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Where’s the beef?!

Yesterday I helped bring a baby calf into the world.  Today I was at the other end of the spectrum, taking a trip to our butchers to see four sides of our beef cut into retail cuts.  The circle of life. (Apologies if you now have scenes from The Lion King flashing before your eyes!).

 

For the last few years I have been the point person for selling our family’s beef. Whether it’s friends from college or people from the gym, I have a pretty good pool of people who are interested in locally-raised grass-fed beef.

 

If it’s not obvious, I LOVE beef.  I like to cook it (all of it, including the odd bits!), I like to eat it, I’m interested in the ethics of it, I’m keen on the impact of local grass-fed beef for the economy and the environment, and I’m interested in the potential health benefits of grass-fed beef.  Oh, and I’m all about saturated fats.

 

When I talk to friends and potential customers about our beef I can talk about our animals, recipes, or anything else on the list above, but when it comes to discussing the traditional bits of the animal I sometimes find myself woefully unprepared.  Yes, I can explain that you either get T-bones and Porterhouse or Filet and Strip Steak (those are the options when it comes to the loin of the animal- we’re not going to discuss grinding it!), but quite how you break down the round, chuck, and rib is a topic I sometimes skirt around (though I don’t skirt around skirt steak- it’s probably my favorite cut!).

 

Today was the day the butchers were cutting the last four sides of our beef, which had been dry aging in their cooler for the last two and a half weeks.  I just started an EMS elective that has me doing six 12hr shifts and I had today off, so I asked my butchers if they would mind me hanging out and hopefully learning a thing or two as they finished the work on our animals.  They kindly obliged, and I think they actually quite liked having a young lady around the place to liven things up!

 

When I first showed up they were half way through butchering the first side, which was now broken down into a number of primal cuts.  Primal cuts are large sections of the animal that are then cut down further into retail cuts.  Some of the names will be familiar. “Chuck” is the shoulder, “rib” is the next area back, followed by the “loin”, “sirloin”, and then the “round”.  On the underside of the animal, starting from the front, you have “brisket”, “plate”, and “flank”.  You also have the shanks, and some people break the sirloin down further.  The round is broken into a top round and a bottom round.  These are all names you may see slapped on a piece of meat in the supermarket, but seeing a carcass go from a hanging side to a retail steak helps put it all in perspective.

 

This is what a 400# side of grass-fed beef looks like!

This is what a 400# side of grass-fed beef looks like!

 

The rounds... Eye of round, bottom round, and top round from front to back.

The rounds… Eye of round, bottom round, and top round from front to back.

 

The butchers we go to have been in operation for 75 years.  They service the local farming community, and are butchers for people who raise a single animal for themselves as well as farms that are sending multiple animals to the butcher every week.  While there has certainly been an increase in nose-to-tail eating, I think my “paleo”/“foodie” customers are still somewhat in the minority in their preference to have tail, shin and marrow bones, and offal… “Everything but the squeak”, one of the old guys said.  These guys are good at doing simple, standard cuts, and if we ask for something special they try and oblige, but requests for flat-iron steaks and flap steaks have gone unanswered.  When I made a plea for the hanger steak today they gave me a questioning look, but obliged (I think many of their customers don’t even want skirt steak- the horror!).

 

Some beef options- the loin can be cut into T-bones and Porterhouse (bone in) or Strip Steak and Filet

 

T-bones-

T-bones

 

Strips- the other option (with filet mignon) for cutting the loin.

Strips- the other option (with filet mignon) for cutting the loin.

 

Roasts, steaks, or stew…

Some people want the big roasts all cubed for stew meat.

Some people want the big roasts all cubed for stew meat.

 

One of our other topics of conversation was the difficulty of USDA inspection.  Our butchers have a USDA inspector onsite 8hrs per day, 5 days per week, but for smaller butchers that is a burden they can not shoulder.  Likewise, while our butcher has stayed up to date with regulations and standards, some smaller butchers have not been able to keep up and have dropped their USDA inspection or closed.  It also seems that the mountain of paperwork is a real burden- taking the boss one full day per week to handle.

 

Talk of USDA was a bit demoralizing, but it was fun to chat with the butchers about meat.  I recently had a patient on the floors who had been a butcher (he was 85).  We talked about a number of things over his extended hospitalization, but if I really wanted to get him talking all I had to do was get him talking about meat…  Ask him about his favorite steak and he was off telling you about the best way to age things, the best part of the country for raising beef, and how he liked to cook things.  On the other hand, one of the guys I worked with today admitted that he sees too much meat during the day and doesn’t care for it much at home (this was not my problem- I was very keen to head home to a steak lunch).

 

I also asked the various butchers about their thoughts on grass-fed beef.  They laughed and said it was all the rage, but if they wanted something grass-fed they’d just walk outside and eat the grass themselves- give them corn-fed beef any day! They commented that grass-fed meat smelled different, looked different, and tasted different.  When I asked one of them how our grass-fed meat faired in comparison to other grass-fed animals the guy gave me a shocked look and said “This is grass-fed? I had no idea… All grass-fed? How’d you get all that fat on it?”  It is true that our beef had quite a bit of fat on it*, and for grass-fed meat had quite a bit of marbling.  British Whites are supposed to do well on grass, and my mother is very proactive with rotational grazing, so hopefully this is a testament to how good grass-fed meat is good meat!

 

London Broils being cut from the top round.  Good marbling for grass-fed beef.

London Broils being cut from the top round. Good marbling for grass-fed beef.

 

Short ribs. Our butchers tend to debone these and grind it all, but some people asked for them to be kept whole. They'd be trimmed, but it's still a high fat cut.

Short ribs. Our butchers tend to debone these and grind it all, but some people asked for them to be kept whole. They’d be trimmed, but it’s still a high fat cut from our grass-fed animals.

 

Seeing a side of beef broken down into retail cuts is quite sobering. For every 1000# animal there are only a few pounds each of skirt steak and flank steak.  For those who like these cuts, and eat them on a regular basis, it’s good to realize quite how limited they are (and to be thankful that there are those who don’t care for them!).  As delicious as some odd bits are, a commitment to eating nose-to-tail frequently means eating a lot of roasts and ground meat…

 

*As I said, there was quite a bit of fat on our steer.  I asked the guys to save me a couple boxes of trimmings so I could render it down for tallow.  I’ve done this the past few years.  It’s a messy task, but grass-fed tallow isn’t easy to come by and I like to use it in cooking and as gifts!

 

Tallow in the making.

Tallow in the making.

Rendering down trimmings for tallow

Rendering down trimmings for tallow

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*I suppose some warnings are in order.  Some might consider one or two of the following pictures graphic.  In comparison to my post on human delivery, however, this is totally G-rated!

 

My family boasts the largest herd of British White Cattle in the state.  I should probably admit that it’s also the only herd in the state and that up until a week ago that herd was an impressive five heifers (we recently sent 7 animals off to the butcher).  In the last week the herd has almost doubled (and should be truly doubled by mid November when our last heifer is due to calf).

 

This morning was a misty fall morning at our farm.

A misty fall morning at our farm.

 

Over the last week, while I have been on a palliative care elective having a lot of ‘end of life’ discussions, my mother has been keeping a dutiful eye on “our girls” and their ‘beginning of life’ activities.  As of this morning we had three beautiful heifer calves added to our herd.  Though my mother lost a lot of sleep (and a touch of her sanity) worrying, nature took its course and our first three heifers delivered unassisted.

 

2/3 of our new heifers.

2/3 of our new heifers.

 

That changed today.  I happened to be on my way home to visit my parents when I got word that Snowflake, the smallest of our heifers, was in active labor.  There’d been signs of labor (bulging membranes, and even a foot or two) for a while: my mother actually thought the calf would be delivered overnight, but dawn broke without a new addition to the herd.  I hoped I would be able to make it to the farm before the calf was born.

 

When I reached our farm I found the three post-partum mothers peacefully grazing with their youngsters resting quietly nearby.  Our heifer that is due in November was also grazing peacefully.  The heifer in labor was pacing around the field, obviously uncomfortable.  At time she would lay down and strain, and you would see feet and membranes protruding, but despite her best efforts she didn’t make any progress.

 

Poor Snowflake couldn't make any progress past this...

Poor Snowflake couldn’t make any progress past this…

 

After an hour or so, and after a phone consultation with our bovine vet (who was away on another call and couldn’t come to the farm), we decided to move Snowflake up to the barn and get her in the chute.  We were concerned there might be a malpresentation (the feet were coming out first, but we couldn’t tell the orientation and it was possible the calf was upside down), and at this point we were concerned that our little heifer needed assistance.

 

We got her to the barn and in the chute easily. It happened that a pair of locals (new acquaintances) stopped by the farm to pick up some equipment just as we were getting Snowflake situated, providing an extra pair of hands (and a willing photographer, which makes this post much more interesting!).

 

While our vet wasn’t able to make it, Snowflake was rather well attended.  My mother is a veterinarian (though as a pathologist she hasn’t managed a delivery in many decades), one of our visitors had been a vet tech at an equine hospital for many years, and I’m a fourth year medical student.  Not exactly your A-team for a bovine delivery, but you could do worse.

 

Fortunately my mother had prepared for a labor dystocia (a difficult delivery) and had the requisite calving chains on hand.  Quite how I, as the medical student, got the job of doing the internal examination and heavy lifting of the delivery I’m somewhat unsure, but it is certainly a task I will remember for quite some time!

 

With the calving chains in place, it was time to pull.  So maybe this is why I crossfit. As I pulled the calf out today our observer commented "Wow you're strong!"

With the calving chains in place, it was time to pull. So maybe this is why I crossfit. As I helped pull the calf out today our observer commented “Wow you’re strong!”

 

 

After quite a bit of sweating, grunting, and the occasional obscenity, a healthy bull calf was born.  Our smallest heifer was carrying our biggest calf (82 pounds), and while the calf was in a normal presentation, she couldn’t get him out without some extra help.  Just as in humans, delivery is determined by the three Ps: the power (the pushing power of the uterus), the pelvis (size of the outlet), and the passenger (the size of the fetus). *

 

Success!

Success!

 

The calf was vigorous- mooing within minutes of birth and nursing within the hour.  He now has the distinct pleasure of being the lone British White bull in New Jersey!

It doesn't take long for Mum o get pretty protective...

It doesn’t take long for Mum to get pretty protective…

Good to see our young calf up and nursing!

Good to see our young calf up and nursing!

 

*An interesting aside when it comes to comparative obstetrics- in humans and horses we frequently use oxytocin to induce or augment labor.  According to our vet it is NOT used for these purposes in cows (though we did have some oxytocin on hand in case it was needed for expulsion of the placenta).  Apparently in cows the risk of uterine rupture is quite high with oxytocin use.

 

The cuteness factor is a little overwhelming!

The cuteness factor is a little overwhelming!

 

 

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“Doctor! Heal thyself!”

 

Those were the words of the orthopedist as he entered my room in the Emergency Department.

 

Two weeks ago, while taking a break from working on residency applications, I decided to go ride one of my horses.  Alas, as I was leading him and his pasture-mate to the barn they spooked and one of them literally jumped on my foot.  I’ve been around horses for decades (eek!), and have had my toes crunched many times, but I immediately knew this time was different, not least because he had landed on the side of my foot not my toes.  The pain was instantaneous and overwhelming, I was doubled over and hyperventilating within seconds (at which point I realized that the horses hoof had actually torn my leather boots- let this be a lesson to ALWAYS wear boots around horses, a lesson I’ll admit that I haven’t always followed).  After taking a couple of minutes to catch my breath I hobbled to the barn, optimistically hoping I’d still be able to go for a ride.

 

Once in the barn, with the horses secured, I pulled my boot off and had a quick palpate. One good squeeze and I knew I needed to make a trip to the hospital for some X-rays. *Sigh*  This was NOT how I had planned to spend my evening!

 

A little later, at the community hospital, the X-ray tech snapped a few angles.  I asked if I could see the films before hobbling back the waiting area and immediately spotted two, slim, hypodensities in my 4th and 5th metatarsals.  With an expletive, I pointed to one of the lucencies. The tech tried to reassure me that it wasn’t anything significant: “just an artifact” because there was a similar line in the adjacent bone…

 

After the Physician’s Assistant examined me in fast track, he went to go check out the X-rays.  I asked if I could take another look, admitting that I was a med student (and currently on rotation in this community hospital for my sub-internship!). When he came back to pull the images up on the computer, he let me know that he and the ED doc agreed that I did, indeed, have non-displaced fractures of the 4th and 5th metatarsals.  There wasn’t really much they could do, but the orthopedist was coming into the hospital to see a couple other patients and if I was willing to hang out for half an hour he’d take a look at my images as well.

 

They don't look like much, but those two little lines are really cramping my style!

They don’t look like much, but those two little lines are really cramping my style!

 

Half an hour later, the cheery orthopedist came in, chatted with me about my future plans in medicine, and told me to follow up with him if things got worse instead of better.  I headed home with a walking cast, crutches, and a few Percocet.

 

This was two weeks ago, and while my foot is by no means “fixed” it is certainly getting better.  Hobbling around to take a shower the first morning was rather excruciating, but the walking cast was my saving grace in the hospital and I’ve been able to do more normal activities without the boot with time (though I think I may have pushed my limits last night heading into the city for a book release party and am paying for it today- on that note, definitely check out John Durant’s book The Paleo Manifesto).

 

So why am I writing this, other than catharsis? (It’s perfect fall hiking weather and I’m out of commission- boo.)

 

Healing takes time.

 

With things like a fractured bone people know this, but sometimes we (“we” the public, and “we” the medical community) seem to forget that healing takes time.

 

There’s no denying that I am “into” preventative medicine.  However, as much as we can try and prevent injury and illness- something is bound to happen.  In that vein, I don’t think preventative medicine is only about avoiding problems, but encouraging a physiology where healing is promoted.

 

I’ll admit that I’ve been frustrated at times in the hospital when my stable patients have complained to me on morning pre-rounds that they had a horrible nights sleep because someone was taking vital signs every couple hours, and the phlebotomist came for morning labs before 5.  Vital signs are vital for the management of some patients, but others would benefit much more from a good nights sleep. Of course, making the decision that your patient needs sleep more than monitoring is not an easy one- no one wants to find that their patient is hypotensive on morning rounds and not know when the problem occurred, but for some patients the risk seems quite low.  On my neurology clerkship I remember thinking that what many of our stroke patients needed most was a good night’s sleep.

 

I recently read, at the recommendation of my favorite cardiologist, the book Cutting for Stone.  It is amazing, in many ways. I particularly loved a short passage that talked about the success one person had in improving women’s recovery from fistula surgery.

 

Hema shared with us that she and Shiva had operated on fifteen successive fistula patients with not one recurrence.  ‘I owe this to Shiva,” she said. ‘He convinced me to take more time preparing the women for surgery. So now, we admit the patients and feed them eggs, meat, milk, and vitamins for two weeks…. We work on strengthening their legs, getting them moving.’…

 

‘Can’t get them to walk after surgery if they won’t walk before.’ Shiva said.

 

When I was on my anesthesia clerkship I saw how hard it is to manage a “sick” patient, and how easy it is to intubate and anesthetize a healthy one (a complicated cardiac patient vs a young ortho patient, for example).  On surgery, you see how well some people tolerate surgery and how poorly other do- how some heal quickly while other seem incapable of healing.  One’s underlying “health” certainly affects one’s ability to heal.

 

This is one of the many reasons I like primary care.  A good primary care doc makes everybody else’s job easier.  They can keep their patients healthy and out of the OR and specialist’s office, and if misfortune strikes, a patient in the best of health is almost always set up to fair better (the only example that I can think of where this is not the case is the pandemic flu of 1918, where the robust immune systems of young, healthy, adults was actually their demise).

 

Injury and illness, at some level, are inevitable.  A healthy lifestyle and good genetics can go a long way to keeping you out of the hospital, and they can also go a long way towards helping you heal if you do find yourself in harms way.  As the Dos Equis man might say “Stay healthy my friends.”.

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It’s been a busy month since my last post.  I’ve studied for and taken the United States Medical Licensing Exams (USMLE) Step 2 CS and (on Friday) USMLE Step 2 CK, two parts of what most people know as “the boards”.  I’ve attended and spoken at the 2013 Ancestral Health Symposium (AHS) and moved out of the apartment I lived in for the last 18 months.  I’m also half way through my “Acting Internship”, a clerkship most medical schools call a Sub-Internship, where I basically function as an intern (a first year medical resident).  I’m doing this rotation at a local community hospital and I’m really enjoying the atmosphere, personnel, and patients.  The hours are long, but not as long as for many of my classmates doing acting internships in Internal Medicine, Surgery, and Ob-Gyn (mine is in Family Medicine, the specialty I am pursuing). Applications for residency programs go live in just over a week which finds me struggling to write (for the fourth time) a personal statement that embodies me

 

Needless to say, things have been hectic , and the last month has been a touch overwhelming at times.  I’m certainly looking forward to some downtime after I finally complete my remaining med school requirements (just 8 more weeks!), have my residency lined up, and am able to catch my breath. 

 

I really shouldn’t complain.  Even in the last, relatively crazy, 6 weeks I’ve still had some good times.  The week of AHS in particular was one for the books.

 

I’ve written before about destinations and journeys.  The destination for AHS was clear- Atlanta Georgia- but the journey I took to get there wasn’t what you might expect. 

 

Many, many, months ago, when the location for AHS was first announced, I made a rather rash statement that Atlanta was almost close enough for a road trip.  While I had no real intention of road tripping to Atlanta, my longtime Twitter friend @PrimalRush (henceforth known as James) said he was keen to tag along for the journey.  At the time I thought an actual road trip was unlikely (it’s a good 13 hour drive and airfare isn’t that expensive), but as the time got closer I realized I would regret turning down the opportunity to create an excellent story (those that know me know all too well that I’m a fan of adventures and stories). 

 

Since I took 4 weeks off from school to prepare for the boards and attend AHS, I was able to take some extra time travelling to AHS.  About a week out, I vaguely mapped a path to Atlanta, made plans to pick up my Canadian travel buddy from the bus stop, and hoped for the best!

 

Three days before we planned to pull into ATL, James and I hit the road with camping gear, a cooler, and a tank of gas.  After making a stop at one of my favorite butchers to fully stock our cooler, we made tracks to Shenandoah National Park in Virginia.  We travelled the length of the park on Skyline Drive, stopping about midway to camp for the night. 

 

At times, we were in the clouds driving on Skyline Drive.  Driving the length of the park added a few extra miles to our trip, and certainly slowed us down a bit (the speed limit is 35mph and you can't help but pull over and ogle at the views), but it is certainly worth it!

At times, we were in the clouds driving on Skyline Drive. Driving the length of the park added a few extra miles to our trip, and certainly slowed us down a bit (the speed limit is 35mph and you can’t help but pull over and ogle at the views), but it was certainly worth it!

 

Without going into detail, our time in Shenandoah involved meeting some mushroomers who confirmed my Chanterelle (and Chicken of the Woods) identification, cooking a truly excellent camp dinner (with Chanterelles), having a run-in with a slightly disgruntled ranger, hiking part of the Appalachian trail in the dark, pitching a tent in the dark, waking up and breaking down camp in the dark, and then scrambling to a 360o viewpoint to watch the sun rise.  When we were finally able to tear ourselves away from our solitude and sunrise we hiked the couple miles back to the car and made tracks through the rest of the park and onto our next destination in Mortimer North Carolina.

 

A delicious addition to our dinner (good thing I had some Kerrygold butter in the cooler!)

A delicious addition to our dinner (good thing I had some Kerrygold butter in the cooler!)

 

I'll take this over dehydrated rice and bean camp dinners any night!

I’ll take this over dehydrated rice and bean camp dinners any night!

 

The view at dawn from Bearfence mountain.

The view at dawn from Bearfence mountain.

 

It was certainly worth waking up at 5, and hiking in the dark, to watch the sun rise over Shenandoah.

It was certainly worth waking up at 5, and hiking in the dark, to watch the sun rise over Shenandoah.

 

How could I resist?

How could I resist?

 

Mortimer North Carolina holds a special place in my heart.  One of my longtime friends has a family cabin in Mortimer, and I’ve twice travelled with her for an escape to the mountains and the beauty of Wilson’s Creek.  Mortimer is also home of Betsey’s Ole Country Store an establishment owned by my friend Bruce.  The address to Betsey’s is a little deceiving- let the record show that “Highway 90” is a gravel road where you need to pull over to let oncoming traffic pass. 

 

Anything I say about Betsey’s or the owner/operator of the establishment, Bruce, would sound like a paid advertisement, so I’m not going to even start.  What I will say is, if you want to visit a beautiful part of North Carolina- visit Mortimer. And if you visit Mortimer- visit Bruce.  He’s got cabin rentals, inner tube rentals, and more knowledge of the area than you’ll find anywhere else.  If you ever find yourself that way, tell him Victoria sent you… Seriously!

 

With Bruce’s back yard as our home base (he is a gracious host), we put in many miles of hiking, had numerous dips in local swimming holes, and managed to spot some of the Perseid meteors.  It was hard to tear ourselves away in order to make it to Atlanta on schedule (we actually didn’t make it to Atlanta on schedule because we opted to take a morning hike before we hit the road).

 

Betsey's. "Peace and Love, Y'all"

Betsey’s. “Peace and Love, Y’all”

 

Putting in some miles in Pisgah National Forest...

Putting in some miles in Pisgah National Forest…

 

I was keen to keep my socks dry, and I did! At least for the first half of the hike (darn slippery rocks)...

I was keen to keep my socks dry, and I did! At least for the first half of the hike (darn slippery rocks)…

 

My new favorite swimming hole, at the top of Gragg Prong fall.

My new favorite swimming hole, at the top of Gragg Prong fall.

 

The reason we didn't make it to Atlanta on schedule- I had to introduce James to one of my favorite spots- Big Lost Cove.

The reason we didn’t make it to Atlanta on schedule- I had to introduce James to one of my favorite spots- Big Lost Cove.

 

It goes without saying that Atlanta was a big change of scenery in comparison to the preceding few days.  I actually didn’t see much of the city, save for the inside of the Sheraton Conference center, a few of the fine dining establishments, and Boyd Eaton’s gorgeous house where the presenters dinner was held.  Prior to the official start of AHS, a number of the Physicians and Ancestral Health docs got together for a brief meeting.  It was great to catch up with these like-minded Docs, and I was reminded, again, how refreshing it is to spend time with people who share passions and interests. 

 

AHS itself was fantastic, save for a few AV snafus. I thoroughly enjoyed some of the plenary talks: namely Nassim Taleb’s antifragile talk, Gad Saad’s talk on The Consuming Instinct, and Geoffrey Miller’s talk on Sexual Fitness (not talking about “reps for time”).  I was a bit surprised by Mel Konner’s and Boyd Eaton’s talk on the history of modern “paleo” diets, where they repeatedly said that our modern diet is much higher in saturated fat and lower in polyunsaturated fat than historic diets… I find it hard to believe that any diet that contains modern vegetable oils has anything other than an excess of polyunsaturated fats. 

 

There were many excellent talks over the course of the conference, and it was often hard to pick which talk to attend out of a very tempting schedule.  I look forward to catching some of the ones I missed online when the videos are posted.  On that note, my talk on Dietary Fats and Fatty Liver Disease, went well.  When the video becomes available I’ll try and post it here!

 

As much as I enjoyed the various lectures, workshops, and posters, the highlight of AHS was catching up with friends and making new ones.  There is quite a vibrant online community of those interested in evolutionary and ancestral health, and AHS can sometimes seem like the interwebz in 3D.  As someone who would happily trade days of online interactions for even brief face-to-face encounters, AHS was a social occasion that refilled my tanks and renewed my enthusiasm. 

 

Back in May, on the Wilderness Medicine elective in Utah, our instructors expressed that one of the goals of the elective was to “stock good memories” for the rough times that were to follow in residency (all but 2 of the 12 students would be starting internship in the next month).  I still have quite a bit of time until I start residency (though the march towards June of 2014 soldiers on), and my goal between now and then is to bank as many good memories as I can.

 

Stashing good memories (and looking for Hobbitses).

Stashing good memories (and looking for Hobbitses).

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Gather

Time to take a break from breasts- though I think I may have one more post in me on that subject.

 

I’m a fan of a paleo diet. There, I said it.  To me it is not “the” paleo diet, and there is no single set of “rules”, but I embrace the idea of thinking about our evolutionary past when talking about health and disease.  Like it or not, what we eat (and of equal importance, what we don’t eat) is one of the major forces that shape our health.  Let’s face it, it’s much easier to change what you eat than to change your genetics (and probably your job, your geographical location, and other things that affect health).

 

There’s been increased coverage of a paleo diet in the media of late- usually not a resounding endorsement, not that I’m surprised- and it’s sometimes referred to by other names such as “the caveman diet” (except our ancestors largely didn’t live in caves) or the hunter-gatherer diet.

 

I generally like (and use) the term ‘paleo’.  For me (and many others), it’s a term that has developed a definition that we all understand.  That being said, I also like the idea of talking about a ‘hunter-gatherer diet’.  It gives a nod to seasonality, encourages us to think about naturally available quantities, and a personal involvement in the food we eat.  Sure, a lot of people who “eat paleo” don’t hunt or gather their own food (though certainly some do), but it’s good to be mindful of when you might actually have access to different foods and in what amounts.

 

I’ve never been a hunter (though I love having friends that are, and appreciate the stock of venison I have in my chest freezer), but I’ve been gathering since I was little.  I’ve been involved in two different types of “gathering”- spending a portion of my summer childhood raiding (or being put to work) picking in my family’s garden and also time in the woods scouting for wild edibles.  It’s funny how times change: these days I love getting out in the sun to pick berries at a local pick-your-own place, but as a child I really thought of it as a chore (I’m guessing it’s mainly because when the plants are yours you don’t want to let anything go to waste so you pick whether you want to or not, and you also pick *everything* instead of just as much as you want).

 

Of course, picking quarts of strawberries at the local pick-your-own place is NOT gathering (in the truly ancestral sense of the word), but it’s fun (at least for me), and while I’m picking vitamin C I’m getting vitamin D for free.  I’m also supporting  local farming families, keeping money in the local community, and keeping an eye on how the food I eat is grown.

 

The farm I go to grows a variety of strawberries, I exclusively pick the “Early Glow” variety. They are, without a doubt, the best in the field, though arguable more tedious to pick since they are quite a bit smaller than most commercial varieties. They are well worth any extra effort, as the flavor is unparalleled (though their shelf life is very limited).

The farm I go to grows a variety of strawberries, I exclusively pick the “Early Glow” variety. They are, without a doubt, the best in the field, though arguable more tedious to pick since they are quite a bit smaller than most commercial varieties. They are well worth any extra effort, as the flavor is unparalleled (though their shelf life is very limited).

 

As a child, while I was duty bound to pick strawberries, raspberries, blueberries, blackberries, and whatever else we had in the garden, I still would go out “exploring” with friends and bring home wild bounty.  To this day wineberries are one of my favorite fruits. Seedy, waxy, and plentiful (if you happen to beat the birds to the punch), I would spend hours with my friends gathering these treats.  I still find it difficult to pass a stand without stopping for a snack.

 

Stopped for a snack- I’m being a bad Pony Clubber, allowing my horse to grab a quick bite with the bit in her mouth, but it seemed unfair to stop for a snack for me and not let her grab a mouthful as well!

Stopped for a snack- I’m being a bad Pony Clubber, allowing my horse to grab a quick bite with the bit in her mouth, but it seemed unfair to stop for a snack for me and not let her grab a mouthful as well!

 

Wineberries are just ripening in my area, but I haven’t had a chance to get out and pick any yet.  However a couple weekends ago I was out hiking on the Appalachian Trail (AT) and came across blueberries- LOTS of blueberries.  I’d seen the green berries at other places earlier in the season, and fortuitously happened to be out on the Blue Mountain portion of the AT when the berries in the area were ripening.

 

These had caught my eye on the trail a week or so before I hit the motherload!

These had caught my eye on the trail a week or so before I hit the motherload!

 

I felt a little bad for my hiking partner, since I seem pathologically incapable of walking past a good stand of berries without stopping to pick.

I felt a little bad for my hiking partner, since I seem pathologically incapable of walking past a good stand of berries without stopping to pick.

 

For a bit of comparison you can see the wild blueberries (or are they bilberries? [ http://en.wikipedia.org/wiki/Vaccinium_myrtillus#Confusion_between_bilberries_and_American_blueberries]) next to some that I picked in my parents’ garden (this years crop are particularly large)

For a bit of comparison you can see the wild blueberries (or are they bilberries?)  next to some that I picked in my parents’ garden (this years crop are particularly large)

Out on the AT, I don’t look all that out of place gathering handfuls of berries, but in the park opposite from my apartment I get some weird looks when I stand on tiptoe to pick the ripening Mulberries.  As I’ve said, my drive to gather might be a little pathological, though I suspect it is a deeply human urge.  Most of the kids that I’ve met have loved to gather food (berries, vegetables, eggs, etc.), but perhaps it’s novelty not nature…

 

When I was up in Maine a few weeks ago I went beach combing with a friend. To our excitement, while we were out at low tide we came across a few pools that housed beautiful large mussels.  We were looking forward to cooking them up in some white wine until we discovered there was a red-tide warning for the area- what a shame!

 

Seafood can’t get much fresher than this…

Seafood can’t get much fresher than this…

 

Most recently I’ve been gathering watercress from a local stream.  I know the thought of this makes my European friends cringe, but the liver flukes that make this practice a hazard in other countries don’t live in the US- or so I’ve been told.

 

WaTERCRESS

 

In the fall I’ll be gathering chestnuts, a task I’ve been doing for years.  My neighborhood has quite a few old Chinese Chestnut trees- I wonder if there was a local craze to plant them some decades back.

 

Best roasted, though I have been known to make a dark chocolate/chestnut mousse at times- don’t tell the paleo police!

Best roasted, though I have been known to make a dark chocolate/chestnut mousse at times- don’t tell the paleo police!

 

A “paleo” diet isn’t about prehistoric reenactment. The point isn’t to only eat foods you’ve hunted or gathered, but personally I like having a role in sourcing the food that I eat, and I do enjoy time spent outside gathering foods.  The food “gathered” at a pick your own berry farm certainly isn’t the same as the food our ancestors gathered (I’ll refer you back to the post I did on bananas– check out the difference between the wild and the domesticated fruit), but what you pick yourself will be infinitely fresher than what you buy at the supermarket.

 

As I was finishing up this post, I heard an interview on NPR with the author of a new book, entitled Eating on the Wild Side. Her premise seems to be that the plants we evolved eating were very different from their domesticated ancestors that we eat today, and that somewhere in the mix foods have lost some of their most valuable micronutrients *.  I can’t speak on the book, but the interview is certainly worth a listen!

 

*Interestingly, some people have suggested that some of the nutrients that the author above touts can actually be problematic.  You can check out Dr. Ede’s talk from the 2012 Ancestral Health Symposium exploring the darker side of plant foods.

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OK- enough (for now) of the photo documentation of my past month of explorations!  While I am keen to write more about the environment, wildlife, and general experience of my last month in Utah, it’s time for me to get back to the reality of a med student and think (and write) about medicine.

 

A number of schools (and programs) offer Wilderness Medicine electives for medical students, but I chose (and was fortunate to get a spot in) the elective offered by UMass Medical School.  A few things drew me to this program.  First- it has been running for 20 years, so I initially suspected they were doing something right.  Second- many Wilderness Medicine courses are taught in classrooms with field trips and forays “into the wild” for practical experiences.  The UMass course is taught in the wild. With the exception of our first day of lecture, conducted in a hotel meeting room, all our lectures were done outside on snow, in boats, on beaches, or sitting in the desert.  Thirdly- we got to experience three different environments in the course of three weeks.  A few other courses are taught in the wild, but they are taught in a single environment.  Utah gave us access to three, very different, environments (as shown in my previous posts: alpine, river, and desert).

 

This was our main classroom in the alpine section.  We'd just arrived and are taking a quick break before setting camp, but this area was left open and we would congregate here for lectures.

This was our main classroom in the alpine section. A classmate snapped this shortly after we arrived when we were taking a quick break before setting camp, but this area was left open and we would congregate here for lectures. 

 

When I initially described this course to friends and acquaintances, many suggested that this course was basically Outward Bound for doctors.  The answer, I suppose, is yes and no.  There was certainly a lot of medical learning done in this class, but we also gained life skills that will not only help us in future endeavors in the wild but will also give us confidence as we go forward in our medical careers.  Broadly, it taught us to have confidence in our decisions and to use what we have available to do the best that we can.  I’m unlikely to ever have to improvise a splint in the Emergency Room, but knowing that I can, and having that confidence, will carry me and my classmates a long way as we progress to interns, residents, and one day attending physicians.

 

As you might expect, the medical topics that we covered were married to the environments and activities we were doing.  Before heading out on our first big trek we had a thorough lecture on blister pathophysiology, prevention, and treatment. Once in the alpine, we promptly learned about hypothermia, and how to create a hypowrap to help someone with hypothermia.  We learned about frostbite and non-freezing cold injury, as well as thermal burns, sunburns, and sun blindness.  While in the mountains, we also discussed various problems that occur at high altitude.

 

A lot of injuries in the wild are orthopedic, so we had multiple sessions on splinting, immobilizing, and caring for these injuries.  We also learned various lifts, rolls, and carries, utilizing minimal equipment- since you don’t always have a backboard and a team of people to help you.  Along those lines, we learned just how difficult it is to litter carry someone out of a bad situation (you need about 18 people to go 1 mile, and it will take you a LONG time).

 

It's not what you would do in a hospital setting, but how do you get someone with a potential cervical-spine injury free after you’ve just dug them out of an avalanche slide? Stabilize their neck with their arms and drag them! (And kudos to our instructors.  Not only did they dig a deep snow cave for us to locate with avalanche beacons, but one of the brave residents agreed to be buried down there for one of our “scenarios”. I wish I could have seen the look on my face when we realized there was a person 5 feet under the snow!)

It’s not what you would do in a hospital setting, but how do you get someone with a potential cervical-spine injury free after you’ve dug them out of an avalanche slide? Stabilize their neck with their arms and drag them. (And kudos to our instructors. Not only did they dig a deep snow cave for us to locate with avalanche beacons, but one of the brave residents agreed to be buried down there for one of our “scenarios”. I wish I could have seen the look on our faces when we realized there was a person ~5 feet under the snow!)

 

 

The slope that we dug our patient out of- the instructors made the scenarios very realistic while keeping everyone safe.

The slope that we dug our patient out of- the instructors made the scenarios very realistic while keeping everyone safe.

 

Injuries in every settings... here I’m sporting a mid-humeral splint fashioned out of a camping chair (in the rain and on the river).

Injuries in every settings… here I’m sporting a mid-humeral splint fashioned out of a camping chair (in the rain and on the river).

 

A number of dermatologic conditions occur in the wild, so we discussed their various etiologies.  We also discussed methods of wound management, including wounds caused by snakebites, insect stings, and mammalian injury.  (On that note, during our time in the desert our group spotted rattlesnakes, scorpions, and a black widow spider.)

 

A trio of beasties spotted on our trip.

A trio of beasties spotted on our trip.

 

Many of the topics we covered are much more likely to be encountered in the wilderness than in a clinical setting, but some topics are ever-present in any setting.  Anaphylaxis and allergies can occur at any time, and while you may acquire tick-borne illnesses or infections diarrhea in the wild, the incubation time for many of these mean that they frequently present at a primary care office.  Nonetheless, these were topics we covered on this course, frequently harking back to the “bible” of wilderness medicine: Wilderness Medicine written by Paul Auerbach.

 

Thus far I’ve mainly focused on the didactic portion of the course, but much of the learning took place in “scenarios”.  I’ve never participated in simulation medicine, save for the standardized patients we get on our OSCE (Objective Structured Clinical Exam) at the end of most clerkships. While at first it can be awkward to “practice” medicine on people that you know are acting, once you get into the part it is a wonderful way to learn.

 

The beauty (and perhaps the terror?) of our scenarios was that our instructors would let us “play it out” in the field.  In clinical settings, while students may participate in discussions about patient care, they are never in the driving seat.  In our wilderness scenarios we were allowed to make the decisions and deal with the consequences.  At times this was frustrating (can’t I just ask the Wilderness Fellow standing over my shoulder what I should do), but it also allowed me to make mistakes that will stick with me for years to come.  For example, if a “helpful” stander by hands your patient some food, make sure they’re not allergic to it before they take a bite (that’s how a painful case of sun blindness can progress into life threatening anaphylaxis).

 

The scenarios also allowed (or I should say made) students make decisions about evacuation. Do we evacuate the patient? How? Can they walk? Do they need a litter? Do they need cervical-spine protection? Do we leave now or hunker down for the night and head out tomorrow? What’s the best evacuation route? Could a rescue team get a helicopter in here? A snowmobile? Maybe we should send runners to a ranger station? Where’s the closest location we can get cell phone reception?

 

The scenarios progressed with our wilderness medicine knowledge, as well as our knowledge of Incident Command Structure (ICS).  There were twelve medical students in our class, and when we had a scenario with one patient, it would be easy to have “too many cooks in the kitchen”.  On the other hand, when we had three patients, we could quickly run out of hands as people were relegated to “safety officer”, “equipment”, “communications”, and if the scenario necessitated it “runners” leaving the scene to make contact with civilization.

 

All in all, the medical education side of this course was excellent.  Some of the medicine was a review, but it was a much-needed review and one that frequently found we students (who are trained to practice medicine in well-stocked hospitals with multiple imaging modalities at our fingertips) asking “what do we have that we can use” and “how can we do what we need to get done”.

 

Medically, this class was a reminder of quite how much we’ve learned about medicine in the last few years.  It also emphasized that frequently there is no “right way” to handle a situation and your best guess and best efforts may save the day. We were also reminded of the reality that sometimes there is nothing you can do to save a life… and that is an important lesson to learn as well.

 

 

Not a bad place for a lecture...

Not a bad place for a lecture…

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I’ve been hesitant to write this post.  This blog is certainly not a travel blog, and it was never intended to be a place where I posted my exciting travels (and to be honest, during the final years of my PhD and third year medical school I didn’t really have any exciting travels to write about).  That being said, I can’t help but post about my adventures in Moab.  If my antics encourage just one person to get outside and enjoy time in the great outdoors, I will consider this post a huge success…

 

Moab…

After completing my Wilderness Medicine Elective, I opted to take two weeks of vacation time (4th year medical students can get a rather absurd amount of vacation time if we play our cards right) to recoup, relax, and since I was already out west, spend time in Colorado with my best friend.  With over 100lbs of luggage to lug around, I managed to sweet talk my best friend into picking me up in Salt Lake City (where my elective wrapped up), instead of hopping a plane to Denver.

 

My best friend is a good sport about road trips (I suppose she should be, as I once drove 28hrs straight with her when she moved cross-country to Colorado), and she was happy to come pick me up, suggesting that we route our trip back through Moab for a bit of outdoor adventuring before heading back to Colorado.  I didn’t know much about Moab before I got there, but I knew Arches National Park was right next door and that the desert portion of my course was in Canyonlands National Park, so I thought it might be fun to swing back through and at least check out Arches on our way back.

 

That was before heading west… Once I met and talked with the river guides who work out of Moab and spent a “transition” day there between the river portion and the desert portion of the Wilderness Medicine elective, I was counting down the days until I would be back.

 

Moab is a stunning place- the rock formations and geology surrounding the town are truly “other worldy”, with the red rock shaped by time and weather into precarious and beautiful structures.  There is also a LOT to do in Moab for people who enjoy the outdoors.  The Colorado River can be enjoyed from rafts, boards, boats, or the shore, there seems to be a new hike for every day of the year, biking (mountain and road) is king, and the weather in May is wonderful for camping (sans-tent, for those-like myself- who are so inclined).

 

There are plenty of places to stay in Moab, but being on a budget and having spent the majority of the prior 3 weeks sleeping outdoors, I was more than happy to camp in Moab.  There are many campsites with RV hook ups, tent sites, and amenities such as showers, but I’m a fan of primitive camping.  Fortunately, for those in the know (or those who get the scoop from knowing river guides), there is plenty of dispersed camping to be had in spots around Moab.

 

view from one of our camp sites up off Klondike Bluffs, about ten miles north of town.

The view from one of our camp sites up off Klondike Bluffs, about ten miles north of town.

 

We spent out first morning in Moab getting coffee (“That Paleo Guy”, Jamie Scott, would swoon at all the coffee spots in Moab) and sorting out plans for the next couple days.

 

Wicked Brew- home of a mighty fine shot of espresso

Wicked Brew- home of a mighty fine shot of espresso

 

After a morning in town we headed out for a hike at Fisher Towers.  This hike, while popular, is a bit off the beaten track (at least in comparison to the tourist heavy hikes in Arches National Park).  The rock formations are stunning and the plant life was beautiful. This place is popular for rock climbers, and it was breathtaking to see them atop the tallest towers.

 

Fisher towers- if you go on this hike, make sure you get on the proper trail… we ended up scrambling quite a bit looking for a trail on various dead ends when we erroneously got started on a “photograph trail”.

Fisher towers- if you go on this hike, make sure you get on the proper trail… we ended up scrambling quite a bit looking for a trail on various dead ends when we erroneously got started on a “photograph trail”.

 

“The Titan” is the tallest structure at Fisher Towers, and is very striking.

“The Titan” is the tallest structure at Fisher Towers, and is very striking.

 

 

Alas, I seemed to have a knack for attracting rain on this trip… As we rounded the turn at the top of the hike, we were greeted by storm clouds and a flash of lightning.  Needless to say, we made a rapid retreat (I did learn about lightning strikes on my Wilderness Medicine course, but like almost all aspects of medicine, the best solution is prevention, prevention, prevention!)

Alas, I seemed to have a knack for attracting rain on this trip… As we rounded the turn at the top of the hike, we were greeted by storm clouds and a flash of lightning. Needless to say, we made a rapid retreat (I did learn about lightning strikes on my Wilderness Medicine course, but like almost all aspects of medicine, the best solution is prevention, prevention, prevention!).

 

After our hike, we headed back towards Moab, making one stop at a local vineyard and a detour down Onion Creek Road.  If you are around Moab and have an AWD vehicle (or are comfortable taking your vehicle through multiple stream fords), definitely check out Onion Creek Road.  If you’re really lucky, one of the dispersed camping sites might be open and available (we didn’t have any luck on that front).

 

My best friend is an avid paddle boarder, and she’d contemplated packing her paddle boards down to Moab for us to use on the Colorado River.  It seemed that renting boards in Moab was a much better option, so after making some inquiries, we ended up renting two inflatable boards (Badfish MCIT) from Canyon Voyages, strapping then to our car, and driving them up river to our drop-in point.  We’d scouted the river the day before and had decided to drop in at Take-out beach and to get out at Lion’s Park: a ten-mile paddle downstream (with my friend opting for the hitchhikers shuttle after parking her car down at the pull-off site. Pro-tip: carry your PFD (personal flotation device) and catching a ride is pretty easy).

 

Boards- Ready for adventure.

Boards- Ready for adventure.

 

While a road parallels the Colorado River the length of our ten-mile paddle, the trip was still very calming.  I’ll be honest- I went through our lone rapids and a couple of the choppy fast-water sections firmly on my knees.

While a road parallels the Colorado River the length of our ten-mile paddle, the trip was still very calming. (Though I’ll be honest- I went through our lone rapids and a couple of the choppy fast-water sections firmly on my knees.)

 

The rest of our day was spent driving out to Dead Horse National Park, seeking out dinosaur footprints (yes really), cooking dinner at our campsite, and then meeting up with a new friend from my Wilderness Medicine Elective- one of the river guides from my travels down Desolation Canyon.

 

I can’t tell you if they’re Therapod or Sauropod footprints, but they were pretty cool!

I can’t tell you if they’re Therapod or Sauropod footprints, but they were pretty cool!

 

As much fun as the previous two days had been, the real adventures began when we started hanging out with a local… My river guide friend was just back from another long trip down Desolation Canyon, which meant that he had a bit of time off before heading back to the river.  The next morning he took us on a hike up to Cable Arch, an arch off the beaten track on an unmarked trail.  Our drive out to the trailhead took us past quite a few petroglyphs, including one that I found very interesting.

 

The birthing rock- my picture isn’t the best, but this petroglyph seems to show a breach position birth.  Some readers may remember that I’m interested in “traditional” positions for giving birth, so I found these depictions particularly interesting.

The birthing rock- my picture isn’t the best, but this petroglyph seems to show a breach position birth. Some readers may remember that I’m interested in “traditional” positions for giving birth, so I found these depictions particularly interesting. (Here’s a better picture.)

 

An arch all to ourselves… something you seldom get in Arches National Park

An arch all to ourselves… something you seldom get in Arches National Park

 

Not another person for miles...

Not another person for miles…

 

Scrambling up and down rock faces is a lot of fun (and an excellent work out)…

Scrambling up and down rock faces is a lot of fun (and an excellent work out)…

 

After a relaxing lunch in town, we headed up to the Sand Flats for an afternoon adventure of rappelling.  I’ve never been rappelling (save for the ~15’ rappel we played with up in the alpine on the Wilderness Medicine course), and I’ll admit that at the top of our first descent I was more than a little nervous.  However, as I lowered myself into the slot canyon (into an area aptly named “the medieval chamber”), my fear was replaced by exhilaration.

 

Rappelling down into the "Medieval Chamber".

Rappelling into the “Medieval Chamber”.

 

The second rappel, off a natural bridge, landed us at the focal point of a somewhat well travelled out-and-back hike.  My best friend went first, and her adventures were well documented by some of the sightseers below!

 

Kate, headed down off the natural bridge

Kate, headed down off the natural bridge

.

The next day found us rappelling again, this time in Arches National Park.  We were truly spoiled to have a local show us yet another awesome spot, for while we left our car in a crowded parking lot, we quickly backtracked along the road and scrambled up a rock fall to find ourselves isolated atop a large mesa.  Hundreds of feet above the other tourists below us, we spent much of the morning relaxing above Arches, in our own world, away from any other visitors to the park.

 

Above Arches- We spent quite a bit of time wandering around the top of the mesa, but eventually we settled down to soak up the sun, talk, and relax.

Above Arches- We spent quite a bit of time wandering around the top of the mesa, but eventually settled down to soak up the sun, talk, and relax.

 

Above Arches- I’m not sure the scale comes through…

Above Arches- I’m not sure the scale comes through…

 

After an hour or so of basking on the rocks, we started our descent back down into the canyons.  This (again, unmarked) path took us down a number of small descents before finally putting us atop a 100’ wall down to the canyon floor.  The rappel was a rush.

 

Can you find me? Hopefully the scale comes through now!

Can you find me? Hopefully the scale comes through now!

 

My best friend and I did plenty of other things in Moab, including taking a drive and some hikes through Arches National Park. Arches IS stunning, but after getting an insiders-tour to some stunning and relatively unknown-to-tourists spots, hiking along crowded groomed trails to ogle at postcard views lacked some luster.  I don’t mean to sound snooty, and I hope it doesn’t come across that way, but I think my favorite moments of this trip to Moab were the moments with friends around bonfires, scrambling up rocks, and quietly taking in all that our surroundings have to offer.

 

After more than a month away, I am finally headed home to New Jersey.  I am heading home physically tired but psychologically refreshed.  I have always believed that nature is *good* for humanity, but I have never experienced this goodness so intensely as in the last month.

 

Through the wilderness medicine elective, my trip to Moab, and then a Memorial Day Weekend camping trip in the mountains of Colorado, I have experienced many different environments.  A big part of experiencing these environments, to me, is learning to be present in the moment- to quiet the mind of all the banality and drama that so easily catches us and to really appreciate what surrounds us.  In the hustle and bustle of normal life this skill takes practice, but it is practice that pays back in dividends on the principle that nature satisfies a deep and primal part of our humanity, and we should seek it out and absorb it whenever possible.

 

Memorial Day Moonrise over Twin Lakes in Colorado- Not sure I can think of a better way to end the day…

Memorial Day Moonrise over Twin Lakes in Colorado- Not sure I can think of a better way to end the day…

 

Find your people, find your places, and enjoy the moment…

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