I have spent only 5 of the last 25 nights in a bed (4 different beds, to be precise). At this point I feel a touch claustrophobic in bathrooms and feeling clean is certainly a novelty. My Wilderness Medicine elective is over and I have had an exceptional visit in Moab (more on that in another post). Tomorrow I head to the mountains of Colorado for one last stint in the wilderness before heading back to New Jersey where I will start a radiology elective on June 3rd. From a month in the wilderness to an elective spent in dark, windowless rooms- the change in environment couldn’t get much more extreme (which is saying a lot, coming from someone who has gone from alpine camping to desert camping in the course of 3 weeks).
This is the final installment of “Pic of the Day”, at least for the Wilderness Medicine Elective. I may not be able to resist a “Pic of the Day, Moab edition”… we shall see.
For the desert portion of the course we headed to Canyonlands National Park, specifically The Needles District of the park. We spent 4 nights in 3 different sites, hiking up to 12 miles a day with heavy packs. I found this portion of the course the most physically demanding, but at the end of the day it was unquestionably my favorite section.
I’ll write details in future posts, but for now: Pic of the day- desert edition.
Day 1- Canyonlands
The geology of Canyonlands (actually, the geology of much of Utah) is stunning and fascinating. This is in the Needles District, near Lost Canyon, where we spent our first night in the park.
Day 2- Perspective
Looking back at Lost Canyon as we hike out to Elephant Canyon, our next campsite. From many vantage points in the park you could see the snow capped La Sal Mountains in the distance.
Day 3- Druid Arch.
Before we hiked our big packs out to Chesler Park, we took an early morning hike out to Druid Arch.
Day 4- The Joint Trail
One of the coolest trails I have every hiked, The Joint Trail winds through a narrow slot canyon.
Day 5- Sunrise and out.
We left camp at 4am for the 3+ hour hike out. I led the group of 19 by head lamp for 2 hours before stopping on a bluff to watch the sun rise around 6am. Pre-dawn hikes are something I will be adding to my repertoire.
I did not expect to fall in love on this trip, but I have certainly fallen in love with the desert. I don’t know when I’ll be back, but I hope it is soon…
My Wilderness Medicine elective has officially come to a close. In the last three weeks I’ve experienced three very different environments (alpine, river, and desert) and learned lots of pre-hospital medical care for emergencies that arise in the wilderness. I have quite a bit to write about, but I liked doing a “pic of the day” for the alpine session, so before I get to a thorough write up of the course I’ll post a “pic of the day” for the river and desert portions.
While the course is over, my adventure hasn’t come to an end. I’m currently taking 2 weeks of vacation time to visit with my best friend, first spending more time in Utah in and around Moab and then heading back to her home in Boulder Colorado. I hope to get some good writing in during this time… we shall see!
Without further ado- “pic of the day” river style!
Day 1- We started our adventure at the Sand Wash put in on the Green River where we camped, sans-tent, under the stars…
Camping under the stars.
Day 2- Over the next 5 days we travelled ~87 miles down the Green River, passing through Desolation Canyon and Gray Canyon. We saw a few different areas with petroglyphs, presumed to be from Fremont people.
Petroglyphs carved into “desert varnish”, which according to the river guides (and wikipedia) is at least partially made of manganese.
Day 3- Sun rising on the cliffs of Desolation Canyon. This pic is a bit deceiving, as we actually had more “bad” weather than good. I suppose we should consider ourselves lucky that we got to experience rain in the desert, but getting hammered with more than a third of the area’s average annual rainfall over 4 days could get a bit demoralizing!
The morning view from our campground. A great view by which to enjoy your morning coffee…
Day 4- Please allow me two pics for this day- I couldn’t chose just one (it would be easy to pick a gorgeous landscape for each day, but there really was a lot more to see).
The view from another campground…
Equipment at an abandoned ranch. During our float down the river we saw abandoned ranches, old mines, and even an old moonshine distillery.
Day 5- At the end of the day we would gather around a fire recapping the day, telling jokes, and marveling at where we were. Off the grid, without technology or the distraction of modern society, it was wonderful to decompress.
Social gathering place and hot spot for heating evening beverages.
Day 6- Our last day of camp was spent just below Rattle Snake Rapids (I loved going to sleep to the sound of rapids). We were pampered on this portion of the trip, being taken care of by river guides- renaissance men of the modern age. They’re guides, chefs, handymen, naturalists, historians, and fascinating individuals… I hope to reconnect with some when I return to Moab.
The nomadic life, with a new campground each night, was great- especially when gear was being floated down the river and not packed on our back!
I’ll post some pics from the desert section when I get a chance!
——-
And for the skeptics, who question whether there was any medical learning on this trip…
I’ll write more on the medical learning in a future post, but here you can see me rocking an improvised humeral splint… in a torrential downpour (thank goodness for Gortex!)
If you read my last post, you’ll know that I’m currently away in Utah on a Wilderness Medicine elective. I’ve just come back from the first evolution, the alpine section, and have one night in Salt Lake City before hitting the road tomorrow morning to head to the Green River and Desolation Canyon to take on the next portion of the course.
I certainly don’t have time for a thorough write-up of the last week, but I thought I’d give a quick “pic of the day” from the last week to give you an idea of what I’ve been up to. The pics certainly can’t show all the learning that’s been going on- while there is certainly a large component of this course that many would consider recreation, I think I’ve learned more practical medical skills in the last week than I have in quite some time. Sure- I don’t know when I’ll next be using an avalanche beacon or when I’ll next use an ice axe to “self arrest“on the side of a cliff, but the skills of dealing with medical emergencies is non-hospital settings and with limited means is certainly important.
Without further ado (and because I don’t have much time…)
T-minus 1 day… I went shopping. I knew I wouldn’t be enthusiastic about much of the food available on our trip, so I packed a significant personal stash to keep me going (I ate more nuts in the last week than I have in the last few months). I also rented double plastic boots, snowshoes, and an ice axe from REI.
Yes- I packed a stick of butter and a jar of coconut oil up the mountain… And if I never eat cold, unseasoned packages of salmon again, it will be too soon
Day 1- The hike up. I’ve never hiked in snowshoes with a big pack before, so why not add in dragging a loaded sled to the process! Our group of 20 (12 students, 4 residents, 2 fellows, and 2 attendings) hiked up to our site near Lower Red Pine Lake in the Wasatch Mountains.
Can you spot the avalanche beacons?
Day 2- Water. Our group was broken into 4 teams of students and residents, and each day we had different tasks. On our second day my team was in charge of water, which we filtered from this lake.
It is incredibly peaceful out on the lake pumping water (at least when it was warm enough that the water didn’t freeze almost instantly in the tubing).
Day 3- Snow. Yeah… this happened. A good 6” of “dust on crust”.
Fresh pow
Day 4- Home. This tent was my home for 6 days. I shared it with two other medical students, and with overnight temps dipping into the teens (F) I got very familiar with the workings of my 0o mummy bag.
Our camp was quite impressive- 7 tents, a double kiva with dug out benches and tables beneath, and a kitchen dug into the snow pack.
Day 5- Hike day. On our last full day we hiked up to the ridge leading to the false summit of Pfeifferhorn. The views were stunning.
Day 6- Out. This morning we woke at 6 to pack camp and head back to civilization. My feet won’t miss the heavy double-plastic boots, but I will definitely miss these mountains.
I plan to write more about the actual medical aspects of this course, but for now I hope you enjoy these pics!
And for those that see the t-shirt picture and think this was a warm-weather hike, this is how I was dressed most mornings in camp.
No- this isn’t another post about books (though I did enjoy the book of this title by Jon Krakauer and I love the soundtrack by Eddie Vedder). Rather- I wanted to let you all know what I will be up to for the next few weeks.
Wilderness Medicine is, well, kind of what it sounds like- providing acute medical care in various outdoor environments. Being an outdoor person, this was an area of medicine I’ve been rather interested in exploring. My school doesn’t offer a Wilderness Medicine elective but many schools do, and they generally welcome students from other schools.
A number of months ago I set to, looking at a number of Wilderness Medicine electives offered by other schools and organizations. There are quite a few options, but one, run my U Mass, really caught my eye.
I should interject at this point to say that, due to the timing of my PhD defence, I started the clinical years of medical school half a year off schedule with most students. Unfortunately, that meant that when I started looking at wilderness electives, I was a bit behind the eight-ball timing wise.
A number of months ago I sent an e-mail to the organizers of the U Mass Wilderness Medicine elective enquiring if they took students from other schools. They replied, kindly informing that they did but that the course usually fills up a year in advance (and it runs from the end of April for three weeks). Somewhat disappointed, I set up my schedule for the remainder of fourth-year medical school, sans wilderness medicine elective.
Fast forward to three and a half weeks ago when, out of the blue, I got an e-mail from the program coordinator asking me if I was still interested in the Wilderness Medicine elective. After some frantic shuffling of my schedule I was able to say yes, and have been hustling to get myself prepared ever since.
Bags are packed and I’m ready to go (both under 50lbs, though I’m getting close).
Tomorrow morning I leave New Jersey to head to Salt Lake City (and to think- I was there less than 3 months ago). After spending a couple days meeting up with friends and seeing the sights of SLC, I meet up with the students, residents, fellows, and faculty who will be participating in the Wilderness Medicine elective.
The main reason I was particularly interested in the U Mass elective was because it is a 3 week elective taught almost exclusively IN the wilderness (unlike some other programs that do a lot of classroom-based learning and then have excursions into remote areas).
The elective is broken up into 3 components, an alpine section, a river section, and finally a desert section. In each we receive faculty taught lectures, participate in scenarios, and hear (and give) student lectures (my topic is diarrhea and communicable diseases). I’ll write more when I return, but this is what I know for now.
The alpine section
We head up into the Wasatch Mountain range where we set up a base camp that we will be living in for the next 6 days. We snowshoe in with all our gear (apparently about 50lbs in our packs, plus pulling sleds, and then camp on snow for the next 5 nights. Here we learn how to live in the alpine environment, the basics of mountaineering, avalanche training, how to lift and move patients with spinal injuries, as well as attend lectures on topics relevant to the alpine environment.
The river section
After snowshoeing out of the mountains we have a day to recover in Salt Lake City before heading to the Green River for the river section of the course. Over the next 5 days we raft down the river (camping on the banks each night) and learn about water-associated injuries (drowning, of course), as well as other injuries and illnesses that occur in the bush, including fractures (and improvised splints), dislocations, wilderness dermatology, mammalian injuries, and evacuations.
After a transition day in Moab (where we can apparently opt to participate in outdoor activities of our choice, or perhaps enjoy a needed day of R&R), we then head to the desert portion of our course.
The desert section
Having had a chance to check out Moab, we head to Canyonlands National Park. Here, we hike into the desert (in smaller groups, so as to decrease our impact), and set up camp for 4 days. We meet daily for lectures on topics such as snakebites, heat illness and injuries, communicable diseases, wilderness toxicology, and other relevant topics while also learning skills such as orienteering and mass casualty training.
Throughout the course, in addition to many lectures, we participate in 12 “scenarios” which further train us for practicing medicine in the wild. There will be 12 medical students, 4 residents, and 2 Wilderness Medicine fellows, as well as faculty.
I’ll be interested to see what happens when it comes to camp dinners. They asked if anyone had “dietary restrictions”, with a special shout-out to vegetarians. While I’ll be willing to eat things that I usually don’t consume (rice and beans, for example), I really hope I’ll be able to largely avoid processed foods, grains, and vegetable oils… we shall see. I’m also a little nervous that I’ll get some foul looks for my choice of footwear. The packing list suggests bringing hiking boots (or maybe hiking shoes) for the desert and river portion: I have neither, and imagine that trying to get some and break them in would not be a good idea (not to mention that I am kind of opposed to thick soled heavy hiking boots). Instead, I have my minimalist trail running shoes and my vibrams… I’ve climbed a 13er in Colorado with them, hopefully I can hack it carrying a heavy pack!
Up Matterhorn in Colorado, happy in my VFFs.
So there you have it- starting Monday morning (maybe sooner) I’ll be off the radar for large chunks of time (though you wouldn’t know I was on the radar with the frequency of my blog posts). When the course is done, my best friend will be picking me up in SLC and I’ll be heading back with her to Colorado for a vacation before coming home to start a radiology elective in June. On the way back to Colorado we plan to spend a couple days in Arches National Park- since I’m sure my appetite for the outdoors won’t yet be sated.
A few months ago I did a two-week elective with our hospital’s Emergency Medical Services. Over those two weeks I saw all manner of medical “emergencies”. Some were true emergencies, but plenty were BS calls where first responders and ambulances were called into action when what was really needed was an $8 taxi ride to the emergency room (or even better, $8 worth of broth and a couple days in bed to get over the flu, but I digress).
I met some wonderful first responders on this rotation. People that really want to help others and who obviously get a high from the adrenaline of being called to duty in an emergency. As I saw bits of the recent Boston and Texas events unfold I imagined how the EMTs and medics I worked with would have jumped to duty in these situations. Indeed, many of them did 11.5 years ago when they responded to the attacks on the World Trade Centers. One of the women I worked with lost a friend who was responding that day.
Unlike the hospital environment, where people usually avoid any controversial conversations, I frequently found the topics of religion, politics, taxation, healthcare reform, and gun-control being discussed. The disagreement was sometimes vehement, and the conversations often heated, but there were never any hard feelings at the end of the day.
I worked with a number of EMTs and medics on my 2-week elective, but I bonded with one in particular. I think we had matching (or perhaps complementary) streaks of cynicism and optimism (yes, you can be both a cynic and an optimist. In my case, I think my cynicism protects my optimism from being snuffed out by reality). He asked if I had read The House of God [1], by Samuel Shem, (the nom de plume of psychiatrist Stephen Bergman), and when I said I had not he insisted that I must.
I ordered the book right away, but like so many excellent book recommendations, it took me a while to get around to reading it. I finally started a couple weeks ago, and quickly devoured the whole book.
The House of God is a satirical novel that portrays the life of a medical intern in the early 1970s. A lot of things have changed for interns since this book was published- the most notable (for the sake of this novel) is work hour restrictions. Nonetheless, there is much about this novel that made me, even as a mere medical student, laugh, cringe, and nearly cry. I have since recommended it to many other medical students and residents with the description that it is “brilliant, hilarious, and terrifying”.
The book is, of course, fiction, but it is, in essence, true. It is as poignant today as when it was first published in 1978.
Some of the scenes are things that I can relate to, if not describe verbatim, from my experience as a third year medical student. Some of the patients I have seen are the embodiment of the caricatures described in this novel. “The Yellow Man” with his failing liver, the (relatively rare) young patient who invariably has some condition we can not treat and who sadly dies, the (common) old patient that we can not treat effectively but that we can patch up well enough to carry on… These are patients I know, even though they are fictional.
I won’t write a review of the book- it is brilliant, and I think everyone involved in the medical community should read it. I find myself wondering what non-medical people think of the book… I suspect it would be hard to decipher satire from actuality- the line is definitely not clear, even for those who work in the medical community.
The House of God uses terms that are familiar to those who work in a hospital- and I’m not talking about words you find in a medical dictionary. The term “turfed” is when a patient is moved from one medical team to another (such as from a general team to a specialty team, or vice versa), a “bounce back” is a patient that your team treated who was then transferred to another team or discharged from the hospital, only to “bounce back” to your service. The term “gomer” is one that I write with some reluctance. It is a word that I have never heard uttered in the hospital, and have only heard in “humanism” lectures (in which it was made clear that no one should ever use the term), which describes “a human being who has lost-often through age-what goes into being a human being”. The House of God is how this term first became well known, a term that is an abbreviation for “Get Out of My Emergency Room”.
The same author, again under his pen name, published a piece in 2002 in the Annals of Internal Medicine entitled “Fiction as resistance” [2], in which he describes using storytelling to illustrate, and retaliate against, the brutality and inhumanity of medical training and the practice of medicine. Fiction makes reality palatable.
In this article Shem writes about how he encourages people to resist the inhumanities of medicine. The keys, he believes, lie in (1) learning our trade and being aware of the world around us and our patients, (2) avoiding isolation, (3) speaking up, and (4) learning empathy. I am not sure how one learns empathy. Sadly, some aspects of medical practice almost seem designed to dispatch it.
Just as I finished The House of God, my mother sent me a book for my upcoming birthday. I’ve quickly read about half of On Call: A Doctor’s Days and Nights in Residency[3], written by Emily Transue, an internist on faculty at the University of Washington.
Reading these books in immediate succession is powerful. One is satirical fiction while the other is reality, but if you changed the writing styles you could easily swap the real stories for the fiction. Both write of the dehumanization that occurs during medical training, but Shem follows the adage “if you want to tell people the truth, make them laugh, otherwise they’ll kill you”.
Sometimes I think I’m too young, too “wet behind the ears”, to write about dehumanization in medicine. I’m only a fourth year medical student, how much have I really seen. Other times (well, most of the time), I worry that expressing my feelings, especially in writing especially on the internet, is just asking to have things I say come around and bite me at some point in the future…
Another part of me, however, thinks that medical students are best positioned to recognize dehumanization in medicine. We are the least indoctrinated, the least hardened. As students, we also know that there’s a lot we can’t do. The idea, of course, is that with training we will be able to fix people, heal people, make things better. Sometimes we can; frequently we cannot.
As students, we know that we are fairly powerless in the management of a patient’s medical care. This can be frustrating when you think there is something that could be done that might help a patient, but also leaves you in a position where you don’t feel like you’re personally failing a patient when there is little to be done (at least medically speaking). When those with more medical clout, more medical ability, are faced with a situation where the best medicine we can offer will do little good, they sometimes have a hard time letting go. As if saying “there are no more medical options we can try” or “this isn’t going to get any better” is admitting defeat.
Perhaps it is defeat. But maybe in this circumstance admitting defeat makes you better. When you realize that you have exhausted your medical options, perhaps you can finally treat the person, not the disease. It’s just a shame that we don’t always treat the person first.
1. Shem, S., The House of God. 1978, New York, New York: Dell Publishing.
2. Shem, S., Fiction as resistance. Ann Intern Med, 2002. 137(11): p. 934-7.
3. Transue, E.R., On Call: A Doctor’s Days and Nights in Residency. 2005: St. Martin’s Griffin.
I’ve previously written about the benefits of squatting for ailments of the gastrointestinal tract, specifically diverticulitis and hemorrhoids. Some argue that squatting to defecate can prevent all manner of illness and while there are some clinical conditions I’d like to explore further in the squatting-in-the-bathroom paradigm, today I want to write about something quite different.
I finished my Obstetrics and Gynecology clerkship 5 weeks ago. I did my clerkship at a large, and rather posh, private hospital that is affiliated with my medical school. There are some great doctors there, but I was sometimes aghast at the rather aggressive approach to delivery that many took. The cesarean section rate for the last year was 47%, well above the national average of 33%, and most labors were artificially augmented. I did not witness a single VBAC (Vaginal Birth After Cesarean), and was told that only one of the house attendings would perform them.
On the first day of my clerkship, I asked the clerkship director if women delivered in a variety of positions or if they were restricted to delivering in lithotomy (what many today think of as the “traditional” birthing position with the mother on her back with her feet in stirrups). The director seems to be a rather progressive woman (she is the driving force pushing the hospital to become a “baby-friendly hospital”) and she gave me a rather knowing look and said “I know what you’re getting at, but unfortunately everyone here delivers lying down”.
Indeed, as I went through my rotation, all the vaginal deliveries I saw were done in the semi-reclined position that is common in western hospitals. This is not universally true. When I ask my family physician (who actually delivers babies- quite a rarity in this day and age) what position her patients delivered in, she immediately responded “whatever position they’re most comfortable in!”, a response I have heard from a few other MDs as well as many midwives and labor coaches.
Birth is, of course, a risky thing… Death in childbirth was historically a significant cause of mortality, and the rates are still high in some countries. I think it’s important to recognize that birth is still a risky endeavor, and while pregnancy and labor is a normal human experience, it is one that comes with real dangers. Nonetheless, just because historic rates of maternal demise were much higher than they are today does not mean we should not cast an eye to historic practices when thinking about birth. As I’ve argued before, I think modern medicine (in obstetrics and in most fields) could greatly benefit from casting an eye to evolution and our ancestors to further improve our current medical system by combining ancestral and evolutionary knowledge with modern technology and science.
I planned to write a significant argument for the consideration of “non-traditional” (though they are, in fact, traditional) positions for laboring, but then I came across a book from 1883 that said it all already. The book, entitled Labor Among Primitive Peoples (with the subtitle Showing the development of the obstetric science of today from the natural and instinctive customs of all races, civilized and savage, past and present.) by George Julius Engelmann MD, is available in it’s entirety thanks to the power of Google Books.
This book is fascinating, and at many times frightening (more on that later), but I found the “Posture in Labor” chapter of particular interest for this post. There, the author divides the positions into 3 main categories: Perpendicular (including standing, partially suspended, and suspended), Inclined (including sitting erect, squatting “as in defecation”, kneeling, and semi-recumbent), and horizontal (on the back, side, or chest and stomach (!)). He also goes through the then common birthing practices of countries in Europe, Asia, Africa, North America, Central and South America, and Australia and the surrounding islands [1].
Curious?- here are some highlights from the book, but I highly recommend you take a scroll through the book to at least see the illustrations!
The squatting position of the Tonkowas- a Native American group indigenous to present-day Oklahoma and Texas.
The squatting tradition of the Pawnee Native Americans- the laboring mother squats with her back to a female assistant while someone (in this case a shaman) assists with the delivery. This position (with an assistant acting as a back support) was apparently popular in many cultures around the world.
If you’re curious (as I was) about what a “suspended” birth looks like, here you go.
There is plenty to be said on each of the positions mentioned, but for the sake of this post I will focus on what the author says on squatting. He states that squatting
is hardly to be defined with exactness, yet we may, in a general way, consider all postures as squatting which resemble that assumed in defecation. Though apparently inconvenient, and repugnant to the refined woman, this position is certainly the most natural one for expulsion from the abdominal or pelvic viscera, and will certainly, in many cases, facilitate labor. (72)
He documents the experience of another physicians, saying:
“… he tells me of attending a lady of good position in society in two labors. ‘In her first labor, delivery was retarded without apparent cause. There was nothing like impaction, or inertia, yet the head did not advance. At every pain she made violent efforts, and would bring her chest forward. I had determined to use the forceps, but just then, in one of the violent pains, she raised herself up in bed and assumed a squatting position, when the most magic effect was produced. It seemed to aid in completing delivery in the most remarkable manner, as the head advanced rapidly, and she soon expelled the child by what appeared to be one prolonged attack of pain. In subsequent parturition, labor appeared extremely painful and retarded in the same manner; I allowed her to take the same position as I had remembered her former labor, and she was delivered at once squatting.” (73)
Information on traditional birthing positions can also be wrought from the Old Testament. The King James translation of Exodus 1-16 says “When ye do the office of a midwife to the Hebrew women, and see them upon the stools…”. However there is some scholarly debate about the translation of the word “stools”, as a more accurate translation might actually be “stones”. You might wonder what stones have to do with birthing, until you see this depiction of a popular Persian birthing position.
If you’re curious (as I was) this is what a “suspended” birth looks like, here you go.
A friend recently shared a video of women delivering in the squatting position. I post this video with the STRONGEST OF WARNINGS. I warn (only slightly jokingly) that that which is seen, cannot be unseen*. Proceed at your own risk! Birth is magical (though not mysterious), but some people find the imagery rather disturbing.
With that warning in place, I present the following video:
Those that have seen (or perhaps experienced) birth in the modern conventional position will probably agree that these women make labor look somewhat easy…
It’s also interesting to explore the delivery position of some of our closest living ancestors. It appears that chimpanzees naturally deliver in a squatting position (with a similar “occiput anterior” presentation).
One of the most basic elements of obstetrics that we learn in medical school is the “7 cardinal movements” of delivery. Medical student must know these movements- engagement, descent, flexion, rotation, external rotation, and expulsion- and on the labor and delivery floors we are expected to participate in and assist with deliveries. I remember watching many of my classmates “air-deliver” babies- going through the maneuvers of “catching” (a much more honest term than “delivering”) a baby, as we discussed these cardinal movements. While I understand that it is important to know these normal movements, the idea that a physician actually guides these movements is laughable. Truly, in most deliveries, our hands are there to catch and support. In fact, they are likely only necessary because of the position that we have developed for women to deliver. In this youtube video explaining the 7 cardinal movements, the doctors hands only show up once the head is expulsed so that the baby’s head does not rest on the perineum. Indeed, “protect the perineum” is the mantra chanted to med students and novice doctors learning to deliver babies in a reclining position. In the squatting position, gravity protects the perineum.
Support is needed because of maternal positioning, not intrinsic necessity.
Gravity isn’t the only reason to consider delivering in a squatting position. I’ve heard it said (though haven’t found a reliable source) that squatting not only increases a woman’s ability to push (allowing her to better utilize her abdominal muscles), but also helps the pelvis open wider for delivery (due to the pull of abducting muscles). In this position, and with the aid of gravity, it seems (and again I’ve heard it suggested) there is a lower risk of a perineal tear, something that I saw all too frequently during my Ob clerkship.
Squatting is by no means a perfect solution to birthing. According to at least one study conducted in Nepal, squatting deliveries (along with multiparity and early age of first birth) are associated with an increased risk of pelvic organ prolapse later in life [2]. Also, opting for a squatting delivery removes the option of an epidural for pain control. An epidural causes a loss of sensation below the level of anesthesia, thus making walking (and squatting) impossible.
Squatting is not the only traditional (though now it would be classified as “non-traditional”) birthing position that women can consider. I whole-heartedly appreciate my family physician who encourages women to find a position that is most-comfortable for them. Hands-and-knees (exactly what it sounds like), has actually been studied in the first stage of labors for mothers whose babies are delivering in the occiput-posterior position. While the study was small, the findings were encouraging [3].
Sometimes when I talk about evolutionary and ancestral medicine people assume that I am anti-modern medicine. I am not. In childbirth in particular, modern advances in general health, pre-natal care, diagnostics, medicine, and surgery have saved countless lives. I am, however, in favor of assessing (and re-assessing) our beliefs (new and old) about how to best obtain and preserve health.
I find Dr. Engelmann’s book fascinating, and while there are elements that are rather disconcerting (the traditions of male and female circumcision, a surgery performed on men to decrease fertility, and the tradition in one culture of removing one testicle to prevent the conception of twins to name a few), I find his observations and his humble admissions (as well as his love of commas) lovely. His conclusions are well worth reading (emphasis mine):
Abler obstetricians than myself have undoubtedly understood the movements of women, and the positions which they assumed in the agony of the expulsive pains. As regards myself, I must candidly confess this was not the case; and it was not until I had undertaken this work, and had begun to study the positions assumed by savage and civilized people during labor, that I began to understand that there was a method in the instinctive movements of women in the last stage of labor. I had seen them toss about and sought to quiet them; I bade them have patience and lie still upon their backs; but, since entering upon this study, I have learned to look upon their movements in a very different light. I have watched them with interest and profit, and believe that I have learned to understand them. It has often appeared to me, as I sat watching a tedious labor case, how unnatural was the ordinary obstetric position for the parturient woman; the child is forced, I may say, upwards through the pelvic canal in the face of gravity, which acts in the intervals between the pains, and permits the presenting part of the child to sink back again, down the inclined canal. If we look upon the structure of the pelvis, more especially the direction of the pelvic canal and its axis, if we take into consideration the assistance which may be rendered by gravity, and, above all, by the abdominal muscles, the present obstetric position seems indeed a peculiar one.
The contractions of the previously inactive and rested abdominal muscles are a powerful adjunct to the tired uterine fibre, in the last prolonged and decisive expulsory effort, and in the dorsal decubitus they are somewhat hampered; they act to the best advantage in the inclined positions, semi-recumbent, kneeling, or squatting. We know that the squatting position is the one naturally assumed if an effort is required to expel the contents of the pelvic viscera; we, moreover, all know how difficult, even impossible, it is for many to perform those functions recumbent in bed, and mainly because they have-not sufficient control of the abdominal muscles in that position. Much more is this the case in the expulsion of the child; but the recumbent position is sanctioned by custom; it is pointed out as apparently convenient; it is imperatively demanded by prudery; and by a false modesty which hides from view the patient’s body beneath the bed clothes; and above all it is dictated by modern laws of obstetrics, the justice of which I have never dared question; we have all been taught their correctness, and we all thoughtlessly follow their dictates. There is no reason for assuming this position, though we are taught it; it is not reason, or obstetric science, but obstetric fashion which guides us,- guides us through our patients; and blindly do we, like all fashion’s votaries, follow in the wake. (140-141)
Obstetrics is a specialty where many do not want to question the norm. Indeed, fear of litigation generally pushes physicians to be overly aggressive in managing labor and quick to opt for cesarean delivery. Randomized controlled studies that push the boundaries of modern “obstetric fashion” are unlikely to be performed for fear of litigation, but observation of mothers who choose to deliver in various positions as well as consideration of ancestral practices can potentially help drive modern medicine to a higher standard.
The “progression” of the obstetrical chair. The first stool is not unlike some modern birthing stools, while the final incarnation is not too far displaced from the modern delivery-room bed.
*A brief story from when I was on an Emergency Medical Services elective. The ambulance I was on was called to back up another team that had gone to attend at precipitous delivery. When we arrived, it became apparent that we were not there to assist the patient (it was her fourteenth (!!!) delivery), but rather to make sure that the EMT who had just witnessed his first delivery did not pass out. He had a very pale and shocked look to him, and he just stared at us blankly as we helped the mother with her new child. After a couple minutes, he looked at us and asked “does the mental image ever go away?”. He later admitted that he didn’t want to sleep with his girlfriend for at least two weeks… I believe this is what a good male friend of mine describes as figuring out the difference between “medical vagina and sexy vagina”.
1. Engelmann, G.J., Labor Among Primitive Peoples. Second ed. 1883, St Louis: J.H. Chambers and Co.
2. Lien, Y.S., G.D. Chen, and S.C. Ng, Prevalence of and risk factors for pelvic organ prolapse and lower urinary tract symptoms among women in rural Nepal. Int J Gynaecol Obstet, 2012. 119(2): p. 185-8.
3. Stremler, R., E. Hodnett, P. Petryshen, B. Stevens, J. Weston, and A.R. Willan, Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth, 2005. 32(4): p. 243-51.
And finally, for your viewing pleasure, this classic:
It has officially been one year since I started blogging (1 year and 4 days if you’re being exact). Starting blogging as I started third year medical school was probably not one of my smartest moves. Third year medical is tough, mainly by being incredibly demanding of your time and sanity. All the same, I’m really glad that I finally started putting words-to-website and getting some of my thoughts out there for others to read. Blogging is something I had wanted to do for a while, but wonderful people though they are, I think my parents might have disowned me if I’d started writing a blog before I’d finished writing my thesis!
Starting blogging during my clinical years has led to a couple things. First- I haven’t been able to put the requisite time into a number of the topics I originally wanted to write about (though I plan to get to these topics eventually!). Second- I’m surprised by how much I want to write about clinical situations and my general experiences on the floors. Together, this means that my blog is slightly different that I had initially imagined and that I have a long list of potential future blog posts (as well as a folder on my desktop with a significant number of “started posts” that may never see the light of day or the glint of a readers eye).
I sincerely want to thank everyone who has joined me over the past year on my blogging journey. I deeply appreciate that you take the time to read my musings. I really enjoy getting comments and I apologize that I sometimes get too caught up to reply to all the thoughtful responses.
I also want to thank everyone who has shared my blog and my posts. I’ve had a couple big days when some rather “big shot” bloggers have shared my posts (most recently Mark Sisson gave me a big bump when he shared my snuggling post in last week’s “Link Love”) but I really appreciate (and am humbled) that readers like my posts enough to share them on facebook and twitter . One of the fun elements of having a blog (at least for those with a significant nerdy streak) is keeping an eye on the statistics generated by your blog host… more on that later!
Exciting News…
I’m very excited to announce that I have been invited to speak at the 2013 Ancestral Health Symposium this August in Atlanta. I attended the last year’s conference in Boston, and am excited to be speaking on one of my favorite subjects, lipids and liver, at this year’s event. Tickets are already on sale for society members and early registration starts for non-members on March 15th. The symposium sold out the last two years, so if you plan to attend make sure you reserve your tickets early!
In addition to giving a talk on liver and lipids, I’ll also be heading up a panel of ancestrally minded physicians. The details are yet to be settled, but with a panel including Dr. Emily Deans (of Evolutionary Psychiatry), Dr. Anastasia Boulais (of Primal Med Ed), Dr. Jacob Egbert, and Dr. Don Wilson, I’m sure there will be some interesting discussion exploring how to use ancestral and evolutionary thinking in a variety of clinical fields including psychiatry, hospitalist practice, physiatry, and ob/gyn respectively. More details to follow!
Fun with Stats…
As I mentioned above, one of the joys of having a blog (at least for those of us with a nerdish interest in numbers) is keeping an eye on the blog’s stat page. In addition to showing me which posts are popular and why, it also shows me the search terms that navigate people to my page. “Principle Into Practice” is a popular google search that navigate people to my page. Some of the more obscure ones are a little more puzzling (and amusing). Here are some favorites:
Help me, I’m dating a medical resident
- “Dating in medical school”, “dating a medical student”… some variation on this theme is one of the more popular phrases that gets people to my blog, no doubt linking them to this post . I’m sure that’s not the kind of dating advice the googlers were looking for- sorry! As for actually dating a med student? Good luck… the first two years are probably more “dating friendly” as the schedule (at least at my school) is quite flexible, but my experience with third year is that your time is generally spent in the hospital or sleeping. Date a med student at your own peril- they will undoubtedly want to practice physical exam skills on you and they’re probably a bit short on time for making much of a relationship. Also, if you think dating a medical student is bad, I can only imagine the horror that is “dating a medical intern”. Their schedule makes a med-student’s schedule look like a walk in the park!
Can you burst your appendix by eating a lot of pickles
-Umm… no
Can you get out of the country if you have c difficile
- Actually, a lot of people are walking around with C. diff in their system. Problems arise when you have an overgrowth, at which point you probably can’t be anywhere too far from a toilet… (and you need prompt medical attention)
Victoria Principle nude
-This web-surfer undoubtably went away disappointed…
Asparagus therapy and human parasites
also
C. diff and asparagus
-I got nothing…
How to sleep during medical school
- My answer? As much as you can, whenever you can. Refer back to “dating a medical student” if you’d like.
What speciality [sic] in medicine combines clinical practice and evolutionary theory
- I’m not sure, but if you figure it out, please let me know! (Actually, as I’ve argued before, I think there’s a need for an evolutionary perspective in ALL fields of medicine, though perhaps some have more opportunities for evolutionary thinking than others.)
Most search terms guide the seeker to appropriate pages, and I hope that my posts enlighten and entertain. Many of my favorite posts, some of which are also my most popular posts, can be found here on my “Favorites” page, if you’re ever looking for some interesting posts you might have missed!
A final thanks….
I said it before; I’ll say it again. Thank you to everyone who reads, shares, and/or comments on my blog. It’s been a fun year of blogging and I’m looking forward to more posts, speaking at AHS 2013, and continuing to interact with readers, friends, and those who share an interest in ancestral health and evolutionary medicine… and also those who are curious about dating in med school!
