Port McNeill and Kingcome: Remembering lessons learned

Lessons learned from her mentor Dr Granger Avery 25 years ago continue to guide the authors practice today. It was a fairly sunny day in June 1981.

Dr Granger Avery and I had done rounds in the little 10-bed hospital that also functioned as my place to sleep for 6 weeks, and I was getting my stuff together for our trip by floatplane to an outlying clinic. Lets see, rain jacket, gum boots What do you wear with gumboots? I guess pants would be the easiest, take shoes along I was quite excited and a little apprehensive about the upcoming adventure. For one thing, I had never been in a floatplane before. I had read about Kingcome in Margaret Cravens book I Heard the Owl Call My Name, but the vastness and beauty of the BC coast, its inlets and islands, its mountains and sheer endless forests, were still very new to me. At 37, with two children and a husband left behind in Vancouver, I was hardly your average second-year medical student. Growing up in Holland was not much of a preparation to tackle the BC wilderness.

Without a doubt, the UBC rural family practice program for second-year students is one of the outstanding opportunities in the curriculum, and as I was sitting in the room with my classmates a few weeks earlier, studying the map of BC with the little red dots signifying where the various practices offering this 6-week elective were located, I knew that this was a chance for me to gain some completely new and unique experiences. I wanted to go far enough away so that it would be truly rural and yet be able to come back for one weekend in the middle of what would be the longest time Id ever spent away from my family. Port McNeill, high up on the inland coast of Vancouver Island, seemed ideal even though there were no references to it from past program participants as it was a brand new location option in the program. I was relieved that it was still available when my lottery number came up. It turned out to be even better than expected since I was lucky enough to have Dr Avery as my mentor. Passionate about rural medicine, Granger had pioneered a number of innovations since coming to Port McNeill, including doctors visits to small, isolated Aboriginal villages such as Kyuquot and Kingcome. He was (and Im sure still is) an excellent teacher who approached medical questions and patients differently than my professors in Vancouver and would come up with questions and insights that changed my perspective. We also had a lot of fun.

At that time, the same pilot always flew Granger on trips to outlying communities. Extroverted and full of stories, this pilot gave me a rapid history and geography lesson of that part of the coast and gave Granger an update of the local gossip.

The water of the Queen Charlotte Strait at the north end of the island is an unbelievable colorlight green-bluethe color of ice-cold glacier water. The village of Kingcome sits in a crook of the river that flows into Kingcome Inlet and the current is such that the plane has to land at a dock across from the village. We were picked up from there by the locals in a small boat and ferried across, landing on the beach; hence the gumboots. Granger looked as if he were going to a downtown luncheon or tea party, dressed in a shirt and tie and an immaculate three-piece suit, with only the pant legs disappearing into the gum boots revealing a different destination. We were welcomed by several of the villagers, and after having changed our gum boots for shoes and having washed our hands, a ritual unfolded.

We had arrived before noon and had had time to visit some carvers before being treated to lunch by a couple of the female elders of the village, who gave us an update on the happenings in the past 3 weeks. A review of village health issues followed with the Native nurse practitioner who runs the clinic. After this we went for a walk down the one street (a path really, since there are no cars in Kingcome) to make a few house calls. As we walked past the church and then the longhouse, a most remarkable sort of dance started to unfold. As we walked by, there were folks sitting on their front steps or porches or busy in their yards and they would strike up a conversation:

• "Hello, doctor. Are you here today?"
• "Yes, Im here today. How are you keeping?"
• "Nice day today doctor. We have been busy with"

As this banter went on, they would start to walk along with us on a converging course, eventually remarking something like, "I cut my hand cleaning fish yesterday. Wonder if you could have a look at it", or "My back has been really sore lately", or "The pain in my leg has been getting worse lately." We would stop, Granger would briefly inspect the offending part and say, "Yes, you know, I really think we should have a good look at that. Im here in the clinic all afternoon. Why dont you come by later?" to which, almost invariably, the answer was, "Oh you are here today eh? Okay. Ill do that. Ill come to the clinic later."

At least four or five appointments were made that way, and I began to understand a little about the difference in culture and why our way doesn't work out there.

There was one patient in the clinic that afternoon who served to teach me many more lessons. A 43-year-old man came in complaining that he had been unwell since that morning. Perfectly well in the previous days, he had gone out to chop wood and quite suddenly felt very tired and weak. No other helpful history was made available. He had never felt this way before. As I watched Granger examine him, I wished I had a camera or the ability to quickly sketch this picture of the English gentleman-physician examining a West Coast Aboriginal man, which I might entitle Two cultures connected by a stethoscope. The picture is still vivid in my mind: the patient was not tall but very powerfully built, sitting on the examining table, massive head with a red bandana as the headband in his very dark hair, hardly a neck visible but broad, powerful shoulders stretching his T-shirt, his deep-brown, muscular arms and legs, and his impassive immobile face in such strong contrast to Grangers slender figure in the three-piece suit, reddish-blond hair, mustache, and muttonchops framing his attentive face as, stethoscope in hand and ears, listening intently to heart and lungs. When he was finished, he asked if the young doctor who had been sent out from Vancouver to help him might do an examination as well. Although somewhat nervous initially, I soon became really interested in my findings and when Granger asked, Well, what do you think? I answered quite happily, Hes in atrial fib with a rapid ventricular rate, about 130.

I had been very fortunate to have had Dr Doris Kavanagh-Gray, eminent cardiologist at St. Pauls, as my clinical teacher. She had made sure that we heard what there was to hear and could make a diagnosis from our clinical exam. Granger took a step back. "Are you sure?" "Yes, I said happily. Im sure." All right was his answer. So what do we do now? My confidence bubble burst immediately. We had done some diagnosis, but treatment? I scrabbled around in my brain. How do you treat atrial fib? (Remember, this was 1981.) I guess we need to give him some digoxin? Granger smiled. Well, yes perhaps, but we are here in Kingcome and you think he is in atrial fib but I think he maybe just has some PVCs and a rapid rate. So what do we do now, here? It slowly started to dawn on me. Oh, yes, of course. We need an ECG and we dont have one here. Right. We need to take him back with us! So indeed we took him back with us in the floatplane. Over 200 pounds of extra weight, it required some readjusting of the planes load! Fortunately neither Granger nor I was particularly heavy and the pilot was used to unexpected changes in plan. Once we were back at the hospital in Port McNeill, the ECG did confirm the diagnosis of atrial fibrillation and Granger made him my special patient. Precipitating factors such as hyperthyroidism were ruled out and he did receive his digoxin. His ventricular rate slowed and he converted back to sinus rhythm in the next few days, but in the meantime, I was in charge of explaining to him how his heart had been responsible for his sudden weakness and why avoiding alcohol was very important for him in order to prevent a recurrence. That was perhaps the most difficult task.

This is but one of many fondly remembered experiences of my rural practice time. The things I learned were very helpful during the rest of my training, and are still today. My time in Port McNeill was a major influence in my decision to go into family practice. Thank you, Granger, for teaching me, first, to think things through not just to diagnosis and treatment but to their further ramifications, influences on family and community, and second, to ask the important question, Can I treat this here or do I have to send it out? The clarity required when there is no immediate backup available allows no fuzzy thinking. Your question, Why is this patient here now? still helps me regularly to find a useful direction in a circumstantial history. The rural family practice experience has been cut to 4 weeks now, but I am very glad that I had 6 weeks in Port McNeill.