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.