I'm free!

Here we are, the morning after. I put the bin bags and recycling box outside the front door - the air smells fresh, the wind riffles gently through my dreadfully unruly hair, and a new metaphorical dawn has broken. I don't have to do any revision today! Or tomorrow, or the day after! The trampoline glints in the sunshine, speckled with bird poo and purple grains of ceanothus blossom, enticing me to come out and have a little bounce. So with all the wonderful opportunities of a few days when I can just decide to go outside and enjoy myself in the sunshine that is forecast, I sit at my desk and turn the computer on.

Yesterday was brilliant, at least after 10.30 a.m. Before that I had the usual 6 a.m. start to make sure that even if I was delayed an extra 90 minutes on the motorway I might still make it in time for the exam. This is more of a gesture than a real precaution, because on the two occasions I've actually been delayed on the motorway, I was more than two hours late each time. The exam wasn't very pleasant because of its format as short compulsory questions, but I won't dwell on that. Afterwards I went with Dipti to the gym at the local Hilton hotel where she swam and I didn't, then we went together to meet an old friend of mine and have lunch, then we picked up some more marked coursework and went home.

Mr A was looking and feeling cheerful, which was nice. We had booked a rare dinner out at our favourite Stratford restaurant to celebrate my freedom, and then paid a visit to the Cricketers just because we could. A big European football match was on, which meant a very full noisy pub, but the end where you can't see the TV was nice and empty for us.

It was the second trip to the pub this week - we dropped in on Monday for the quiz. It was a very good idea, because it got us both out of the house and we always meet all sorts of people who are happy to talk about nothing and take our minds off whatever's going on in the real world. There was a oldish man we didn't know who started chatting, and told us a great deal about the drugs he likes, while occasionally mentioning that he doesn't do that much any more. But LSD is great, and he likes cocaine too. Our neighbours H and K dropped in, and then someone else they know who has a very senior job at Jaguar. Meanwhile, we were trying to achieve greatness at the quiz.

Even with help from friends, the bar staff and at one point from the quizmaster himself, Team Next Door couldn't repeat its winning form. The key seems to be in the picture round: on the occasion that we won, the pictures were of authors. The other time we played, they were word puzzles, and our team did quite well that time. This time, there were twenty pictures of people who had won Reality TV shows. I think we got just one answer ourselves - we couldn't even think of the names of twenty different shows, let alone recognise the faces of the winners. The round on sport and leisure was similarly hopeless. But for our £2 entry fee per person, we got a bowl of chips and chicken korma at half time, a consolation prize of a bag of chocolate-covered peanuts, and a great deal of social intercourse and entertainment.

We often reflect happily on what a difference it can make when a pub is run properly and enthusiastically. The latest news is that Smurf has bought a number of Cricketers-branded hoody-style sweatshirts, apparently so that smokers can borrow them to wear when it's a bit cold outside. Last weekend he knocked on the door to let us know that there was going to be a party with a barbeque in the beer garden, and to ask if it was OK for them to have music out there. We said yes, and two minutes later he came back with a bottle of wine for us.

Today I turned to the list of stuff I have been jotting down over the last month: To Do After The Exams. The most pressing task is to get my hair cut to a length that eliminates the 'electrocuted monkey' look. Weeding and pruning in the garden, a new broadband contract, tasks in town that Lola II has been saving for me until the exams were over, like picking up clothing from shops that don't have the right items in the London branches she has visited. I'm going to do some cooking! And clear the drain from the shower, look hard at our financial situation from every angle, and perhaps even get my hepatitis B antibodies checked now that I've completed the course of vaccinations.

I'll be going to London to catch up with Lola II and see her Extremely Tidy Flat that's now on the market. Most exciting of all, Mr A has organised a short trip to Devon, where we will be visiting two lots of friends, and camping. It should be a wonderful, relaxing break, and if the weather is good then that will be an extra bonus.

Boing

The lovely Mr A brought our trampoline out of storage and put it together in the garden on Saturday, so I've been bouncing in the sunshine a little bit, in between stints pretending to revise at my desk but really reading blogs and looking at Facebook. Then actually revising vitamins: thiamin, riboflavin, niacin and pantothenic acid. Today I've got to get down to regulation of food intake and dietary reference values, then tomorrow will be malnutrition and free radicals and it's all over on Wednesday.

Exam update

You probably want to know how things are going. I've done three out of four exams so far, and they could have been much worse.

There's a fair amount of overlap between the different modules this semester, so yesterday in 'Nutrition, Metabolism and Disease' I turned out an essay on diabetes that was remarkably similar to one I did for the 'Medicine and Pathology' exam. Obesity was a major topic in both NMD and Human Nutrition, even to the extent of being taught by the same lecturer and including some of the same slides.

In the multiple choice section of the Computing Techniques exam, there was a wonderful question asking what the meaning of 'interpolation' was, where one of the choices was something like 'sharing of information on international crime'. Inspired. Luckily I could avoid all statistical questions, so I managed to focus on use of Excel and maths, even including a question featuring binary numbers. The only things I definitely couldn't remember were the specific reasons for sample replication and randomisation, but I'm not about to go and find out what the answers should have been.

Today the weather is beautiful and the forecast for tomorrow is the same. Everyone else has a Bank Holiday Monday to look forward to. Unfortunately, given four days before the next exam, I will find revision to fill four days - if the exam were two days away I would probably manage to do the same amount. The human brain and its talent for procrastination have a lot to answer for. I should read 'Parkinson's Law' again: didn't he write that the work expands to fill the time available? So true. If the exam were tomorrow, I wouldn't be blogging now.

It all kicks off tomorrow

I haven't been outside the house for days. Mr A and I went for a walk on Friday - or was it Thursday - it's all a blur. I think that was the last time I saw the sky...

It's been fairly traumatic in Lola Towers recently, but I'm not ready to write about Mr A's business, nor am I sure he would want me to. Combined with my revision, we have struggled to maintain sanity, and we have succeeded so far. I have ten days to go before my ordeal is over; Mr A has to wait a lot longer, but there is a glimpse of light on the horizon. A new dawn, the beam of a torch in a darkened building, the lights of oncoming traffic in a tunnel, the last rays of the setting sun: when the time comes we will find out which it is.

My first exam is tomorrow afternoon, followed by another first thing on Wednesday morning, and the third on Friday. That's the thing about exams, they take absolutely ages to arrive, and then they're all over before you can blink. Actually, the last one isn't until Wednesday next week, but that seems like next year at the moment.

I haven't found revision very easy this time, and I am nowhere near as well prepared as I have been previously. Rather than being ready with in-depth answers to some questions and well-prepared answers to anything else, this time I am relying (as most other mortals do) on the right questions coming up on the day. It's fine, I'm sure I'll be OK, but being confident of knowing everything definitely took a lot of the stress out of exams I've done so far.

So I'm still alive, even though there's nothing interesting to report. Revising Computing Techniques doesn't lend itself to fascinating nuggets of bloggable material, unless you want to know how the variance ratio is calculated from the sum of squares of residual errors, or how negative numbers are handled in binary notation. You really don't need to know.

I spent a day on how it is thought that the brain regulates food intake and some of the neurotransmitter receptor targets for obesity therapy, which wasn't as interesting as I thought it would be, nor as successful in real life as inhibiting fat digestion in the gut. Today I'm back for the final stretch on medicine and pathology - that's the exam tomorrow. Wish me luck.

Re-feeding syndrome and the garden in spring

I have decided that my revision is going OK - not well, but OK. Yesterday wasn't too good. I spent all day at my desk, but really only worked properly between 5pm and 7pm.

I learned about re-feeding syndrome. If you starve for more than a few days, the body switches over to a different type of metabolism, burning mostly fat and a bit of protein to keep going. If you then start eating carbohydrate again, there's a chance of a seriously adverse, potentially fatal effect. It happens because blood phosphate and stores of potassium and magnesium are seriously depleted. As insulin is secreted in response to the carbohydrate for the first time in ages, all the phosphate in your bloodstream goes into the cells with the insulin to do all the things phosphate is needed for. To a lesser degree, potassium and magnesium do the same, and this is not good for you in the short term. You can also get hallucinations and other neurological symptoms from thiamine deficiency, but I'm not sure why this happens on re-feeding rather than while you're starving. Perhaps this vitamin is also used up when carbohydrate metabolism is jump-started in this way.

This medicine and pathology exam is going to be tough. Two hours are allowed to answer three questions, so that's at least half an hour per question, which implies a fair amount of depth and detail to the answers. The questions are mostly two, maybe three sentences ("The patient reports abdominal discomfort after meals, and occasional breathlessness on exercise. What is the likely diagnosis? What further tests would you suggest?") and there is the distinct possibility that you might write for thirty minutes on the wrong medical condition. I suppose that as long as you justify your choice, the question allows for more than one diagnosis.*

Past papers cover a vast array of conditions, some of which were hardly mentioned in lectures, so it's difficult to imagine knowing enough to answer three random questions in depth. I'm probably going to concentrate on diabetes, gastrointestinal diseases, cardiovascular disease and heart failure, and hope that either anaemia or burn injury comes up (because those were the subjects of our research and presentations during the term). But I'm going to have to know a bit about obesity, eating disorders, endocrine problems, electrolyte disturbance, renal failure, liver disease, biochemical tests, cystic fibrosis, HIV/Aids malnutrition, cancer, ascites, chronic obstructive pulmonary disease and asthma as well.

I have been studying other subjects as well. I have learned that there are a large number of ways that your blood cholesterol and lipids may go awry, but none of them is very interesting. Even less thrilling is the use of Excel to solve non-linear equations, but I do marvel at some of the things we can do in seconds with a spreadsheet that would have taken days with log tables, graph paper and a ruler.

While I'm stuck inside at my desk, this is the most wonderful time of year to be walking about town, admiring the colours of Nature. In the garden the wisteria and ceanothus are in full bloom, we have bluebells and cornflowers (purple overload!) but also something I don't know the name of that flowers profusely in white. My herbs are doing quite well, although something ate one of the mint plants, leaving only the stems. Mr A is doing most of the cooking, in between his business crises. I may write an update soon on the activities of Mr A, but not at the moment.

[There's no particular reason for the Oxford photo at the top, it's just there because I haven't put up any pictures recently, and I haven't taken any pictures in the garden yet. And because of the busts of stern academics, who appearing to be doing some serious thinking.]

* For this question, I'm guessing cystic fibrosis. But I suppose it could be cancer obstructing the gut with secondary tumours in the lungs?

Sounds of Korotkoff

Earlier this year I was telling D and Lola II about how we’d been taking blood pressure measurements the old-fashioned way with a stethoscope and a cuff on the upper arm attached to a squeezy ball. You pump up the pressure until there are no pulse sounds, then you let the pressure down until you start to hear a pulse at the elbow (this is the upper number = systolic pressure, equivalent to the force that the heart can pump), then you let the pressure down further until the sounds disappear (lower number = diastolic pressure, equivalent to the resistance in the arteries, capillaries and veins). It all seemed very straightforward until D asked what the sounds actually were, and I had no idea.

Yesterday I was revising cardiovascular medicine, and came across a paragraph in a textbook that explains it perfectly.

“At the systolic pressure, a faint tapping sound is heard as blood first begins to pass the cuff. With further lowering of the pressure, the sound becomes louder, then dull and muffled before finally disappearing. These are the sounds of Korotkoff, which are produced by turbulent flow in the brachial artery. The change from staccato to muffled sound occurs when blood first passes under the cuff continuously, even though the artery is still partially constricted. Continuous flow has a different auditory quality than interrupted flow.”

[It’s an American textbook; ‘different... than’ always makes me wince. I can tolerate 'different... to' and 'different... from' but not 'different... than'.]

I’m back with cardiovascular disease again today: atherosclerosis, dyslipidaemia, reverse cholesterol transport. They think that women have a lower rate of heart disease because of a protective effect from oestrogen – after menopause the risk seems to become comparable to men. There’s something to look forward to.

Looking to the future

Nothing to write, no activity to report, except revision. Either I'm revising, or I'm thinking about revision, or I'm feeling guilty because I've been staring into space for 20 minutes instead of at my books. This ridiculous urge to get high marks in exams can be quite painful. Taking this time off to write something for the blog feels very self-indulgent.

My salvation has been a) doing the odd bit of cooking for relaxation, and b) not worrying too much about the Computing module. If I could spend the next two weeks just doing revision for Medicine and Pathology, and none for any of the other modules, that would be just lovely, but Nutrition and Metabolism need a little bit of attention. Computing deserves none, it was a poor choice. I provided fairly scathing (though still constructive) module feedback, which will be discussed this afternoon. I am slightly nervous that nobody else will have written anything, and it will be very obvious that the feedback is mine.

Next year's module options are fairly unsatisfactory too. The problem is that our compulsory modules are unevenly split between the two semesters: 40 credits in the autumn and 60 credits in the spring. We can choose 20 credits for ourselves, but the recommendation is one 20-credit module that runs for the whole year. That means a 50:70 credit split between the semesters, but worst of all, six exams this time next year. I've got 4 exams this time and it feels dreadful enough.

Today I've come into school, starting with a visit to two different libraries to pick up some books, then a meeting with one of the lecturers to talk about whether I might work with her over the summer. It doesn't look like there will be much opportunity this time, but we have hatched a plan that may result in a useful project in the fourth year. It's in a really interesting area: she's trying to determine objectively whether teaching communications skills to dietitians actually leads to an improvement in their skills, and more importantly, whether the patients seen by those trained dietitians achieve better dietetic outcomes than those seen by untrained dietitians.

So it looks like this summer I might be helping out with a lab-based project at Warwick uni after all. I am quite excited about this prospect, as it will certainly be nothing like anything I've done before.

What I've been reading

Overture to Death
by Ngaio Marsh

narrated by Ric Jerrom

"It was planned as an act of charity: getting up an amusing play to finance a new piano for the parish hall. The question now under bitter discussion is, who shall play the overture? Though Eleanor Prentice wins, on the night of the performance she cannot play. Miss Campanula steps triumphantly into the breach. A chord is struck, a shot rings out, and Miss Campanula is dead, shot between the eyes. Inspector Roderick Alleyn realizes she may not have been the intended victim and sets the stage for a repeat performance."

Well, it was OK. Good story, good characterisation, but a bit dated - not surprising since it was written in the 1930's. Having said that, it was a classic whodunnit, where all the clues are laid out for you. Was it the squire, the squire's son, the rector or his daughter, the doctor or the worldly lady or the nasty old maid (the other one, not the nasty old maid who was murdered)? My only quibble is that the characters are all a bit one-dimensional. Two nasty old maids? A soft-hearted widowed vicar? Young love! Even the Inspector becomes uncharacteristically soppy at the end.

Leave it to Psmith
by P.G. Wodehouse

narrated by Jonathan Cecil

"The idyll of Blandings Castle is about to be disturbed, for the Hon. Freddie Threepwood is poised to make his debut as a jewel thief. Freddie, however, is not alone: Blandings is simply brimming with criminals and impostors all intent on stealing Aunt Constance's £20,000 diamond necklace."

This is a repeat performance, the first in the history of this blog, so I'm not sure if it should feature for a second time or not. What happened was that I ran out of audiobooks and podcasts, and rather than buy another book or wait for the next monthly book credit to arrive, I thought I'd revisit a previous one. It's really good, though, worth a second listen. I love the turn of phrase that Wodehouse uses. For example, Psmith (the P is silent) is a natty dresser and cares about how he looks, but is asked to wear a chrysanthemum so that he can be recognised at a meeting point. "That's a chrysanthemum?" he asks the flower seller disparagingly. "Just one?" He then describes walking through town 'behind the shrub'. It's all about the words, and luckily the readers they use for professionally recorded books know how to make the most of them.

Don't get burned

The last couple of bits of coursework have involved presentations, the first about burn injury and the second about coffee and Parkinson's disease. I've written at length about the second (and it went very well in the end), but the burn injury one was actually much more interesting.

It was in the Medicine and Pathology module, which has been taught over at the Medical School rather than on our Biosciences campus. We've had the most wonderful lecturer I've ever encountered, who delivers lectures that are so interesting that I want them to go on longer, even though the Medical School is further from home and I get home pretty late anyway. He will ask the class a question, and although you give an answer that's completely wrong in every respect, he can tell you the right answer and still make you feel good about yourself.

So the task for this module involved 12 case studies, which were randomly allocated to groups of 2 or 3 students. We all went away, researched our topics, and came back to give a presentation to enlighten the rest of the group on our particular subject. Each presentation was supposed to be about 10 minutes plus time for questions, which isn't really very much time, but when you have 12 of them to get through... well, it drags on, especially if they're a little bit boring. Some of them were indeed a little bit tedious, and many of them concerned subjects that aren't very thrilling - an overweight woman with type 2 diabetes, someone with gestational diabetes, a man with Metabolic Syndrome, which is officially the most uninteresting condition in the world. I challenge even the most inspirational speaker to make the subject of fluid accumulation interesting. As we reached the last presentation my head was almost on the desk and I was wishing for it all to end.

Our subject was the only emergency situation out of all of them, and I think we were lucky to get it, compared with some of the other topics. Here are some things I didn't necessarily know about a burn injury before this assignment:

• The patient almost always has to have a breathing tube inserted - if not because of heat or smoke inhalation then because of fluid pressure later on. If the gas exchange surface of the lung is badly damaged, you're really in trouble.


• For the first 48 hours or so the capillaries become leaky, fluid and protein flood out of the blood into the tissue (which is where the fluid pressure comes from that might restrict the airway) You have to set up intravenous infusion to replace the fluid pretty quickly, and put in a urinary catheter so you can monitor fluid out as well as fluid in.


• The skin damage is categorized according to the depth of the burn and the percentage of total body surface area (TBSA) that's been damaged. Anything more than 10% TBSA of superficial burn is starting to get serious.


• Skin that has been burned loses its elasticity. If the burned skin goes all the way round a limb, then it can act like a tourniquet and restrict the blood supply to the extremities. The answer is simply to slice longitudinally through the dead tissue to relieve the pressure - this is called escharotomy. Apparently it's not done under anaesthetic because the nerves have been destroyed in the dead tissue that's being cut through.


• If the burned skin surrounds the chest, then it can hinder chest inflation and affect breathing. Same treatment: escharotomy, in a "W" shape over the chest. Nasty.


• Full depth burns provide a perfect environment for bacterial growth, which is why most patients with serious burns used to die from infections. Nowadays, the recommended treatment is to cut out all the dead stuff and close the wound within a week, using skin grafts.


• There are various types of skin grafts, the best obviously being the patient's own skin harvested from a part of the body that hasn't been burned. If there isn't enough of this, they put it through a cutter that allows it to form a mesh, like expanded aluminium or the lattice on a pie crust, so it covers more area.


• Nutritional support is really important, because the body mobilises all the protein it can get its hands on to repair the damage and replace the proteins that have been lost from the blood through the leaky capillaries. It uses stored energy and protein from muscle to do this, which can lead to fatal wasting if you don't get energy and protein into the patient somehow.


• There is quite a risk of hypothermia, given the damage to the insulating layer of skin, the cooling effect of fluid evaporation, and the patient's metabolic rate being all over the place. You cover them up, and then pipe warm air under the sheet. Hospital burns units are HOT.


• Pain relief. Stands to reason.

The main conclusion to all this research was: don't get burned, it's really nasty. Really, very unpleasant. What's more, if you're lying there immobilised in hospital, bandaged up like a mummy and in serious agony, a physical therapist will come round and make you move all your joints so they don't seize up. The interview for those guys must include something like "Do you enjoy inflicting pain as part of your job? Your last job was as a professional sadist? Good, you'll do."

So now I have just one more bit of coursework to do, and two more scheduled lectures - one today, and one next Thursday. I have four exams, starting on 19 May and ending on 27 May, and if I get on really well then we may be able to go to one or two days of the music festival that takes place over the weekend before the last exam. We bought the tickets two years ago but it's been cancelled twice - I wouldn't have chosen to buy tickets for this year's event, given the timing.