Amyotrophic Lateral Sclerosis (ALS) is a terminal illness of the nervous system, resulting in the degeneration of neurons. When the motor neurons in the lateral spinal cord degenerate, the muscle cannot be stimulated and gradually atrophies. As the disease progresses, the brain cannot initiate and control muscle movement, so voluntary muscle actions, such as reaching for your phone or typing on a keyboard, are lost. Currently there are no treatments or cures to reverse the effects of ALS and the disease process is still widely unknown. Some noteworthy individuals diagnosed with this disease have included Lou Gehrig, Stephen Hawking, Jon Stone, George Yardley, Henry A. Wallace, and Steve Gleason. These are the facts, but I could have never realized what living with ALS was like until I listened to a retired senior, a teacher, and a musician tell me their stories.

The older couple told us of their past year as the husband wrote on an electronic note pad to fill in the gaps of his spouse’s version of their story. They had first noticed his symptoms when he began choking on his food, and they had to adapt as the disease progression got more and more severe. His wife comically said that she doesn’t know where to look when he’s trying to talk to her – “Should I look at his eyes, his mouth, this pad?” Every day, they had to face a new challenge and overcome it together, as a family.

Another patient was a mother, a teacher, now wheelchair bound and with a respirator to help her breathe. Because of her age, none of her physicians expected ALS and thought she was struggling from carpal tunnel syndrome or an ulnar nerve injury. She told us her husband was her biggest caregiver and supporter; her husband joked, “She makes the list and I carry it out.” He talked about his struggles, working full time as well as being a full-time caregiver for his wife and their 3-year-old daughter, as well as still finding time for self-care. Even with all this juggling, he felt guilty. This guilt was expressed by many of the caregivers: some because they didn’t even notice the symptoms and others because they felt like they couldn’t help their spouses. Guilt was felt by the patients too. The mother was upset because her daughter would only remember her in a wheelchair. Despite the difficulties, family was a major support system for each patient.

When asked about how she felt after getting her diagnosis, the musician said, “I felt like a deer in headlights… I never pictured I was going to go out that way… with a terminal illness… Last year I had no trouble walking, singing, cooking, gardening, and this year…” Despite all of this, she said she felt relieved. Her struggle to find a neurologist who respected her was heartbreaking. She had gone to a physician because she felt helpless; she was having trouble playing guitar, she was losing her identity as a musician. However, the physician assumed from her past medical history of anxiety that she was having mental issues with memory, anxiety, and depression. As she continued to receive hostile treatment, she found a second doctor who listened to her. Unfortunately, even though he took her seriously, he didn’t have the courage to diagnose her with ALS, telling her instead that she had a motor neuron disease and referring her to a specialist. When she finally received the diagnosis of ALS, she was relieved. She no longer felt crazy. She was able to be heard. She was able to communicate with someone who wanted to help her. ALS is already a hard disease to diagnose; not having someone on her side only made her situation more difficult. She says now, as each symptom appears, she isn’t afraid anymore, because she knows it’s ALS. This relief of having a concrete diagnosis, of having a diagnosable disease, even one that is untreatable, was reiterated by several of the other panelists.

Although a diagnosis was a relief for many of the patients, they all saw the importance of taking part in clinical trials. They recognized that ALS affects everyone at different times in different ways and hoped that one day they could explain why this illness is so hard to detect and track. Participating in various studies and trials made them feel like they were helping future patients and physicians to be able to better understand why this terminal disease can strike at any time, with no discernable warning signs, affecting each individual uniquely in initial symptoms and progression.

Getting a concrete diagnosis gave these patients the freedom to seize the day and live in the moment. For the musician, as her ability to play guitar diminished chord by chord, and she started slurring her words, preserving her voice and her identity became very important to her. She is using a message banking app to preserve her voice. The software requires her to read thousands of words and sentences. Although she had to accept the things she could no longer do, she realized that she did not have to give up her identity or love of music because of ALS. Overflowing with her love of music, she told us about how when choirs sings together, their hearts become synchronized; and how music lowers blood pressure and stimulates all areas of the brain. As she interwove details about her symptoms with her favorite song, Fire on the Mountain by the Grateful Dead, the two had become part of the same spiritual transformation. Smiling peacefully, she explained, “Maybe nobody else hears it the way I do. I see death as the final healing, finally being released from your body.” She viewed her diagnosis as graduating early and the symptoms that came attached with it as her disappearing slowly, rather than all at once. The unavoidable indignities were just something she had to accept. What mattered most to her was keeping her individual personality in the face of intense daily struggles.

By the end of our discussion, I felt the weight of my white coat as I never had before and recognized that this would be the first of many times that I would have to carry this symbol of patient advocacy. As these patients spilled all their vulnerabilities to a group of 50 students, I realized the most important thing I will learn in medical school is opening my heart without getting crushed under negativity. I learned that, as doctors, we have the tendency to think the ultimate solution is life, when in truth, mortality is the reality. What matters is being present when there is a fire, realizing that “a pail of water” may not be enough to put it out, but continuing to carry that water for your patient.

Long distance runner, what you standin there for?
Get up, get out, get out of the door

There’s a dragon with matches that’s loose on the town
Takes a whole pail of water just to cool him down
-The Grateful Dead

After the discovery of using steel to reinforce concrete, reinforced concrete buildings became extremely popular and presented a significant solution to the housing needs of urban populations.

The composition of concrete

Concrete is a structural material formed via blending sand, gravel, cement, and water. The specifications and ratios of the materials present in the mix directly determine the quality of the concrete. Generally, this ratio is 31 sand, 46 gravel, 15 cement, and 8 water. These ratios may vary depending on the construction needs.

The mixture of sand and gravel is described as an aggregate. Usually, aggregates up to 7 mm are called sand, and aggregates between 7-70 mm are called gravel. The most important role of the aggregate as a fill material is to reduce the volumetric changes of the concrete. The dough composed of water and cement displays great changes in volume. The introduction of sand and gravel into the cement helps to lessen these changes and also saves resources, since it is cheaper than cement. In order to obtain a concrete of good quality and applicable texture, the sand and gravel grains should be as round as possible and have similar diameters to each other.

Cement is produced from grinding a mixture of clay stones and limestone (CaCO3) that are cured at high temperatures. Cement is very important; when combined with water, it helps concrete to quickly solidify. The time the mix takes to solidify is called the setting time, and it is usually between an hour and an hour and a half, depending on environmental conditions. This time is shorter on warmer days and longer on colder days. Concrete begins to gain endurance (hardening) as it solidifies. It takes 28 days for the concrete to reach an endurance of 60-90 , and a much longer time to reach 100, depending on conditions. The cement amount in a cubic meter of concrete is called the dosage. One common and incorrect perception is that concrete endurance changes with the dosage. However in a mixture of a well adjusted sand and gravel ratio, concrete endurance depends on the water-cement ratio.

The water that can be used in the concrete mixture should be drinkable water that does not contain acids and salts. It is important that the water has a pH value higher than 7 and is free of carbonic acid, manganese compounds, ammonium salts, free chlorine, mineral oils, and industrial waste. Therefore, it should not be forgotten that sea water must not be used in the concrete mixture because of the salt it contains.

The properties of steel

Iron alloys that can be processed mechanically – either through pressing or rolling – are called steel. Iron is the most abundant metal in the Earth’s crust, making up nearly 4.5 of it. The most important element that specifies the property of steel is carbon. The role of carbon in steel’s structure is to harden the iron alloy and prevent the shifting of iron atoms. By adjusting the amount of carbon in the alloy, steel’s hardness, ductility, and endurance can be changed. Both the endurance and hardness of steel increases as the amount of carbon is enriched. However, this application increases steel’s fragility, reducing some of its features, such as ductility. Therefore, a 5 carbon level in the raw iron obtained through the melting of iron ore is decreased to 0.1 0.2, enabling steel to be processed. Iron alloys (steel) composed of elements such as carbon, silicon, manganese, chromium, copper, nickel and molybdenum are utilized in building structures.

The conformity of concrete and steel as reinforced concrete

Reinforced concrete materials are used in the construction of buildings, bridges, dams, and tunnels. The use of reinforced concrete became common at the end of the nineteenth century. For the best final product, the concrete and steel should be well integrated, and both should be of high quality.

Concrete and steel are two substances with very different characteristics. However, an inseparable coupling forms by balancing one’s disadvantages with the other’s advantages. Concrete is a material of high pressure endurance. And even though steel also has high pressure endurance, it still faces the risk of bending. The tensile strength of concrete is weak, but it is high in steel. Concrete is fire resistant; steel is vulnerable. Concrete is durable against external impacts, whereas steel is vulnerable, with a high risk of corrosion. Concrete has a brittle, breakable structure; steel, however, has a higher level of ductility. Even though concrete and steel generally behave the opposite of each other, they compensate for each other when they are together. For example, the tendency of steel to bend disappears after it is surrounded with concrete; concrete also increases steel’s resistance to fire and corrosion. Furthermore, with the steel’s presence inside it, the tensile strength of concrete is enhanced.

The first of the three characteristic features of reinforced concrete buildings is the compensation of all tensile forces via steel rods; the second one is the integration of concrete and steel into each other like the adherence of flesh and bone; and finally, concrete and steel have the same thermal expansion coefficients. The thermal expansion coefficient is the value that determines the amount a material will expand or retract when impacted by heat. The thermal expansion coefficients of substances on Earth vary greatly. For instance, aluminum has a coefficient of 2,2×10-5 L/0C, copper of 1,7×10-5 L/0C, gold of 1,4×10-5 L/0C and glass of 0,85×10-5 L/0C (L= Length). It is harder for materials of different thermal expansion coefficients to have conforming movements. The most important reason for the harmonious union of concrete and steel is that their thermal coefficient values are almost the same (1,2×10-5 L/0C). If this was not the case, because of the temperature differences of inside and outside environments, the concrete and steel that make up the reinforced concrete would expand at different speeds, resulting in cracks and fractures of the load bearing elements of the building (columns, beams, flooring).

Though concrete and steel have vastly different properties, their thermal expansion coefficient values are the same and this causes them to move together during temperature changes. A similar system is put to use during the creation of cartilage, bone, and connective tissues in our body. The fibers of the connective tissue resemble the iron and steel, the cells are similar to gravel, and the intercellular matrix resembles the cement. The difference is that this system is renewed dynamically, and is flexible and strong.