By Matthew C. Wiencke

Forget storks and cabbage patches. In the Appalachian hills of southeastern Kentucky, home of the Frontier Nursing Service (FNS), parents have a different way to explain where babies come from. In 1925, when the FNS started, nurse-midwives rode on horseback to deliver babies around the rural region, so "little children were told that babies arrived in the saddlebags," says DMS student Julie Zitterkopf. She was one of seven DMS students—four M.D. first-years and three Center for the Evaluative Clinical Sciences (CECS) students—who made a one-week spring service trip to Kentucky. They shadowed caregivers at the FNS's hospital and rural clinics and volunteered in an after-school reading program and a food pantry.

Idea: Sarah Dotters-Katz, a first-year who was born in rural Kentucky, came up with the idea for the trip after doing a summer internship at the FNS. The FNS includes the 25-bed Mary Breckenridge Hospital, five rural clinics, a home-health service, and the Frontier School of Midwifery and Family Nursing—the largest such school in the United States.

Jobs: Leslie County, where the FNS is located, has a population of 12,000 and an unemployment rate of 8.8%. Other than coal mining, jobs are scarce. Rates of both drug use, legal and illegal, and teen pregnancy are high.

The FNS is working to address the former problem, as the DMS group discovered. Many of the students helped out in a detox program that uses opiate-receptor-blocking implants to treat patients addicted to oxycotin and methadone. "They had only been doing this for a couple of months and they had put in more than 100 implants," says Dotters-Katz. "And they weren't advertising—it was [just] word of mouth that was spreading around the community."

The students also saw colonoscopies, laparoscopic gall-bladder surgery, and a hysterectomy.

For Zitterkopf, it was an exam on a woman in her 32nd week of pregnancy that had the deepest impact. "I had never seen a bimanual exam, let alone performed one," she says. "As I witnessed a physician skillfully perform a bimanual exam . . . he turned to me and asked, 'Any questions?' After [I shook] my head 'no,' he handed me a glove and said, 'Good. Your turn.' I was very nervous." But the physician guided her through the process. "I was able to feel the head of the fetus," she recalls. "It was a feeling I will never forget."

Static: Maureen Shyu was moved by a prenatal visit, too: "Through the static of a Doptone, I heard the thumping of a baby's heartbeat. It was loud and rapid, so different from my own. . . . It was my first time hearing a life growing hidden inside a woman's belly. Something shifted in me and I recognized it as a special moment in my life."

For CECS student Clara Savage, working with the FNS was a "wonderful" experience. "There are a lot of pockets of society in this country that are disenfranchised from proper health care," she says, "and I think that exists in rural Appalachia."

Susan Linsey, codirector of Dartmouth Rural Health Programs and coordinator of the Kentucky trip, feels it was a great experience for the students who went. They showed "strong team spirit and good bonding," she says. And FNS officials were pleased, too, she adds. "Frontier Nursing tells us over and over, 'Please come back.'"