Island Practice Read online

  One night, “I got five stabbings from a Star Market, and they weren’t all in the same fight.” A man doused his body with gasoline and set himself on fire. Another jumped off a roof, and Lepore operated on him three times in one day, peeling off dead skin from gangrene that had developed in his legs.

  If the violence weren’t enough, there was a constant stream of car accidents from the nearby highway. A teenager driving a station wagon struck a pole so hard that a spare tire flew forward, pinning the kid against the steering wheel and crushing his larynx. Lepore managed to get him breathing.

  Calamity lurked everywhere. Christmas decorations ignited a major fire in a women’s dorm at Providence College. When Lepore arrived at the hospital at 1 AM, “every stretcher had a burned or dead girl. Some had jumped; some had smoke inhalation. There were some horrendous burns. I was really the only one there. I went down the line and took care of everything, intubating people, sticking in IVs. It took about twenty minutes for anybody else to show up. After that they decided I should be head of the ER.”

  Lepore made a point of living about two hundred yards from the hospital so he could always get there instantly. He and Cathy bought a house, but the hospital was not situated in the safest neighborhood, something the Lepores began to worry about more after they had children: Meredith, born in 1977, the day they moved into their Providence home; T.J. in 1979; and Nick in 1982.

  Cathy was flashed twice by men when she was walking with the children on the street. At an auto repair class at a nearby garage, she saw people bringing in bags of money—bookies, she assumed, or corrupt cops. People would break into the house when they saw her leave to take the kids to school. Their car was burglarized repeatedly.

  Even worse was the summer night Cathy heard men arguing outside. Lepore went to investigate and see if he could help. Instead, he was shot at. For Cathy, “it was just awful. I hated living in Providence.” Plus, Lepore was so busy he had little time for the family. He worked thirty-six-hour shifts and had academic responsibilities at Brown University. When Cathy went into labor with Nick, Lepore was treating a Brown urology professor who had fallen down an elevator shaft.

  Then, in the summer of 1980, Lepore was invited to visit Nantucket by a medical school friend, Paul Thompson, who worked summer emergency room shifts at Nantucket Cottage Hospital. Lepore had been to the island only once before, in the fall of 1974 with a girlfriend. His main recollection was of trying to teach her to drive a stick shift there; he claimed she nearly blew out the transmission.

  But when Lepore visited Thompson, he liked what he saw. The hospital was small and manageable. Cases could get wacky—water injuries, exotic diseases, a woman who brought in a rabbit with red eyes—but they were unlikely to involve gang violence or the carnal wreckage he saw in Providence. And the shifts were better: twenty-four hours on, then forty-eight hours off.

  It was an appealing arrangement, recalls Jeffrey Drazen, a summer doctor from 1974 to 1979 who is now the editor in chief of the New England Journal of Medicine. “You worked every third day, they gave you a house, they paid you $200 a week, and you saw twenty patients a day.” A head nurse staffed the door. “If you had a fishhook sticking out of your head, she’d let you in. But if you had poison ivy or something like that, she’d tell you to come back.”

  When the Lepores first saw it, the hospital had an exam room, a room for sewing up patients, and fifty beds (nearly three times as many as it has today). An heir to the Campbell Soup fortune, whose family had donated a lot of money, stayed in the hospital as if it were a residence. And there were free meals for the medical staff. “You could come in and order breakfast, do your rounds, and get your eggs over easy,” Drazen remembers.

  But despite its comfortable trappings, this was a hospital that needed to be more medically sophisticated, to learn to operate with greater urgency. Drazen recalls his first case, a thirty-year-old with serious heart problems. The physician in charge said to “just wait it out. He was into doing that for a lot of things.” Drazen finally persuaded the doctor that the patient should be sent to the mainland.

  With the island drawing ever-wealthier summer residents and the working-class people to support that influx, it was time to give Nantucket the sort of health care people could rely on whether they trimmed hedges or owned hedge funds.

  Lepore’s friend Thompson arranged for him to work in the hospital for the month of August 1981. The Lepores returned the following summer, relishing the tranquil contrast to inner-city Providence. Narrow streets, some set with brick or studded with cobblestones, made the pace of life seem more manageable. Strict building codes—pitched roofs, unpainted gray shingles—kept sprawl in check and had a way of letting the island showcase its natural surroundings: plants, birds, water. On the boat heading home the Lepores asked themselves, “Why are we leaving?”

  The island had a vascular surgeon, Earl Mahoney, but he had already retired once, been pressed back into service, and wanted to retire for good. The hospital talked to Lepore about working there full-time.

  “They needed somebody who was well trained, enthusiastic, had good judgment—and wanted to live on Nantucket,” says Drazen, who still summers there. “Boy, they got the right person. He keeps up with what’s going on. He adapts to his environment. He knows what he can’t do and what he can do. He is willing to take chances when that’s the only option, particularly when the weather shuts things down. He’s involved in the community—to succeed on Nantucket, you have to be.”

  Lepore did wonder what he might be giving up at Roger Williams, but he didn’t think he was going to get promoted there any time soon. He was also losing patience with the de rigueur meetings and mundane responsibilities of a big hospital; they seemed to take him away from patient care. In September, he told Roger Williams he would leave January 1. “Nobody quite believed me until December 28.” Then “they put all kinds of pressure on me to stay. They said, ‘It sounds nice, but you won’t be happy there.’ I asked for a leave of absence for six months. They wouldn’t give it to me. So I said, ‘Okay, guys, I’m out of here.’”

  Lepore and his family didn’t know exactly what they were getting into.

  On a visit to the island a few months before they moved, they got blasted by a big storm. Pilot whales were beaching left and right. Boats were blocked from coming or going. The family was stuck. “There’s no reason to get all heifered up,” Lepore decided then. “You’re either going to get off or you’re not going to get off.”

  They stayed for the first few months in a “very fancy-dancy house on lower Main Street,” but it became clear they needed something more affordable. After a stint in a tiny hospital-owned house at the bottom of a hill—“if your brakes fail, you’d run right through it”—the hospital asked if they wanted to buy the land up the hill for $75,000. It was on Prospect Street, right next to a windmill built in 1745, just a hundred-yard dash from the hospital. Meant for a mind-set like Lepore’s. “It’s a conscious decision that I live that close.”

  Cathy, who helped set up Lepore’s family practice next to the hospital and worked there as a nurse for a while, hoped that Nantucket would allow her husband to relax and spend more time with the family. Reality sank in for her all too quickly: “On call twenty-four hours a day. Medically isolated when emergencies occur. You don’t have a lot of backup. Here, he’s sort of it.”

  But for Lepore, the unpredictability of Nantucket was part of the attraction. “I thought it would be an adventure. A situation where I was going to be pretty much on my own. It was, ‘What the hell. Go thirty miles out to sea and see what you can do.’”

  He had a chance his very first night, when a patient came in with complete heart block, needing a pacemaker, something Lepore had never put in before.

  “What do I do?” he asked himself. “Oh, what the hell,” he replied, since there was no one else to answer the question. He racked his brain for a few seconds before calling his friend Paul Thompson, a cardiologist, who talked Lep
ore through putting a line into a subclavian vein, one of two large veins that run from the ribs to the collarbone. Lepore got the pacemaker in. It was a watershed moment and a harbinger of what the next thirty years would have in store: Lepore felt “mildly totipotent after that night.”

  A few nights later he got another call. “Somebody had put a vegetable some place that vegetables don’t usually go, and he wanted me to come and take it out.” Lepore was hooked.

  CHAPTER 3

  CUT, SEW, AND TIE

  Maybe it happened because Doug Kenward came home late and forgot the potatoes. Maybe it had more to do with how much his wife had to drink. Whatever the reason, the result on that Sunday afternoon was bloody. Kenward’s wife stabbed him in the heart with a butcher knife—in front of their sixteen-year-old son.

  Kenward’s son struggled to get him out of the house. He tried to drive but didn’t know how. He flagged down a truck, got neighbors to help hoist his father into the back, and sped Kenward to the hospital, unconscious and in shock.

  There, Tim Lepore, on Nantucket barely a year, realized this was the most life-threatening case he had encountered. That’s counting the gang shootings and car crack-ups whose victims had paraded like macabre mannequins onto his emergency room table in Rhode Island. Kenward was, in Lepore-speak, “making an honest attempt to die.” Lepore aimed to make a liar out of him.

  There was no time to transport Kenward off-island, no time to summon extra help. Kenward had a hole in his right ventricle. Fluid was building in the pericardium, the sac around the heart, making the pressure so high that the math was despairingly simple, Lepore knew: “No blood was going into the heart, so no blood was coming out. That’s what kills people.” Lepore had seconds to determine how to open the chest to repair the stab wound without further imperiling the heart. “The decision,” as he put it, “was the incision.”

  Lepore cut into Kenward’s chest and inserted spreaders to separate the ribs. He opened the pericardium, careful not to slice the vagus nerve, which stretches from brain to abdomen.

  He found the hole in the ventricle and controlled the bleeding by sticking his finger in it. He asked nurses for special sutures for stitching up blood vessels, but the hospital had none. “Give me some black silk,” he demanded instead, his knowledge of obscure medical facts kicking in. He knew that in the 1890s, black silk thread was used to fix a stab wound to the heart.

  Lepore sewed the deep hole, then waited and watched. Kenward, forty-four and a Nantucket Electric Company worker, pulled through. Well enough that he became a swimmer; well enough that he became a marathon runner. A cousin who was a doctor later told him that the chance someone with that kind of stab wound would make it to the hospital alive was 10 percent. The chance of surviving an operation? 1 percent.

  Kenward recalls that when he regained consciousness, he eyed the doctor at his bedside.

  “Who are you?”

  Lepore answered as if he were a gunfighter in a spaghetti western: “I run. I shoot. I fix people up.”

  Typical Lepore, on a not entirely atypical day. There may not be tons of stabbings on Nantucket (“stockbrokers don’t usually go after lawyers,” Lepore observes), but there are always people needing surgery.

  Lepore doesn’t have a surgical specialty, meaning that rather than having extensive experience in particular procedures, it’s more like: “You name it, I’ve done it.”

  Lepore contends that the operating itself is not difficult. “Surgery—I don’t want to demean it—but it really is cut, sew, and tie. In the OR, it’s a controlled environment. It may look chaotic, but it isn’t. The surgeon has things planned out. I like to say if you can eat in a public place without a bib, you can do surgery.”

  Many surgeons with perfectly adult table manners would disagree. Richard H. Koehler, a laparoscopic surgeon who comes over from Plymouth, Massachusetts, to cover for Lepore on the rare occasions he leaves Nantucket, says general surgery is “very, very, very tough. General surgery is by all measurements the worst on-call schedule you have to carry. The risk of the surgery you’re doing is very high. The complications are life-threatening. Sometimes you’re doing it in the middle of the night. You can’t pass it off to somebody.”

  Still, to Lepore the issue is not whether he can handle the surgery, but whether the hospital can. It has one operating room and one person qualified to administer anesthesia at any given time (two nurse anesthetists from Cape Cod trade shifts), so if other cases arise, Lepore will anesthetize patients himself.

  Even more significant, Lepore believes, is whether the hospital can provide adequate care after the patient has been cut open and stitched up. Postoperative care can be constrained in a hospital that now has just nineteen beds and no dedicated intensive care unit. And while Nantucket may encounter a wider range of cases than even some big-city hospitals—how many of them see patients with fishhooks in their eyes?—it may not see any one type of case as often as larger hospitals do.

  “In medicine today, what really makes the difference is the critical care, postsurgical care, and we can’t do a lot of that here,” says Wayne Wilbur, one of the visiting nurse anesthetists. “We don’t have the volume, and we don’t have the equipment.”

  There is no dedicated recovery staff explicitly skilled in the kinds of things that can occur after surgical procedures.

  “If we put a patient on a ventilator, we run out of people that are competent to deal with a ventilator fairly quickly,” Lepore recognizes. “Whoever happens to be there does the postanesthesia recovery,” if they are certified in advanced cardiac lifesaving. “Most are, but some people just don’t want to do it. It can be a little bit hairy.”

  Mary Murray, an obstetrician-gynecologist who spent eighteen months working on Nantucket, says the contrast with larger medical centers she has worked at can be stark. “Not that it is not a real hospital, but when something like this happens in Connecticut or New York, there’s a team, they go in the OR, it’s well planned, there’s a board-certified anesthesiologist, and there’s a postoperative nursing staff that’s highly trained—all just waiting for something like this. That’s what we do in hospitals that are a little more civilized.”

  Many postrecovery questions can arise, Lepore notes: “Are they warm enough, what’s the urine output, what’s the blood pressure, what’s the pulse, the oxygen saturation? They have to be checked much more frequently. It can be a little bit more anxiety-provoking because it’s not something the staff does every day. And if you’re operating on someone with other confounding issues—diabetes, pneumonia—those factors come into play in the recovery of a patient. My concern is this: if I operate on a desperately ill patient and I don’t have backup in recovery.”

  Another potential limitation is blood. Nantucket’s hospital keeps only six units of blood in stock, an amount that could be used up for a single patient with, say, a fractured pelvis, a laceration of the cervix, or a ruptured spleen. If the supply is depleted, more must be flown in from the Red Cross in Boston. “If we run out in the morning, we could have more by the afternoon, but if we run out at night, you’re not getting it. You have to husband it,” Lepore knows.

  The hospital’s constraints constantly guide Lepore’s decision making. “It’s easy to operate on people; the hard thing is not to operate on people.” If he thinks Nantucket is less than ideal, he will quickly move patients to hospitals in Boston or Cape Cod, rather than be “sitting here looking at my belly button—omphaloskepsis, I think it’s called.”

  When Foley Vaughan, a Nantucket lawyer, fell to his knees and began vomiting, Lepore quickly discovered he had scar tissue blocking his colon. “Tim decided he couldn’t wait,” Vaughan recalls. “He cut me open, unkinked it.”

  But when Vaughan experienced the same problem ten years later, Lepore, evaluating the hospital’s limitations and recognizing that surgery could wait a bit, flew Vaughan to Boston City Hospital in a twin-engine plane. In Boston, “they had a team of eight people doing the operati
on,” Vaughan notes. “The country doctor did it his way, and the city doctors did it their way.”

  At first, Lepore had to rely on boats, often the Coast Guard, or on somebody’s private plane to take patients off-island. But he worked to make arrangements with Boston MedFlight because its helicopters can make the Nantucket-to-Boston trip in less than an hour; travel by plane or ferry can take more than twice or three times as long. Also, helicopters can land just outside the hospital and are equipped with oxygen and other medical equipment.

  “What I really respect about Tim is he knows what can and can’t be done here,” says Wilbur, the nurse anesthetist. “If he can’t do it right, he’s not going to do it. The real thing about saving lives here is knowing when to call that helicopter.”

  But sometimes the helicopter isn’t flying. Fog, wind, rain, and snow can keep aircraft grounded. Then Nantucket becomes as isolated as it was before helicopters were invented. Often Lepore ends up playing chicken with the weather. One morning, he may have a patient he is confident he can operate on, but he can’t be sure the patient won’t develop complications that evening when a storm is scheduled to strike. “You can really get into trouble,” says Koehler. “If he knows the weather is going to crap out that night, even though he could do the operation, he makes the better judgment of sending that patient off.”

  Although Lepore transfers many cases, the number of surgeries at Nantucket’s hospital has been increasing, from 250 in 2006 to close to 400 a year. And when Lepore goes off-island, the hospital may need to bring in not only a surgeon to pinch hit, but an obstetrician too.