Whistler Elective - Medical Report

This is a report that I wrote as part of my elective assignment for medical school.

Whistler Medical Clinic-
Family Medicine/Emergency/Ski Patrol/Outpatient Visiting Specialists

When I signed up for this elective last year I was expecting it to be a similar to the experience I had in Ontario during my General Practice rotations. Fortunately, although this Whistler elective had a lot of similarities to my previous experience in Ontario, it ended up being much different and much more varied than expected.Dr. DeMarco is very keen to have students and makes a huge effort to expose his students to as much medicine as possible during electives (while still encouraging a ton of skiing, outdoor and indoor sports, and social activities). I spent most days with him in his family medicine clinic, but also had the opportunity to spend one day in the emergency department, one day with ski patrol and a few days with visiting specialists (including a day with a neurologist, a dermatologist, a pediatrician, and a few orthopaedic surgeons).

FAMILY

I probably shouldn’t have been surprised, but I found that although Dr. DeMarco is a family doctor that the medicine he practiced involved more sports medicine and orthopaedics than I had ever seen. For me, I think this was a good thing since I wasn’t particularly comfortable or experienced in these areas going into it. At the same time, over the 8 weeks, I also feel like I was exposed to a wide range of patients, diseases and problems.

Dr. DeMarco organized about half the days for me to see patients alone (and discuss diagnosis, investigations and management plans with him) and the other half of the days sitting in with him and his patients. I really appreciated the mix of time alone and time observing- especially because as I get further along in my training I have less and less time to just observe doctors (which I think is an incredibly valuable way to learn as well).

Some of the things I saw with Dr. DeMarco included: chronic pain patients and patients with personality disorders, travel medicine, several rashes (including viral exanthems), lacerations, fractures, acne, baby checks, prenatal visits, flu shots, urinary tract infections, upper respiratory tract infections, pneumonia, ear infections, SI joint pain, a new case of diabetes, knees(+++), ankles, shoulders, wrists and hands.

He also had me observe several procedures during my elective. These included: pap smears, cortisone shots (and draining fluid from knees), IUD insertions, mole removals, venepuncture, sutures, casting, and suture & staple removal.

The first patient I saw with Dr. DeMarco was a good example of what was to come for the next 8 weeks. The patient was a 20 year old male who was active and healthy. Dr. DeMarco did 3 procedures on him while he was there: First, he removed a very large mole from his posterior thigh which turned out to be a hemangioma and required ~6 sutures to close. Next, he casted a suspected fractured scaphoid. The patient had snuff box tenderness after falling on his hand snowboarding the day before (negative x-ray, though). And lastly, he removed a common wart off his hand with nitrous oxide. This patient was a good example of the hands-on type family medicine that seems to predominate in Whistler.

Another unique experience I had with Dr. DeMarco was accompanying him to a few house calls around the Whistler village. He was on-call 24 hours a day! These ‘house’ calls involved biking to various fancy hotels around the village in the dark! The calls were pretty interesting and the clients and patients always seemed very appreciative of Dr. DeMarco’s services.Some other interesting things that I learned with Dr. DeMarco involved understanding the benefits of a slightly more aggressive approach with medications. ‘If you’re going to treat them, you have to give them a dose that will work’; some personality disorders could be treated with narcotics (and is possibly a better alternative to alcohol and street drugs) as long as they are strictly controlled and monitored; and if there is a treatment available that can cure a disease, it may be worth a try- ex. Accutane for acne or methotrexate for psoriasis.

Dr. DeMarco also emphasized the importance of saying “I don’t know” at least 5 times every day to ‘stay an honest doctor’ and having the patient involved as a big part of the decision making process (which his patients really seemed to appreciate!)

I felt like I also got the opportunity to see several patients more than once (what I might expect in a small town) which gave me a good chance to do some follow-up and have some continuity.

EMERGENCY

My experience in the emergency department was limited (because of the rules about having students there), but I was lucky enough to be able to spend a day there with my supervisor’s brother, Dr. Jim DeMarco. Dr. Jim is a GP by training, but has a sports medicine diploma and has extensive experience working as an emergency doctor. He was also one of the doctors for the Canadian National Ski and Snowboard team and has traveled with them to various competitions including World Cups and the Olympic Games.

I spent a full shift with Dr. Jim on December 29th, which is known to be one of the busiest days in Whistler and at the Whistler Medical Clinic’s Emergency Department. I observed him with about 30 patients in the one shift and although my role was limited- I did feel involved and got to help with x-rays, casting, and traction more than I expected.

During my time in the Whistler Emergency Department I saw several fractured clavicles and separated shoulders (of varying degrees), injured knees (including a huge number of torn ACLs), sprained and broken ankles, several lacerations, fungal infections, anaphylactic shock (from vegemite, of all things- in CANADA!), head injuries, SI joint pain and more wrist fractures than I could possible imagine.

I learned a lot about the various diagnosis, the required investigations, and the management plans for all these patients and I feel like I absorbed a large amount in a relatively short time.

Apparently, in the Whistler Emergency Department, over 50% of the patients who come in require x-rays and of those, 50% of the x-rays have positive findings! So, I guess it wasn’t surprising to hear that there are about 25 fractured wrists (and scaphoids/FOOSH) per day that come into their emergency department.

The most interesting thing I learned about fractured wrists that I hadn’t even heard about before was a procedure for their management called a BIER BLOCK. This procedure is done several times a day in the Whistler ED and saves the patients a huge amount of time and money by offering a closed reduction of their fracture right in the department (instead of sending them down to Vancouver for further management). The patient’s arm is completely frozen with lidocaine (which is kept localized in the arm with a modified blood pressure cuff). A portable low resolution x-ray is used beside the bed to check that the doctor has been able to achieve a complete reduction. The patient is fully awake the entire time, but can’t feel a thing- and they can walk out of the ER shortly after the procedure is done and the wrist is casted.Needless to say, I found my experience in the Whistler Emergency department useful, interesting and motivating- maybe enough to sway my future decisions regarding what kind of medicine to practice (and where to practice!).

SKI PATROL

Everyday on Blackcomb and Whistler Mountains there are two volunteer doctors who give up their time to help out the ski patrollers who work there. They are not responsible for transporting the patients, but they are there to supervise situations, recommend treatment and mode of transport, manage acute injuries (such as dislocations), and administer medications (if needed). To be a volunteer doctor at Whistler or Blackcomb, you have to be a doctor with relevant training, be willing to give up 8 days of your time per season, and be able to ski any run on either mountain (easier said than done in Whistler!).Needless to say, this was one of the most unique parts of my elective- and it definitely didn’t feel like school or work! We spent the majority of the day skiing around near the top of the mountain and waiting to get called to an incident. The most interesting call on the mountain the day I was there involved a middle-aged woman with a severe combative head injury. She required a huge dose of midazolam to calm her down and prepare her to be transported.Another responsibility that is sometimes required of volunteer patrol doctors is to help with the ‘SWEEP’ of the mountain at the end of the day. After the lifts close in the late afternoon the ski patrollers ski down various runs (just before dark) looking for people left on the hill.This experience with the Whistler-Blackcomb ski patrol was an incredible opportunity that I would definitely recommend to anyone who likes emergency medicine or skiing!

SPECIALISTS

This elective offered an amazing mix of medicine. I was not expecting to have so much exposure to specialists while I was in Whistler, but I ended up having several days with a neurologist, a pediatrician, a dermatologist and two orthopaedic surgeons.

One of the orthopaedic surgeons, Dr. Pat McConkey, is a knee injury specialist, so my day with him was ALL about KNEES and very specialized. I saw a huge number of torn ACLs, patellofemoral syndrome, meniscal tears, other ligamental injuries, surgical follow ups, surgical consults, and complications from osteophytes. I spent some time looking at MRIs and observing the knee exam- and definitely know what a (‘no-end-point’) torn ACL feels like now! I also sat in with a few consults where Dr. McConkey “broke the news” of a major injury to his patients and described the surgical procedures necessary to fix it.

I also had the chance to see some shoulder injuries (mostly rotator cuff tears), elbow injuries, and Salter-Harris fractures with the other orthopaedic specialist who was visiting. This was incredibly valuable and helped solidify my knowledge on topics that I had only read about before this elective.

My day with Dr. Don Hughes, a dermatologist was also incredibly useful- especially since I haven’t done my dermatology term yet. We saw lots of psoriases and eczema and did a number of mole checks. He was also an incredibly enthusiastic teacher with an amazing amount of experience. He used to be a veterinarian, has written 3 books, and has some interesting views on minimizing the use of pharmaceuticals.

The visiting neurologist, Dr. Brian Theissen, also had a variety of patients who came to see him. During my time with him I saw patients with headaches, neuropathies, head injuries, epilepsy, pinched nerves and radiculopathies. I also had several opportunities to watch and practice focused neurological exams.

I also spent a few hours with a visiting pediatrician. I had just finished my pediatric term at Children’s Hospital Westmead before my elective, so can’t say I was overwhelmed with interesting cases in Whistler. However, I did get to see a case of Henoch-Schönlein Purpura and some more routine problems like picky eating and night terrors.

Spending so much time with visiting specialists was a part of the elective that I did not expect to get so much out of. I was overwhelmed with the quality of teaching, knowledge and enthusiasm from all of them.


SUMMARY

This report is not meant to include any detail on travel plans or social activites, but I think it’s important to just mention a little bit about the lifestyle in Whistler. The people in the community are generally young, active and healthy and there are an incredible variety of outdoor and indoor activities to keep busy and stay active.During my time in Whistler I went swimming, I did 7 days of downhill skiing and 2 days of cross-country skiing, I went snowmobiling, did Yoga, went bungee jumping, and went outdoor skating on frozen lakes. I also spent some time in the Whistler village - going to dinners and watching ski and snowboard shows at the base of Blackcomb.

This elective offered me an amazing mix of medicine, an opportunity to learn about the Canadian healthcare system and a chance to spend some time in an extraordinary part of Canada.