The eyes would have it

Except I was wiped out by the food animal exam and then grocery shopping turned into less of an outing and more of an endurance test than I had expected. Instead of going to the Great Big Grocery Store of Limitless Choices, I ended up at the local pricey-elitist food store instead. I put up with it because 1) they have some of the obscure food items I am now looking for, and 2) it's all of a quarter mile away. Which when the snow arrives is pretty handy. But it's still pricey. And I had been looking forward to seeing what Limitless Choices might have had. They might have had kefir! They might have had sugar-free-but-not-plain kefir! I really truly needed to go grocery shopping, though, because I have begun to run out food I can eat.

Background: my last little run-in with Crohn's made me realize I haven't been exploring all the options for treatment. If the medicine was working, I would be getting better, not going to the hospital the night before finals week. I rather foolishly assumed that my doctors knew what they were talking about when they said diet doesn't affect it. I now realize that this is a bit of a blind spot for Medicine. For some unfathomable reason, Medicine doesn't like the idea of diet having anything to do with health, except in a general "eat your vegetables" sort of way. I was told to go onto a low residue diet like a good little patient, whereupon I said, "but that's like what my boyfriend eats."

(My boyfriend, by choice, eats white bread, pasta with no sauce, and blueberry yogurt. Fortunately he does like quality beef, lamb, and zucchini brownies, so we still get along.)

The desperate search for dietary advice (is oatmeal okay? Blueberries? Ice cream?) led me over into the realm of macrobiotic diets (thank you, Google Books!). And while a little more research reveals a certain delusional quality that attends alternative diets (if you're supposed to eat seasonally and locally, and you happen to live in the middle of a continental landmass, explain to me again how Japanese seaweed is local?), there was also a hint of reason. Goodness knows refined sugar isn't natural in the quantities I enjoy it. It took me all of two days on liquid diet to get over the initial brooding about a life without cookies, and all of half a day on solid foods for me to discover a way to make cookies entirely with honey (it's not refined sucrose! Close enough!).

I got into a huff at my GI because she thought I was going to go holistic and quit my medications on her, just because I asked if she knew any nutritionists.
So, goals:
1. Find a dietitian who can tell me whether I'm allowed to eat oatmeal.
2. Find studies showing the effect of diet on Crohn's disease.
3. If there are no studies...well, I may have to reconsider my stance on not wanting to do research. I'm a vet student, not a med student, which decreases my ability to say "Time for a human study!" But there's so many people about my age with Crohn's, I can't believe there's NOT a way to gather some scientifically useful information about how diet affects it. New facebook group, anyone?
4. Cut refined sugar from my own diet, to start with.

Other possible foods to get the axe: dairy, wheat, possibly specific carbohydrates (but that's starting to get pretty extreme, when you cut rice--and chocolate!). I get the sense there's a true correlation between Crohn's and sugar, though. Funnily enough, it's one of the macrobiotic books claims that sugar acidifies the intestines that tipped the balance for me. I don't buy the pseudoscience, but there's sometimes deeper truths that Medicine hasn't gotten around to looking at because it *ahem* has its head up its bum.

The funny thing is that I had a professor last year whose ongoing research is the connection between Johne's and Crohn's. I'm trying to figure out a good way to ask him about his research. It just seems awkward to send him a random e-mail, though, saying, "So, after you gave that lecture about mycobacterium last year, it occurred to me I ought to check out my disturbingly recognizable symptoms, and heeey, guess what disease I am now becoming an expert in?"

Oh, but hey, I'm supposed to be taking a massive scary exam in ophthalmology tomorrow. My perspective is so skewed these days...even as I'm finding more and more compelling reasons to learn medicine really well, the relative value of grades becomes very distant and abstract. I shall study a bit, though, and hopefully I'll finish out the semester with passing grades even with all the road bumps along the way.

4th year what?

We had a 4th year planning meeting today to learn about all the wonderful intimidating aspects of setting up our 4th years rotations and externships. I think for most of us--definitely for me--there was an element of: "Wait, what? Shoot, I have to get on this! I'm not ready!" On the one hand, I want to excel! I want to be enthusiastic and personable and competent on every rotation I do (and I want to do them all). On the other hand, I know I'm going to be tired and frazzled and will want to just go home as soon as I can, so I worry that I'm going to completely FAIL to be enthusiastic and competent (and as for being personable, well, one can only do so much while trying to remember the medicine, the science, the animal-handling, and how that one person is a pain to work with but DON'T let them know that).

Oh, and I have an exam tomorrow. I did not realize this until this morning. Upon reflection, I probably would have spent a lot less time driving around doing errands this weekend had I known. And more time studying the prevention of mastitis in dairy cows.

Too Hot

I need to get up a lot earlier if it's going to stay in the high 80's + humidity. Nine AM was obviously not early enough to be outside doing things. Granted, I think the mosquitos would have been happy to eat me at whatever hour I went outside, but at least I wouldn't have felt like I was wading through liquid warmth to boot. I have achieved one main thing today, and that was moving the roosters. They have been eating the tomatoes as the tomatoes got ripe, and when they chowed down on a golden jubilee I had had my eye on for three days, that was it. (They took a few bites out of every single other tomato that was within a day of ripening for good measure.)

Roosters are easy to catch if it is at night and you have a flashlight to shine in their eyes. They stare at the flashlight and, though suspicious that you might be doing something out of their sight, they don't panic until you have already caught them. Then they shriek bloody murder. We collected all 7 from their various roosts in the barn and sheds. They had to hang out in a dog crate all night, and of course the dogs had a splendid time running over to look in at the birdies, running away when we yelled "No chickens!" and back again as soon as the echo of our voices had died down and, to a dog's brain, had no more authority.

I drove the crate out to the other farm, and released the roosters onto the lawn. Only one of them bothered to check out the corn and water I'd put out for them. All the other roosters were interested only in getting as far away from each other as possible. Hopefully they'll make a couple of circuits and either find the water I put out or, ideally, figure out where the cows' waterers are and drink out of those.

Dog adoptions

This has been a summer remarkably free of veterinary medicine. I believe I had planned to be more enthused about inflicting my presence on local veterinarians, but between driving home every other day, gardening, and the trying to write on a daily basis, I've been remarkably busy. It takes about three hours of procrastination for me to get around to one hour of writing. This is an improvement over it taking three days to achieve the same level of frantic "must-write-NOW". At some point, I may achieve two hours of writing at a time. And that will be about the time school starts, at which point busyness truly descends with a vengeance.

In the meantime--I inadvertently talked my fiance into getting a greyhound. Not YET, but presumably we'll be picking a dog-friendly apartment for next year. I think it's Pye's fault. Pye is one of my dogs, very old but only recently starting to act like it (something about megaesophagus and retching all the time...). We adopted him when I was in middle school. He wasn't a mellow dog then, but the intervening years really reduced the running off/playbiting/barking all night. He now has just about enough energy to wander up and gaze imploringly at you. My fiance, who has never had dogs or cats, is a complete sucker for this sort of canine manipulation. And I may have mentioned, one time when I was trying to explain greyhound dispositions (from what I've seen--I admit I don't have a ton of experience with them), that they do this same sort of imploring gaze.

I'm hoping that adopting a greyhound goes smoother than adopting Pye went. I remember the local Humane Society, which I previously had considered a Good and Intelligent institution, really didn't want to let us adopt a dog from them. The problem? We live on a farm. The dog would be on a farm. The dog would be outside on the farm. Apparently, it is anathema to the humane society's mission to let any dog spend nights outside the warmth and protection of a house. If the dog came from a farm? Well, then it would be okay--unless the dog had become an indoor dog since its days on a farm. All dogs at the humane society are housed indoors. Ergo, all dogs from the humane society are indoor dogs. I think they finally let us have Pye because he had already come through the humane society twice (both times because he had way too much energy for living in a house), and they were getting desperate.

Talking with other people from farms (often vet students), this is pretty common. It doesn't matter how qualified the potential owner might be, the humane society would rather euthanize dogs than adopt them out to farms. Do they think the dogs are going to be unhappy on the farm? Do they envision horrible accidents involving combines? Do they think all outdoor dogs are abused dogs?

That said, greyhounds would not make good farm dogs. From what I know, they are capable of a little too much speed with not enough discretion for wire fences.

Mad Cooking Skillz: It looks like parasites!

I has 'em.

Granted, the last three things I made didn't really turn out, as such. But this one is awesome, I promise! And healthy, which is a huge step out of the ordinary for me. It's just wrong, though, that Whole Foods has cheaper orzo and kalamata olives than the local generic grocery store. On one level it makes sense: Orzo = specialty item, Whole Foods = specialty store, therefore Whole Foods = better orzo selection. But the idea of anything being cheaper there is an alien concept.

I needed the orzo to make salad for the celebratory end-o-finals potluck my class is holding. We have a competition for pathology/parasitology themed foods, and orzo...I mean, have you seen it? It looks almost exactly like little lucilia bots, without the hint of ridges.

I wanted kalamata olives to simulate cuterebra, although really I just wanted kalamata olives because they are tasty. And then I added so much spinach and tomato that it doesn't really look frighteningly parasitic at all. But my main goal is to bring something that people will eat, which never seems to happen when I bring cookies. Even the cross-section-of-the-pons cookies I brought last year completely failed to disappear, and they were delicious in addition to being neuroanatomically correct. Well, correct-ish. It's hard to prevent refrigerator cookies from getting a little lopsided. Those would have been neat to do this year--I could have added red hots and called it nigropallidal encephalomalacia.

Poisonous plants

Continuing my toxicology studying...(this is going to be a long one)

Most poisonous plants do not taste good. If you don't force the animals to eat them, they probably won't. (For a given definition of "force"...leaving a cat in the room with a lily may qualify as forcing the poor feline to chew on the plant).
Other definitions of "force":
-overgrazing
-underfeeding
-lack of forage (i.e. drought) or accumulation of toxins (ex. corn accumulates nitrates)
-misidentification

If the hay contains toxic weeds, stop feeding it. This may fix all the problems.

Berries are bad.

Common names are, well, common. Totally different plants may share the name.

Now, by system:

Cardiovascular
Cyanide and cardiac glycosides are the major toxins here. Oleander, Japanese Yew, and foxglove are potent, as are seemingly innocuous fruit trees like apple, apricot, and choke-cherry (which sounds totally innocuous, doesn't it?).
Kalanchoe has cardiac glycoside-ish substances, and it's sold as houseplant where it doesn't grow wild. But then, everything toxic seems to be sold as a houseplant. Like lily of the valley. And monkshood. And water hemlock.

Choke cherry (prunus virginiana)
delphinium/larkspur
foxglove (digitalis)
Japanese yew (taxus) has red berries with poisonous seeds. On the other hand, they've made a nice chemo drug with it now.
Kalanchoe causes vomiting, diarrhea, in addition to the CV signs. No struggling before death, cyanotic membranes, and petechial hemorrhages in the GI tract.
Lily of the valley (convallaria majalis) works through cardiac glycosides.
Monkshood (aconitum) grows in meadows and mountains.
Oleander (Nerium oleander) is very common in California. Do NOT toast marshmallows on sticks from oleander bushes.
Summer pheasant's eye (Adonis aestivalis) is similar to oleander and foxglove, horses and sheep are the usual victims.
Water hemlock (Cicuta maculata) is even more poisonous than poison hemlock, although it becomes deceptively palatable (to herbivores, presumably) after being sprayed with herbicide.

Blood
Bracken fern takes weeks to start causing bone marrow depression in cattle. Horses are done for by thiaminase and get neurologic signs.
Onions have n-propyl disulfides, which oxidize hemoglobin and cause weakness, depression, pale or icteric mucous membranes. Also GI distrubances, rapid pulse and respiration, and, of course, Heinz-body hemolytic anemia.
Red maple contains gallic acid in the wilted leaves, which kills horses by hemolytic anemia.
Sweet clover (melilotus), a question I got wrong on the neuropath exam, are only poisonous when dried improperly and make dicoumarol. Sheep are more resistant than cattle.

GI
Solanaceae: everyone's favorite little known fact is that tomatoes are related to nightshade! (a guy once tried to impress me with his knowledge of this fact, which would probably have gone over better had he not so obviously been clueless about anything and everything else botanical)
Other fun clinical signs: CNS depression, cardiovascular collapse, hallucinations (a specialty of Jimsonweed, aka datura).
Mountain laurel is related to azalea and rhododendrons, and its toxins can get into meat and honey.
Mayapple (sometimes called mandrake, though it's not the same plant as that mandrake). Vomiting, lethargy are the big clinical signs, but it can be treated with copious fluid therapy. Mayapple doesn't make much of a house plant, but it's sold as a lovely native plant for people doing shade gardening.
Sneezeweed is a direct GI irritant, seen in sheep in the west (where it's probably always overgrazed and droughty).
Tobacco.
Brunfelsia, known as Yesterday Today and Tomorrow, can cause seizures and resemble strychnine. Takes a long time for recovery.

Liver and skin
It turns out plant-filled diets contain phylloerythrin, which is a photosensitive compound that does really nasty things when it deposits in the skin and get exposed to sunlight. Cracking and sloughing sorts of things. Plants like St. Johnswort and tansy ragwort cause liver disease, and then photosensitization (pyrrolizidine alkaloids). Plants like alsike clover just cause photosensitization (mainly horses). Then there's cycad palm, which is just incredibly toxic. On the other hand, in more northern states where it never flowers, you don't have to worry about its seeds, which are the most toxic part.

Nervous system
Hemp grows wild and is occasionally eaten in complete innocence by pigs that are bedded on it. More often it is the basis of entertaining stories about teasing out the truth from people who bring their dogs in after the dog ate someone's stash...Expect nervousness, irritation, CNS depression, and coma. In the dog.
Horsetail shows up in forage. It's related to bracken fern, has the same thiaminase enzyme. Cows that eat it become hyperexciteable, stagger, tremble, lose weight and drop milk production.
White snakeroot also likes wetland areas. Its toxin is tremetol, which causes choke, from partial throat paralysis, and trembling in horses.
Yellow star thistle causes what is sometimes called "chewing disease". Horses develop a very focal lesion at the nigropallidal...um...spot.

Musculoskeletal
Black walnut shavings are used for bedding, and then cause laminitis, severe edema, and ultimately severe GI signs in horses.
Hoary alyssum creates similar problems when it shows up being fed in hay.

Well, that was a brief section.

Renal
Oxalates!
Also alkaloids.
Autumn crocus, honestly, affects the GI more, but colchicine alkaloids in the bulb still do irreversible kidney damage.
Death camas show up most in the western states--they're occasionally mistaken for onions, it seems.
Philodendron, peace lily, dieffenbachia (dumbcane) are all oxalate containing houseplants. Dumbcane is especially interesting--its cells eject calcium oxalate when it is chewed, which makes the throat swell up (rendering the chewer dumb).
Easter lily is the culprit of the cat-in-a-locked-room mystery (at least back before anyone realized that lilies were quite that toxic to cats--or that cats would eat something that was so completely deadly).
Greasewood and halogeton (Jack-in-the-pulpit, another native shade plant) contain oxalates that really screw up rumens and cause other problems for grazing animals.

Reproduction
Goats that eat avocado plants get mastitis.
Locoweed interferes with estrus cycle.
Lupine--which is actually grown as forage for cattle-- causes crooked calf syndrome if the cow eats it between days 40-70 of gestation. The calf may be born with cleft palate or more severe signs.
False hellebore, also known as corn lily, causes "cyclops lambs".
Poison hemlock, which is related to carrots of all things, is most famous for being used to kill Socrates (or was it actually water hemlock?)
Ponderosa pine can cause abortions.
White snakeroot is secreted in milk--that's the one that killed Lincoln's mother.
Then there's castor bean, a lovely toxic looking ornamental that contains ricin, one of the most toxic substances known to man.

Surgery: Anatomy, Art

Today for surgery class (i.e. sit in lecture hearing the basics once, so that next year we cannot say things like, "I've never heard of ___, how do you expect me to know about it?") we're covering anatomy.

So far: anatomy is important.

Anatomy has important implications for suture. Last week we went over suture, so in theory this all makes perfect sense, at any rate makes more sense than enzymology in clin path. In all fairness, the clin path professors do a terrific job, and I'm sure by the time we have an exam, enzymology will make more sense than whatever the next topic is going to be.

Anatomy has been occupying me outside of lecture recently. An artist friend of mine discovered anatomy last year by way of a life drawing class. All of a sudden her sketches of people included such innovative things as triceps. (This year I'm going to be taking the same class, actually, although for different reasons--my drawing skills need help. I know where the muscles are, I'm just lousy at delineating them.) She would like to now spread the joy of knowledge, so we're working on an anatomy workshop for fantasy artists. It will have skulls. If I could, I would bring in a horse leg with intact suspensory apparatus, but that's probably a bit beyond the scope of a one-hour talk that is starting out with "This is a skeleton..."

Pharm studying...

I. need. a. nap. I woke up at 5 am this morning, just like I did back in February on the untapered dose of prednisone. Alas, it was not accompanied by the irrepressible urge to study. It could have been; I caught an early bus to school, but I got sidetracked by the lake and took mostly blurry photos of geese for a while. If I'm going to make a habit of this, I really ought to start carrying my nice camera. It's not pocket sized, and it has the drawbacks of middle-range digital (grainy ISO, anyone?). But I can force it to do things like take photos in poor light that are not irretrievably blurry (or grainy), sometimes within seconds of pressing the button.

At any rate, I still have studying for the exam tomorrow to do, but my eyes are so tired it's distracting. So...perhaps a little nap...

path studying

I think the reason systemic pathology is so hard is because it completely fails to be cumulative. I'm not talking about the exams. The exams are the worst sort of cumulative, because they're two to three hundred different things to know. The class itself, though has no underlying direction. With clinical pathology, you have to know lecture 1 before lecture 2 will make sense, and the same goes for labs. It's easier to keep track of what you know and don't know. With systemic path, however, they really do just keep throwing names of diseases at us. With reproductive and dermatology it's especially bad, because although the diseases are different, all the symptoms seem to be pretty much the same. There's swelling. There's erosions. There may be keratin! And then you differentiate based on...well, based on whether the notes match up word for word with the picture's caption.

Studying after the first ten hours is just frustrating, when you're STILL just scrolling through disease (it's not even that they're diseases, they're specific symptoms which may or may not have a known disease attached).

But for a bit of a change, my kitchen sink clogged up! I used up the last of the drain-o, it's still not draining right, and my entire apartment now smells like rotting eggs. I think it may be time to take my notes to the gym and enjoy the ellipticals for a while.

Hymenolepsis

I have seen the Midgard Serpent and it is a tapeworm.

No, really.

In lab today, we had really beautiful examples of rat tapeworms (hymenolepsis diminuta). The professor put about an inch length on a slide for us to look at, and the first impression on looking through the slide is "Holy heck, it's MOVING!" Which I may have mentioned in the past as a special feature of parasitology lab. It was all the more impressive because through the eyepieces, what was a thin white thread has become a vast field of undulating, scale-like segments. Marvelous to behold, and squirm-inducing.

The odd thing about tapeworms, though, is that as far as parasites go they're pretty innocuous. They are mightily impressive, but they like to just hang out in the lumen of the gut and grow. Granted, they grow pretty impressively. And a couple of really big ones could potentially cause some obstruction. But it's nothing like the damage liver flukes or roundworms do.

Prions

The wet lab today was excellent, not least because I successfully removed a cow's spinal cord on the first go. With a grapefruit spoon. The sheep's spinal cord was trickier, and I'm afraid I shaved off half the section I was supposed to be retrieving, but hey, I found the tonsils! And the retropharyngeal lymph nodes too. An entire year of anatomy and it took a fresh sheep head to make me realize where the darn things are located. It becomes much more relevant when you are trying to obtain samples for very specific histologic testing. In anatomy, it was just, "tell the difference between fifteen different pinkish squishy bits of tissue."

I don't think any of the heads we were working with were scrapie-positive (though with sheep, you never know), but the demo head did come from a deer with CWD symptoms. I have been in the same room with prions...

If only prions weren't so potentially super-super-scary, they would be an awesome thing to study. However, as it is, they seem a little too subtle for working with. In some ways, they are in the same category with tuberculosis and smallpox; the deadly diseases that are so subtle that they've already escaped control again (granted, smallpox has been declared eliminated. But the book Demon in the Freezer makes a pretty convincing case that it would be too easy for it to make a reappearance).

I think this is what makes parasitology so appealing on one level: all you have to do is look, and if the worms are there you'll see them. And you can even remove them by hand if all else fails (sometimes). They make us squirm, but it is productive squirming! Prions, on the other hand, are virtually undetectable and insidious. They can't be killed, they can't be stopped, all you can do is avoid them and try to make sure they don't spread. Which is why CWD is a scary thing, for all that its impact hasn't really been seen yet. Deer across the country are seeding the ground with prions, and no one knows what's going to happen. But the impact, if any, is so glacially slow in becoming apparent that very little action is being taken.

Brr. Yeah, it was an excellent wet lab, but not the sort of stuff that makes you sleep soundly at night.

Snow Frog!

What does this have to do with studying/school/anything?

...

But it was really fun!

Bad knee unregarded, I needed exercise yesterday, so I took the dogs for a walk through the woods. And then there was this wonderful field of snow, and the snow was at that soft crunchy, almost granular stage, where it's really easy to dig into but also compacts into solid lumps very well.

And now it will melt, because we're going through a warm period. But hey, it had one good afternoon watching the sunset across fields of cows, so 'sgood.

Schistosomes are my favorite...

Parasitology lab scores high, high marks for featuring microscopic things that WRIGGLE! We spend so much time looking at blood smears and tissue samples and path specimens (scenterific is the word that comes to mind every Monday morning as I walk in and get a good lungful) that things that move are unique and wonderful. Both squirmy and squirm-inducing. Last time we had live microfilaria in hepatocrit tubes (doin' the dirofilaria dance) and on blood smears.

This week was flukes and other wonderful critters that camp out in the liver (and lungs). I was amazed at the similarity of paragonimus lung flukes to moldy pumpkin seeds: they have the exact same ellipsoid shape and off-putting shade of greenish brown. And Fasciola liver flukes are absolutely lovely, they look like those little leaves that accompany the flowers on linden trees. But with intestines.

Best of all were the schistosomes. These are the wormy things behind swimmer's itch, though that's just in people. In dogs they penetrate the skin and go to the liver. They then eventually work their way to the mesenteric veins. where the males and females hook up for a lifelong spooning session. One of our lecturers very kindly provided live specimens in mouse mesentery, so we were able to see the adults in all their, erm, romantic entanglement. Every egg has a little spike on it that helps it move into the lumen of the bowel (and everywhere else). They're pretty immunogenic, so infected animals end up with lots and lots of granulomas wherever the eggs randomly lodge themselves.

We did tissue squash preps with a thoroughly granulomatous liver. My lab partner isn't a great fan of pathology once it's visible with the naked eye, so I had the privilege of setting up the slide. Large chunks of liver with numerous oval eggs: Success! We were advised to keep watching. Sure enough, after a decent amount of time sitting on a warm microscope, a few of the eggs showed signs of life--little larvae starting to squirm around inside. I was fascinated and would have happily waited for them to hatch, but again, my lab partner wanted to finish with the other slides assigned for the day, so I regretfully put the babies aside. When I came back to the slide, all I could find were the immature eggs and empty egg casings--the larvae had hatched and disappeared.

I was a bit disappointed, and scrolled around a bit more in search of a decently mature egg that might be ready to hatch. Then something shot by in the field of view. Rather like being passed by a car doing 80 on the interstate. I hurried after it as best I could (alas, I did not have enough practice with etch-a-sketches for truly proficient microscope driving). More by accident than anything, it darted back into view again--a tiny, bouncing baby schistosome miracidium. It was very cute, in a flubber sort of way. NOT something I want swimming around my internal organs, mind you. It spun around as a blob, then stretched itself out and darted away again. You could tell around the lab who had gotten to the miracidium stage of their squash mount, because it's hard NOT to exclaim when of of these things swims into your field of view and waves.

Dairy cows

I went and hung out with vet students this evening. Hoard's Dairyman, which is THE magazine of the dairy world, has an annual judging contest where you look at sets of cows and rank them. So we were sitting around a room staring at glossy magazine pages of Holsteins and Jerseys and Brown Swiss, occasionally saying things like, "I really like A's udder in the front, but D has better teats."

All my cow judging experience is with beef, so I don't know that I was picking them out on quite the right criteria. But anytime I get free pizza and chocolate sounds like a good time to me!

Now, however, I have the prospect of studying looming ahead of me...It will be hard to kick myself into gear for it tonight, because we have no exams for a couple of weeks, so there's no sense of priority. On the other hand, I wasted all my time last night discovering that there are very few good wedding dresses out there that that can double as belly dance outfits. (A belly dancer friend who got married had a beautiful, very structured dress that looked great but did not move well at all.) Not a very fruitful search. And since there will be a lot of time before this question of wedding dresses is even relevant, I imagine my time is much better spent learning about infectious disease.

*attempting to muster enthusiasm*

All righty. Path notes, I shall overcome!

Okay, I can understand failing a path exam, but parasitology? Oo, that stings. One of the classes that I really actually like and try to do well in. It really smarts, too, that my lab partner probably did perfectly fine, despite the fact she avows her distaste for all things gross and routinely leaves lab an hour before me.

On the other hand, for once I didn't fail path, so does that mean it all balances out?

EDIT:

Going back and looking at the score, I thought to myself, "Huh, that number doesn't look that low..." Upon reworking the math, I found out that I did not in fact fail the parasitology exam. I still didn't do stellar on it, but apparently my ability to answer questions about parasites is at least a little bit better than my ability to divide numbers in my head.

adjusting

One exam down, four to go, and then the cycle can repeat! After living in terror of the pharm exam for about 36 hours, it turned out that taking it made me the most emotionally stable I'd been all day. It's been really hard getting through days recently, between the prednisone preventing me from sleeping more than 5 hours a day and missing my fiance to a scary degree.

We're still working out how to communicate long-distance, so I never know if I'll hear from him on a given day. My life, after all, is very predictable (aside from the mood swings) and full of opportunities to check e-mail. He, on the other hand, is trying to learn to fit into an entirely new culture with a difficult language, and it's a complete guess when he will have access to the internet (technically he has it at his apartment, but whether he has time to use it is an entirely different matter). I think for me the harder part is knowing that he's going through culture shock and that the only thing I can do is wait. It's not something I can share or ameliorate (which my parents had to remind me; see, this is the problem with the mood swings, is that I feel like I've lost all rationality on top of everything else).

School at least gives me lots of opportunities to stay busy. It's hard to be too miserable when you're learning about the life cycle of lung worms! On that note, off I go to study a bit before class.

Don't eat frozen iguanas

Florida is having a cold snap, and apparently there's been a rash of dogs showing up at vet clinics with paralysis. After several weeks of this, vets are starting to think it's because of the iguanas. See, iguanas don't handle temperatures near freezing well; there's a lot of iguanas in southern Florida (who knew?), so there's dying iguanas falling out of trees and frozen stiff. Then dogs find them and think these are the greatest chew toys ever!

However, carcasses are also great incubators for botulinum bacteria, so the dogs get botulism (maybe...there's actually no confirmed clinical data, but it seems to make sense). Most of the dogs can recover, but it takes a week or two for the paralysis to wear off.

Oh, the joy of Promed Mail. Keeping me entertained when the snow plows wake me up too early.

Lots and none at all

Today I have accomplished lots and nothing at all!

A roll of verbiage, just to get it out of my system:

I spent a lot of the day buffering e-mails between the big organization and the visiting organization, both of which were very confused about the schedule. It took me three sets of e-mails (received and response) to figure out that the problem arose from the misplacement of a date, not the actual deletion of it. If any of that makes sense. I always come out of these things grateful for peaceful resolution, and fervently hoping that no one is going to be angry at me. I can imagine several very specific complaints of negligence to lodge against myself, but I think part of that is paranoia.

And then I had a nice long conversation with my fiance, via Skype. It was the first time I've ever used the video function, so THAT was an adjustment. It didn't feel at first like I was actually talking to him, since I was so very obviously talking at a computer. And then it was hard to draw the conversation to a close (although it was getting on toward 11 pm his time, and he still had homework to do). I think we'll probably have to schedule it like dating, not too often and with a set time to sign off. But overall, a very cool piece of technology.

One thing that really irked me, though--his host mother apparently made some comment about how we were talking too much, and how a previous study-abroad student had spent too much time talking to his fiancee "and that was why they broke up." It's one of those cases where my first reaction is "why would she even bring this up?" And my second reaction is wrathful indignation. So I went and played angry piano for a while, which helped (okay, so Mozart's Sonata in C doesn't really qualify as "angry").

Okay, back to studying! Or, I guess, just to studying, since I haven't gotten around to it yet today.

Study plans

My sister was in town the last couple of days for interviews, so we got to hang out and discuss important things like our complete failure to study enough. We're at different stages of education, of course, so the solutions we found are a little bit different. But I realized that I really just don't budget enough time to study. So the new plan is that I will actually map out two hour chunks of study time. Doing that for this weekend has revealed that I have already failed to plan enough time to study, and it's only noon on Saturday.

On the other hand, I had a wonderful two hour conversation with my fiance yesterday. (it was my congratulations-on-getting-there present for him: a couple of hours of conversation in English)

Hurrah for Skype! It's much easier to call foreign cell phones when you don't have to punch in twenty or thirty numbers to get through. This becomes much more significant when the foreign cell phone drops the call for the third or fourth time.

Whoops, that was an exam

Fortunately it was a small exam. I really need to figure out how to remember drugs better, though. The same thing happened last year. I learned the concepts of drug therapy, and then ran out of time and just sort of glissed over the drugs. I wouldn't treat bacteriology this way! I just need to find a way to anthropomorphize ketamine, that's all. That way, when I am confronted with a table to fill out of five different drugs, I will remember which one is which, instead of staring at it dumbly, feeling all the information I knew running out the back of my head.

Minor plaint

I want cake. I spent a very long time writing an e-mail, and I have an exam in the morning, and I have lab after exam, and who knows how many lectures. Also I am sleep deprived, emotionally wonky, and haven't gotten exercise today (snowing too much to go to dance practice, and my cranial tibial muscles hurt from overenthusiastic elliptical workout yesterday). I am struggling to finish going through the notes for anesthesia.

And I want cake.

*sigh*

Okay, back to opioid receptors.

It's a plan!

I got called in yesterday--which worked out really well, in fact. Realistically, I would not have gotten around to studying anyway. As it was, the surgery was relatively quick (a back--over in three hours!), and fortunately there was no backlog of pans to sterilize in the CS for clean-up.

Also, one of the older surgeons was supervising. He was one of the ones who seems to have endless patience with students, always able to offer a bit of advice in such a way that you're glad to take it. He helped with the teching, which was good--I haven't been called in since fall, and I wasn't moving efficiently enough to have kept up with four surgeons (eh, two of them were students) and the anesthesiologists.

Today, though--I must study! But all my good intentions will run away if I don't set up a study plan, since I keep forgetting how many classes I have.

So!

1. Anesthesiology: set up a chart of the drugs we learned last week, review the calculations. Our first exam is Wednesday.

2. Parasitology: Chart out this week's life cycles. My goal is to hang them on the walls when I'm done, and I have a lot of wall space to cover!

3. Pathology: Review cardio, probably by looking at pictures and reading my notes aloud.

If I feel like it, I will tackle the most recent lecture, which had a lot of diagrams with horrible 60's era typeface. I have trouble keeping up with the professor, who rattles off the complicated proceedings of the endocrine system like an auctioneer at a cattle sale. But without repeating anything, ever. If you were a good student, you'd be paying attention and get it the first time, right? (To be fair, he's perfectly willing to stop and repeat something; it's just hard to recognize when you, the student, need to have it explained again. After all, the professor knows what he's talking about, so it sounds very reasonable when he says it.)

4. Clin path: Technically we have homework due tomorrow afternoon. Hm. In contrast to systemic pathology, the professor for this class has splendidly lucid lectures, so I can probably get away with reading through the notes.

5. And if there's any time left over, making flash cards for all of the above!

On 3 hours of sleep

This afternoon: Studying! I have to catch up on clin path and parasitology, not to mention pharmacy/anesthesia and toxicology. We had a great tox lecture today--emergency triage! Tox promises to be one of the stranger classes, because the nature of toxicology is that you mostly just treat the symptoms. Knowing the specific toxin is great, but it often remains a mystery. But at the same time, you need to know enough to not kill the patient with the wrong treatment. For example, if a dog swallows rat poison, you want to make the dog vomit, right? But if the dog swallowed drain cleaner, which is a nasty caustic material, you want to get it out quickly, all one way--because making it come back out the way it went in can kill the mucosa.

The three hours of sleep is working out pretty well. I was terrible about studying last night; I managed to read some parasitology while going through bellydance exercises (holding up the textbook during shimmies made good upper-arm work-out, AND I learned about pinworms). But then I got distracted by the State of the Union speech and by waiting for a phone call.

The phone call was much later than expected, so I was up really late. We (officially engaged! I hadn't expected to find it so exciting!) had a lot to discuss, including whether it's appropriate to fax letters to a study-abroad student at his school, if the letters are not in the target language. I mean, phone calls are great. But they have no physical presence, and no permanence. I like writing letters, I like having them arrive sooner than six weeks after I send them (or potentially as few as 2 weeks *gasp*), and I have a fax machine.

But...say, I've always wanted to learn Russian. I don't know that in the middle of vet school is quite the ideal time, but you have to start sometime.

Hours

I'm going for a thirty hour day. My boyfriend (actually, I've upgraded him to fiance), has a flight to his study-abroad orientation in two hours that I am helping him catch. Then I have to sit through five lectures. I haven't gotten sleep in the last twenty-three hours, because I was at the CDC Day for Vet Students, and subsequent flight problems meant I almost didn't get home today (tonight? This morning?) at all. As a result, I'm high-strung and mellow at the same time. I was terrified I wasn't going to get home in time, that my boyfriend was going to have to leave before I had a chance to see him, and that I was going to be stuck in a huge airport overnight on top of it all.

There weren't even really any problems at the airport where I was supposed to make my connecting flight--they just took so long to clear the gate of the previous plane that I missed the connection by five minutes. At that point it was eight hours until my boyfriend's flight, and there were absolutely no planes going to my home airport. Thank goodness for long-distance buses (definitely more comfortable, considering my current head-cold). And parents who are willing to stay up an extra four hours to pick me up from the bus stop. And the boyfriend, of course, who was very good about letting me decompress via cell phone.

All of this for the CDC. I have to admit, the margin of value has gotten really, really narrow. But I think, overall, it was still worth it. Oddly enough, I think I got as much out of the eight-hour delay on Sunday (planes and I really are not getting along this week). One of the professors from my school went to the same event, and we had the same (delayed) flight. Usher in long conversation about the school's curriculum and how useful it is to practice in a clinic before branching out into public health. Between that, applying for a USDA summer program, and the CDC event, I think I'm career-dayed out. Time for some straight-up clin path! And some really, really strong black tea.

The terror begins...

We have so many classes this semester: systemic pathology, clinical pathology, parasitology, toxicology, pharmacology, anesthesia (to switch over to surgery midway through the semester), and at some point, infectious disease recitation. Eek! I checked out half a dozen textbooks from the library, so I can figure out which ones I might actually need to buy and scribble all over. Pharm and pathology have returned to haunt me; I barely scraped through the first iteration of those classes. I considered checking out Goodman and Gilman, but the fact it's as large as a breadbox dissuaded me. Instead I found a "Quick Look Series" workbook on pharmacology, which actually is remarkably clear and relevant.

My schedule is doubly complicated by the trips I'm already committed to taking. Fortunately they're in these first weeks of school, so in theory I won't be able to fall too far behind. However...it turns out that the Western Veterinary Conference is the same week I have three exams in a row. And I'm taking a red-eye flight back, to arrive half an hour before the first exam is supposed to start. Um. Perhaps I can take that one a week early? How much can they really cover in the two intervening lectures anyway?

On the plus side, the boyfriend is going to be studying abroad all semester. This doesn't sound too great from the stand point of back rubs and needing someone to remind me not to panic; but, at least I get lots of evenings free to study.

Gearing up

I think I'm going to break my rule of no movies on school nights for the first week of school. My boyfriend and I are still working on the list of things he wants to see before heading off to the wonderful world of Russia (which conceivably has iffy cinema availability). However, I'm also going to try to work around that time constraint and stay on top of things. To that end, I will put fifty dollars on my print card and schedule an afternoon on the school's computer lab. I _really_ don't want to routinely miss the first five minutes of class trying to print out the lecture notes. There's always a mad rush, and I always end up losing a couple of print-outs by the time I start the review for exams.

I made it through my entire e-mail inbox too! I'm mostly caught up, but I get this knee-jerk reaction now when I come across the one or two items I've been putting off for months. They've been lying in wait for this day, I swear they have.

visiting cats

The best part about visiting the farm without the boyfriend is that I get to cuddle with the cats. I have Nanner, a petite tortie, on my lap right now and Beezle, the black and white pigeon-eating monster, is making bizarre whistling noises a few feet away. I generally have to watch my cat exposure carefully, lest I convey cat dander to any of my cat-allergic friends.

Since the boyfriend actually like cats, I can conceivably talk him into allergy shots and then we could have a cat. How well do allergy shots really work? We learned about them briefly in immunology: the repeated introduction of small amounts of allergen gradually switch the immune response from TH2 to TH1. The TH2 path involves immunoglobulin E, which triggers histamine release and the well-known effects of allergy, ex. constricted airways, runny nose, swelling, etc. The TH1 pathway, on the other hand, has less drastic effects on the body, since the production of immunoglobulin switches from IgE to IgG. IgG does not trigger histamine release. In addition, T-cells that react to the specific antigen eventually become anergic.

Now if only all autoimmune diseases were so easy to understand, we'd be set.

Self diagnosis

So the question is what exactly brought on persistent cramps today? My bet is on a combination of raw carrots and iron supplement, on top of my GI tract's general disgruntlement with the world ever since I forced metronidazole on it. However, the reuben sandwich (with extra sauerkraut) and coleslaw may have also acted as predisposing forces. Starting last night and continuing all of today, I've been doubling over every couple of minutes with a fresh round of abdominal pain. I'd been a bit tender in increasing increments after Wednesday's endoscopy, but this is actual pain.

And it's exhausting. It's a good thing our winter break goes for three weeks, because I can't imagine how I would handle classes on top of this. As it is, I don't see a way I can keep up the surgery tech job. Sometimes I feel fine (well, not this week so much, actually). But it's so unpredictable, I don't think there's any way I could ensure I'd be able to work any given night. I know that there's never a way to guarantee you won't come down with a stomach bug on a day you have to work, but I think you can usually count on not having that problem a routine basis.

My hope is that with meds and very careful eating, I won't have this set of problems during school. Even if I do, there's a trance-like quality to studying which can cover up minor discomfort.

I find it interesting that I am much less resistant to the idea of starting meds before seeing the doctor once I'm actually in pain. "Gimme anything that'll help!"

Hopefully the copious amounts of gatorade, pepto bismol, and avoidance of carrots will do the trick and I'll be back to normal tomorrow.

To med or not to med

Did I mention I don't like medicine that's happening to me? Iron was fine, that was a nice, straightforward solution. And it miraculously made all the other symptoms decrease so much that I was happy to consider them gone. Now that I'm paying more attention to it, I realize that they aren't really gone, just masked a bit. The abdominal pain is still there, but so damped down that I don't really consider it pain--just a constant slight unease, like I overate and just have to wait it out. It's easy to ignore moment to moment.

I should be glad that things with the doctors are moving along so fast. I'm sure if they were't I would be fretting my guts out (wait, didn't I already sort of do that?). However, I think I might not have minded having a day or two to pretend that things are normal. As my doctor sister pointed out, nothing has really changed.

The meds in question are asacol and prednisone. Prednisone is one of those scary names, which I prefer to apply to other people's (or dogs') treatment plans. I never heard anything about asacol until being told I was supposed to take nine tablets a day of it. The internet being what it is, it's way too easy to find all the bad effects people have suffered from these drugs.

Sedation, woo hoo!

Finishing off the PEG was only possible with the aid of much cinnamon chewing gum and a relatively mindless Heinlein book. It takes a lot of concentrated sipping to get down a gallon of PEG. It tastes like slightly salty water, but just a little off--almost as though it was slightly salty water that happens to be completely indigestible. Surprise!

Then it was off to the hospital. I wasn't very relaxed. The IV line going in hurt just like someone jabbed a small tube in through the back of my hand (funny, that).

Once they had me settled on the gurney, the soft spoken doctor came and told me about the procedure in a lot less detail than I already knew. The nurse started the fentanyl. I suppose it might have stung a bit going in, but the IV line was already making my hand sting pretty badly, so I wasn't sure. Then I guess the stuff hit my system, because suddenly my chest tightened and I sort of squeaked out, "I'm having trouble breathing!" The thought that flashed through my mind: I don't know that I'm not allergic to benadryl, and the lungs are the anaphylactic shock organ in people...

But then my breathing eased up just as suddenly. The nurse asked cheerfully, "Is the room spinning yet?"
"Yeah, actually," I said.

Then I was lying on my side, very groggy, and wondering if they were going to start the procedure yet. It took about a minute for me to wake up enough to realize that I was in a totally different room now--two hours later.

Once I was more or less awake, I got to see the pictures of my colon. Well, no wonder I've been having digestive problems for years! A number of ulcers, some that look fairly minor, a couple that are probably more concerning. I'm not in a position to make any diagnoses though. That's why I have another appointment next week, to find out what the gastroenterologists conclude.

And in the meantime, I get to eat food again!

Jello vs. truffles

In honor of my imminent 2-day eating ban, I had huge dinner last night: steak, mashed potatoes, and green pepper and mushroom saute. But before that--I made truffles! I've made them before, but only the solid ganache version where you roll them in cocoa powder under the supposition that this prevents them sticking to your hands on the trip to your mouth.

This time, I made a special trip to the local cake decorating store and got a truffle mold.* Ooo, ahh.* I almost got one while I was in Vegas, visiting the land of Sur la Table, but I couldn't think of a good way to pack it. And this way I was able to peruse the rack of concentrated flavorings, which has tempting flavors such as amaretto and blackberry.

Then to the kitchen! I improvised a double boiler with a bowl that I believe started life as a dog food dish, but has seen much use here and in the dorms. I had two types of chocolate: the Trader Joe's pound-o-dark, and the Scharffen Berger elitist bar. The elitist was a pale tan color, since it's been sitting in my cupboard for a year (or two? I don't recall...) and bloomed more than a bank of day lilies. But hey, all things chocolate are fixed by melting! I added in some 99%, too, for that special bitter flavor. I originally had three bars of Scharffen Berger in different grades of sweetness, but I ate the mildest long ago.

The elitist went for lining the mold. The pound-o-dark went for ganache. I had trouble with it--it decided to go all watery and clumpy on me. Adding more chocolate helped smooth it, at least enough so it didn't separate on the spot. I scooped out half to make pure dark chocolate truffles out of, then tried a touch of amaretto.
Meh.
Orange?
Hey...
I revised my plan for dark chocolate truffles to include dark chocolate + orange truffles.

Once they'd set and I'd figured out how to remove them from the mold (one truffle died bravely in my attempts to pry it out with a metal skewer) I tried one of the orange. It was like...like...like a real truffle! I forced one on my boyfriend, who made gratifyingly surprised sounds, and I wrapped up the remainder for my mom, the true chocolate connoisseur. *

Now today I keep looking over at them and then back at my little bowl of pineapple jello. I mean, I like jello. It's the closest thing to real food I'm allowed to eat for the next thirty hours. But the only thing it has in common with truffles is that they both come out of molds.

*EDIT: My mom was not enthusiastic. She felt the truffles were much too dark, with not enough mild flavor for contrast. *sigh*

It turns out...

I like medicine, but not when it's happening to me.

The main thing I remembered about metronidazole is that in our chart for bacteriology, it listed possible side effects: "GI upset" GI upset fails to describe the potential for stomach-knotting pain and uneasy nausea. Sadly, I didn't make it through the full 10 days, so the chances are I'll have to take something like it again. I spent most of my supposed vacation with family in Vegas huddled on a couch, while my GI microflora learned about living in a world with metronidazole. I was cheated out of three days of eating! In Las Vegas!

Now that I actually have doctors looking at my persistent anemia and vague GI symptoms, they want to do all sorts of things to me. The antibiotic was just the start. I spent the morning sitting in the gastro office, facing a very nice poster that details every thing that can go wrong with your digestive system from the esophagus down. I did not find it comforting.

If it were my dog (who, incidentally, ripped his scalp open yesterday and needed sutures) I would be all for finding a diagnosis. As it is, I have trouble. My constellation of symptoms indicate what I always suspected, that my GI tract is a lemon (more of an orange...I mean, it's worked okay so far). How do you fix that? It's not like you can replace it. I just spent a year and a half learning how irreplaceable the digestive system is. I also learned that imaging is often the biggest part of medicine. To illustrate this point, they have to look at my digestive system, which means endoscopes. Endoscopes mean sedation to the verge of unconsciousness, so I won't even be able to write it off as a learning experience. (someone, quick, invent an effective ultrasound scan!)

And I'm getting cheated out of two more days of eating. Hmph.