Island Practice Page 5

  On days when the hospital has to fill Lepore’s shoes “we all remember it,” says Margot Hartmann, the hospital’s chief executive officer. Those covering for him “are used to offering very different coverage than he provides. Patients are used to calling him at the drop of a hat, and people from other hospital systems may not be prepared for it.”

  Koehler, who practices in Plymouth, Massachusetts, and has covered for Lepore since about 2008, is not a stranger to small-town medicine, having spent about seven years doing surgery on the larger island of Martha’s Vineyard. But when he fills in on Nantucket, he says, patients will come into the ER and ask, “Is Dr. Lepore here?” Told he is off-island, some will say: “Oh well, I’ll check back when he comes back.”

  Koehler is not offended. He understands. Lepore is “like the one-man band walking down the street. If you did a cartoon of him, it would be like he’s got the cymbals on the head, the syringe coming off him on one side, the stethoscope on the other side.”

  At least, Koehler says, so far when he has been on Nantucket, “nobody has come up to me in the supermarket and said, ‘I’m rectal bleeding.’”

  A few years after Lepore made a surgical splash saving Doug Kenward’s life, he encountered a case that ended with the exact opposite outcome, mortifying and tormenting him for years.

  One Saturday in February 1987, Michael Butler, forty, a shipyard mechanic and occasional fisherman, showed up in the emergency room. Butler reported that he had eaten some turkey and stuffing left out from the previous day and soon afterward felt stomach pain that kept worsening. Assuming food poisoning, doctors gave Butler ipecac to make him vomit, but his abdominal pain only became more severe.

  The supervising physician was David Voorhees, who had been on Nantucket since the 1960s. Voorhees was not a trained surgeon, but he had handled many operations. Lepore was not supposed to work that weekend.

  Butler, who was separated from his wife and daughter, told hospital staff he had been a heavy beer drinker for years but had recently started cutting back. He had broken his ankle several months earlier and had been unemployed since. Butler’s brother, Chuck, recalled recently that Butler had also been beaten up several years before this hospitalization, suffering a head injury that “put him in a downward spiral,” made him “emotionally unstable,” and caused him to drink.

  After rejecting the food poisoning idea, Voorhees indicated on the chart that Butler probably had pancreatitis—inflammation of the pancreas frequently associated with alcoholism. But he advised it would be good to “rule out appendicitis” and “rule out peptic ulcer perforation.”

  Butler began sweating profusely, his abdomen distended. He was fed intravenously all night, but by Sunday morning, his heart was racing, and he was bleeding internally. X-rays taken for the first time showed a hole in his gastrointestinal tract with “massive contamination.” That, Lepore recalls, is when “I get a call that there’s a forty-year-old guy in the ICU dying. I came in. His heart rate was 140. He had no blood pressure. He had a perforated ulcer and had sat there overnight.”

  Lepore acted immediately: “I called in an anesthesiologist. I called in Voorhees to come and help me. And I operated on the guy.”

  It was a tricky situation. “Because of the delay in diagnosis, the guy was in shock. He was a setup for multiple organ failure. If somebody had recognized it the day before . . .”

  Still, Lepore thought he could handle it. “If I didn’t do something, the guy would have been dead in an hour or two,” so he decided sewing up the hole was worth the risk and “went ahead and fixed it.”

  He irrigated Butler’s stomach to wash away contaminants. He found the rip—it was in the duodenum, a C-shaped tube in the small intestine that opens into the stomach. He plugged it by stringing down a piece of omentum, the fatty apron attached to the bottom edge of the stomach.

  Butler’s condition foiled Lepore’s repeated attempts to insert a small stomach feeding tube, so he made a surgical hole in the stomach and inserted a larger tube. He sewed everything up and gave Butler cephalosporin, an antibiotic to ward against infection.

  Butler began doing better. Then, late Monday afternoon, his breathing grew labored. He was given oxygen but soon became disoriented and feverish. His lungs grew wet and congested. His heart was beating too fast and then slowed to such dangerous levels that he suffered a heart attack.

  Lepore was able to revive Butler and place him on a ventilator. But his white blood cell count plummeted, placing him at greater risk for infection. A chest X-ray suggested he had acute respiratory distress syndrome, meaning his lungs could not pump enough oxygen into his blood. He sank into a coma.

  “I thought that we could control this in terms of multiple organ system failure, but I was wrong,” Lepore recalls. “The problem was the pony was out of the barn. I don’t think anybody could have put all the king’s horses and king’s men back together again.”

  On Tuesday, Butler, still comatose, was transferred to University Hospital in Boston. Several days later, he needed another abdominal operation because the site of his perforated ulcer was leaking, overwhelming his bloodstream with bacteria. He continued to deteriorate and was declared brain dead, and ten days after he entered Nantucket’s emergency room, Butler’s family decided to remove him from the ventilator.

  Then Butler’s widow, Carol, sued—at first only Voorhees, the physician that first day. But later, Lepore was added as a defendant. He was crushed and defiant.

  “I did all the right things. I told the family I was concerned about this. I was out front with them. And I still got sued. If I had done nothing, I wouldn’t have gotten sued because I wouldn’t have had my hands on him.”

  The case alleged negligence and wrongful death. An expert witness for the plaintiffs, Dr. Albert Harary, wrote: “There were several departures from accepted medical practice, which contributed to the poor outcome and death of this patient.”

  He wrote that the X-ray was taken too late, a day after Butler came in, leading to an eighteen-hour delay in surgery and increased severity of Butler’s infection. That was Voorhees’s responsibility, but Harary also questioned decisions involving Lepore.

  He said the antibiotic given to Butler, cephalosporin, was inadequate and probably worsened the infection. He said the staff acted too slowly to try to prevent Butler’s heart attack when he exhibited respiratory failure and that they delayed checking Butler’s arterial blood gas, which measures oxygen and carbon dioxide in the blood and might have indicated he needed to be on a ventilator sooner. And he said that if Butler had been put on a ventilator when CPR was begun, instead of twenty-five minutes later, he might have suffered less brain damage.

  “Both Dr. David Voorhees and Dr. Timothy Lepore were involved in the deficiencies in care that resulted in the death of this patient. This patient’s death was a direct result of unnecessary delay in diagnosis of the perforated ulcer, inadequate antibiotic therapy, and especially a failure to recognize and prevent the impending respiratory catastrophe despite ample warning signs. The medical care delivered to this patient was clearly below accepted standards and resulted in this patient’s death.”

  Lepore was eager to defend himself in court but said the insurance company representing him, Voorhees, and the hospital wanted to settle. His part was settled for $100,000; the other defendants settled for more. Contacted in 2011, Carol Butler declined to discuss the case.

  The lawsuit lasted three years and “was horrible for him,” Lepore’s wife, Cathy, recalls. He felt the settlement “was an admission of guilt. If it was a lapse of something, or if you were tired and made a mistake, that’s one thing, but he would do the same thing again tomorrow.”

  Cathy herself felt responsible because she’s answered the phone when the hospital called looking for Lepore. “If I had said, ‘He’s out running,’ he would not have had any part of it. It wasn’t his patient. And they did not call him before the patient was in really bad condition.”

  Lepore’
s son Nick remembers his father being “really depressed, kind of in a funk for months. At times he’d be angry about it. Doctors get sued all the time, but for him and for us, it was really a big moment. Nothing like that had ever happened.”

  In truth, in the world of medicine these days, it is almost extraordinary that Lepore, fielding such a diverse agglomeration of cases and emergency situations over three decades, has never faced another lawsuit. The only other time anything even resembling legal action came up, he says, was in Providence, where he was periodically contacted by a lawyer for a woman “until they realized that she was being guided by the Martians.”

  Koehler, who has been an expert witness in lawsuits against surgeons, says a single lawsuit in such a long tenure is “incredibly remarkable. The average general surgeon in this country is sued once every five years.”

  For years after the Butler suit, Lepore plagued himself with what ifs. “Once somebody puts that stake in that hole, even though they take the stake out, the hole’s still there,” Cathy notes. Lepore says he is not surprised doctors have committed suicide over such cases: “You beat yourself up. You go for a long time questioning yourself. Somebody goes into medicine trying to do good, and all of a sudden you get accused of this. You go to bed with it; you wake up in the morning with it. Did I do something wrong?”

  Since Nantucket is such a small community, perhaps it was inevitable that, several years later, Lepore entered the emergency room to find that his next patient was Butler’s brother, Chuck. He was a lobsterman who had collided with a piece of lobstering equipment and needed stitches in his head. “I don’t try to avoid him or anything,” Chuck Butler recalls. “I personally respected all the doctors here and thought they were doing the best they could in a little one-horse town, and I didn’t think it was appropriate to sue. I never really blamed them for it.”

  But the case still haunts Lepore. After every procedure, even the simplest suturing, he revisits each step at home.

  “Should I have put a stitch in there? Did I do that right? Could I have done this better?’ You play these things over and over. I do, anyway.”

  In the mid-1990s, Lepore, as the hospital’s medical director, had a decision to make. He was performing most of the surgeries, but Voorhees occasionally did some. Lepore liked Voorhees. While self-taught at surgery, he had what Lepore called “a great kinesthetic sense.” He was eccentric too. His father was a musician who had conducted the “Bell Telephone Hour,” and “David would walk around the halls humming the New World Symphony.” Voorhees lived in a house that used to be a cow-birthing barn, and he installed operating lights over the dining room table.

  Now, though, Voorhees had had several strokes, and Lepore was noticing that problems were cropping up, especially with obstetrical cases. Some Caesarean sections “went too long.” Other births Voorhees presided over were risky enough to require surgery, but Voorhees delivered them vaginally. “It was obvious the skills had atrophied.” Lepore fretted about what to do.

  “That was hard for Tim,” recalls Steve Tornovish, a police detective who is married to one of Cathy’s sisters. “Tim had great respect for him.”

  Finally, Lepore confronted Voorhees. “Look, I think you should retire. Your skills have eroded, and you shouldn’t be doing surgery.”

  Voorhees reluctantly accepted the verdict of the younger, newer doctor. Two years later, at sixty-five, Voorhees died of a stroke.

  Lepore himself finds obstetrical cases to be some of the toughest. Not the surgery itself, usually an emergency Caesarean section, which he considers “a semimindless procedure you can do if you got opposable thumbs.” But with a pregnancy, “you are dealing with two people,” and “when it goes wrong in a C-section, it can go wrong very fast.”

  Koehler says it is almost “unheard of for a general surgeon” to do C-sections. “When I cover over there, I could do a C-section if I really, really needed to do one. But it’s high-risk.”

  Lepore is much more comfortable if he knows the patient’s health and pregnancy history, “if I have an understanding of the patient as a surgical candidate.” Once, in fact, while running a half-marathon, he was tailed by a police car and stopped at mile 10 to come in and perform an emergency C-section on a patient he had been treating. He finished the race later.

  But when Lepore is unfamiliar with a pregnant woman’s health history, “it becomes more than cut, sew and tie.” The case of Lee Ann Psaradelis was like that. In her third trimester of pregnancy, she arrived in the emergency room with massive internal bleeding. “All of a sudden, they lost the fetal heart,” Lepore recalls. Despite an emergency C-section, the baby did not survive.

  Psaradelis turned out to have a big tumor on her right adrenal gland, called a pheochromocytoma, which causes excess release of hormones that control heart rate and blood pressure. Psaradelis had not been Lepore’s patient, and whichever doctor had been caring for her during her pregnancy had not spotted the tumor. “Going through the chart we could not find anything that would have told us it was there,” Lepore recalls.

  Now it was causing her to bleed so profusely that Lepore started seeking blood donors. Thirty people showed up to donate, but it was too late. “She just went downhill and died,” Lepore remembers. “I can see it in my mind’s eye right now.”

  He says he has also encountered many cases in which women needing emergency C-sections have not signed consent forms ahead of time. This disturbs him because he worries they may not be able to consider their choices in a calm and reasoned manner while in the throes of labor. “You cannot obtain informed consent on a patient who is non–English-speaking, has been medicated, and it’s 3 o’clock in the morning. You tell me that that’s informed consent, I’ll say to you that that’s bullshit.”

  For years, Lepore has felt “pushed into” performing such emergency Caesareans, “but that doesn’t mean that I think it’s right. Sometimes I’m tempted to sign my name on the chart with invisible ink.” As a precaution, he will write in the patient’s medical record that informed consent is needed, something that, he knows, “does not necessarily make the administrators happy” because it suggests the hospital did not follow procedures to the letter. He has also worked to persuade the hospital and family practitioners to discuss emergency Caesareans well in advance.

  “I’ve had people tell me that the patients would be scared about it,” he says. “Well, you know what? Every patient should be told about possibility of the C-section. They make great DVDs of these things in English, Spanish, and every other damn language. They should sign something ahead of time. The patient should meet the potential surgeon and understand about the procedure.”

  Lepore was thrilled in 2009, when he and the hospital’s emergency room director recruited the island’s first full-time obstetrician-gynecologist, Mary Murray, a summer visitor from Connecticut who was recently divorced with young children.

  “I immediately liked him,” Murray says about Lepore. “I did immediately feel like I’ve known him in a previous life. I could literally complete his sentences, and he could complete mine.”

  That Murray could perform emergency C-sections was especially important to Lepore.

  “The guy had been out there for all these years handling emergencies,” Murray explains. “He never trained to do a C-section. He taught himself to do it. He’d come flying in in the middle of the night to operate on a person he doesn’t know, maybe a language he doesn’t speak, with no backup.”

  Suddenly, he had someone to share obstetrical cases with. And Murray felt she “could have worked with him for twenty years. In times of stress the guy always has something in his back pocket. He’s also very irreverent. You never know quite what’s going to come out of his mouth.”

  But Murray grew frustrated with what she describes as a number of hurdles. She had trouble getting equipment and approval for procedures like minimally invasive hysterectomies. The reimbursement system and other policies made it hard for her to earn enough to live on t
he island, and she bridled under some restrictions set by the hospital’s parent company.

  Lepore tried hard to keep Murray on Nantucket, offering to invite her into his practice and even take out a home equity line on his house to help her out. But eighteen months after she arrived, Murray left and moved to Georgia. Now one of the island’s newer family practitioners, Mimi Koehm, performs C-sections, but Lepore would love to have more help.

  Bruce Chabner, a prominent physician at Massachusetts General Hospital in Boston, who is on the board of Nantucket’s hospital, says everyone recognizes the island’s need “for people that deliver babies,” but “it’s hard to find the right person, and people can make more money elsewhere.”

  So Lepore carries on, fielding obstetrical cases and their sometimes-dicey complications. One of the bloodiest was a D&C, dilation and curettage, on a woman who had just given birth. The procedure involves removing tissue and remaining fragments of placenta in the uterus, so the obstacles don’t cause too much blood to be lost.

  Before he could even start, “all of a sudden, we have audible bleeding—you can hear it bleed. That’s exciting bleeding.”

  Wary of using too much of the hospital’s blood supply, he transfused the woman with two units, cleaned out the uterus, packed it with absorbent material, administered medication, and “crossed my fingers and crossed my toes. It stuck. I have great respect for what can come out of the vagina: some wonderful kids, and lots of bleeding.”

  Richard Ray has seen a lot as director of Nantucket’s health department, but even he was unprepared for what Lepore was proposing. Ray was hospitalized with pneumonia and an ear infection, and Lepore’s approach was to puncture the ear drum to drain the fluid. Standard enough, but there was a catch: Lepore wanted to use a scalpel he had carved himself out of obsidian, a volcanic glass.