort to preserve the impeccable rhythm of life, weaving a seamless balance that reverberates through the entire human body in striking fashion. One step turned wrong, and the whole system might just go haywire. A nephrologist, after all, isn’t called an internist’s internist for nothing.

Two weeks of rotating in the section exposed me to the fluidity of our wonderfully structured kidneys, and conversely, to the remarkable, sometimes even dramatic, clinical results that materialize in their stead. I  must admit that I never fail to get short of amazed whenever I see a previously confused, drowsy, and disoriented patient zap back to sanity and reality with just a mere few sessions of hemodialysis, or a previously wan and weak-looking patient suddenly appear with the rosy touch of health after a quick correction of sodium and potassium deficits. By delving into the root of the problem and going molecular, we consequently trigger nano-ripples of change that eventually translate into meaningful overt clinical outcomes and manifestations.

Unfortunately, I also got to realize that many, if not most, patients hardly recognize or are even aware of kidney disease at all. A good number dismiss it as something similar to and as trivial as an uncomplicated urinary tract infection – and thus tragically arrive only for consult when they have already been plagued to unbearable lengths by anemia, breathlessness, and extreme bodily discomfort – with no possibility whatsoever of fully reversing the damage save for a lifetime contract with dialysis. Which is why, marching down the streets and waving balloons and hollering cheers on World Kidney Day couldn’t have been timelier to serve as the rallying cry for such an endeavor. In the lay forum that followed, we tirelessly promoted the relevance of CKD to the public and felt immensely satisfied when a few patients and watchers came up to us to show their appreciation, casually stating that the activity inadvertently pushed them to acquire a newfound change of paradigm.

What goes in must go out. As I entered this rotation exactly two weeks ago less informed and less confident, so I emerge from it more assured and armed with extra ammunition of knowledge and food for thought (getting to observe catheter insertions were definite bonuses.) At this point, I am still far off from being a perfect master of fluids and electrolytes, just as Dr. Alonso’s CRRT talk still keeps me mildly at a loss. But I know I’m getting there. All I need is to focus, plod down the long winding path, and let the fluidity of things take over.      

first aid(s).

I still remember that fleeting moment way back in ICC year when we had our very first lecture in HIV/AIDS, handled ever so unpretentiously and so ingeniously by the tireless Dr. Lim, with matching “Wildfire” games and mock condom demos (using a banana to represent the, ahem, thing) to boot. At the end of the session, seeing us sated and sedated with a plethora of information ranging from “retrovirus” to “non-nucleoside reverse transcriptase inhibitor”, he decided it was time. He finally brought her in.

The very first HIV-positive patient I encountered in medical school.

“I want you to hold her hand. I want you to know that she is just like any one of us.”

I was one of those who readily shook hands, although deep inside still half-harboring the slightest hint of reluctance as to the true extent of such a feared disease and wondering about its consequences. Of course, textbooks and common sense would easily tell you now that you don’t contract full-blown AIDS from a mere handshake alone, but what I realized that fateful morning stretched farther than just a sheer mechanical dialogue on retroviral genetics and pathogenesis: They are simply one of us – walking, talking, breathing human beings with their own lives to live.

And now, two weeks after and nearing the tail end of my Infectious Diseases stint, I must say that the single most significant thing about this rotation was the way it exposed me, in all honesty and openness, to the burgeoning spectrum of HIV/AIDS patients and thus continued the crucial legacy left off after ICC year (History actually repeated itself when I attended the same HIV/AIDS lecture given by Dr. Lim, who also facilitated a “Wildfire” activity, this time among the unsuspecting fellows.) My rotation aptly came at a time when I was fresh off watching the blockbuster musical “Rent” with its bohemian and HIV/AIDS awareness themes. It was as if cryptic skeletons finally tumbled their way out of an invisible closet, where I had to face the reality of seeing call center agents, bank employees, massage therapists, teenage students, and even an Ateneo professor congregate in pursuit of a common goal – to confront the disease squarely in the eyes, at the same time seek timely help in the process of rebuilding the momentum of their callow youth, shattered so abruptly by the stigma of a society that fears what it does not fully know. There’s no denying the clarity of the message, though: HIV/AIDS is quickly becoming a global epidemic, and it’s closing in on us faster than we can say “PCP pneumonia prophylaxis”.

I was fortunate enough to be working alongside a bunch of feisty fellows who knew their stuff, and knew it well. This was manifest in the way the patients rendered their trust and starkly divulged even the most sensitive bits of information, without so much as a trace of hesitation. In all aspects of the past two weeks, from the wards and OPD to the pay floors, peripherals, procalcitonin lectures and PPRISM conferences, I have to admit that it had been quite an enjoyable and insightful experience. The nature and practice of infectious diseases has indeed grown on me, with its corresponding nuances and peculiarities. What initially seemed a drab, dreary realm of boring antibiotics and culture studies was revealed to be so much more with a closer, more discerning look – what with my share of exciting mycoses and unconventional TB cases, not to mention the handful of STD patients that destiny unwittingly transported to my doorstep.

And by bringing to fore the clarion call of giving first “aid” to “aids”, I thank the world of Infectious Diseases with all my heart for these unwritten lessons, and for igniting in my head the rallying cry of such a relevant endeavor.