Island Practice Read online

  Lepore hit on the idea as an off-shoot of one of his many hobbies: flint knapping, the ancient art of carving stone tools. Why not make his own scalpel blades? he wondered. So what if the technique was 30,000 years old, from the Upper Paleolithic era.

  He took a rock of obsidian like “a round piece of cheese, flat on the bottom, flat on the top. Now make the cheese into an octagon, with eight or maybe nine points on it. When you hit the top of one of the points, you knock off a sliver.”

  Using a stone, he dulled one end of a long sliver, making that part into a handle. The rest, about an inch and a half long, became a blade that he considers “as sharp or sharper than a steel scalpel. For cutting soft tissue, you can’t beat it: amputating a leg, cutting at the knee joint, ligaments, tendons, muscle, fat, skin. The only drawback is obsidian blades are extremely brittle. If you try to cut against the bone, you may break it. But if it falls in, you can X-ray and see it,” so the errant blade can be retrieved.

  For a while, Lepore was so enamored of his obsidian creations that he tried to using them whenever he could, asking patients’ permission. He did hernia operations and appendectomies. When a visiting photographer showing his work on the island developed a hernia, Lepore performed the obsidian operation for free. The photographer paid him with a photograph he had taken of a Nepalese shaman, which still hangs in Lepore’s office, adding to the impression that Lepore has shamanistic powers of a sort. Or would like to.

  Ray was wary about the obsidian ear drum puncture but agreed after setting some limits: “Tim wanted to just walk into my hospital room and apparently wanted me to bite down on a towel while he stuffed this thing in my ear. Our nurse anesthetist talked him into putting me under for a few minutes while he did this. Worked fine.”

  The obsidian era ended only when Lepore became unable to sterilize the scalpels. Obsidian cannot withstand typical high-heat steam sterilization, so Lepore sent the scalpels to Cape Cod Hospital, which would use ethylene oxide, a gas that kills microorganisms and bacteria. Unfortunately, ethylene oxide can also hurt people. Although invisible and pleasant smelling, it can be explosive, flammable, and carcinogenic. “I think it was teratogenic” (able to cause birth defects) “or something,” Lepore says. “Or it killed wildebeests. I don’t know—it was discontinued.” And the obsidian operations had to be, too.

  The enthusiasm Lepore shows for obsidian and other offbeat approaches can belie the care with which he makes medical decisions.

  “When someone has that swagger and is not good, then it’s empty, it’s bluster,” says Michelle Whelan, who runs Sustainable Nantucket, a nonprofit organization. “But when they have that excellence and integrity, you tolerate it.”

  In August 2011, a six-year-old boy broke his wrist, and an orthopedic surgeon visiting from New York was ready to operate. Lepore told the orthopedist he’d have to wait six hours because the boy had recently eaten, and anesthesia should be administered to a patient with an empty stomach.

  The orthopedist got angry, threatening to complain to Hartmann, the CEO. But Lepore stood firm: “It’s nice that he doesn’t think it’s unsafe. I think it’s unsafe, and the anesthetist thinks it’s unsafe, so it isn’t going to happen. If I have a young child who gets into trouble because he ate too close to anesthesia, I don’t have any backup. I’m stuck with that kid if he turns sour. So why not just try and arrange everything so it’s as safe as possible?”

  Hartmann says cases like this show that Lepore is “not a cowboy. You could miss that because he comes across like that. He likes to shock, and he has that kind of swashbuckling, outrageous quality to him. But inside there’s really an excellent conservative clinician with very good judgment.”

  Still, Lepore loves a surgical challenge. Like the man with what looked like appendicitis, who neglected to mention that he had just eaten a club sandwich. Lepore discovered the man had swallowed a toothpick, which had perforated his small bowel. A toothpick-ectomy was the operation of choice. Another patient had a swollen, oozing sore that Lepore thought was “a big abscess around his anus.” But “when I put my finger in to feel it, I could feel this fish bone. I had to cut it out.”

  Lepore’s toughest surgery, from a technical standpoint, involved a woman in her sixties with diverticulitis, inflammation of pouches in the lining of the colon that can lead to serious infections, bleeding, or blockages. The woman needed to have the infected portion of the colon removed and two healthy colon sections sewn together in its place.

  An imprecise surgeon might nick the tube that links the kidney to the bladder or cause the colon to dangerously leak stool into the abdomen. The patient was very overweight, making surgery riskier because excess fat can obscure what the surgeon can see while cutting. “This was not someone that I would have gone out of my way and operated on,” Lepore recalls. But Diane Pearl, an internist, “pushed me into doing it.”

  Lepore first had to delicately remove part of the rectum. Wanting to be extra careful, he did it in the most technically difficult way, hand-sewing the connections between blood vessels and loops of intestine rather than using a stapler. Lepore wanted to remove the damaged piece of colon on one day and then sew the healthy pieces of colon together another day. But Pearl urged him to do a single operation. “You know, Tim,” she said, correctly in this case, “Nantucketers are hard to kill.”

  Sometimes Lepore’s patients are willing enablers, encouraging him to try something new, even when others are skeptical.

  “Hey, Dr. Lepore, do you want to cut these off?” Mary Monagle called out to him one day in 2010. Monagle, then the charge nurse on the hospital’s evening shift, was referring to loose flaps of skin under her arms that jiggled like Jell-O. The flaps were the result of gastric bypass surgery Monagle had undergone on the mainland to offload more than a hundred of her three-hundred-plus pounds.

  When Monagle approached Lepore about removing the flaps, he was intrigued. Poking what he called her “bat wings,” he sounded instantly confident. “I can do that.”

  “Really?” Monagle asked. The operation, a brachioplasty, is usually done by a plastic surgeon. Lepore had zero experience with it, and Monagle’s friends were astounded: “Are you crazy? Are you really going to let him do it?”

  “I trust him,” Monagle replied simply. Lepore ordered a $400 copy of Body Contouring After Massive Weight Loss and set about studying. Monagle figured this could be interpreted in two very different ways: “Oh my God, you’re going to let someone who needs a book do your surgery?” or “Wow. He bought a book.”

  “I want to do it right for you,” Lepore told her.

  The surgery took five hours, longer than usual because of Lepore’s unfamiliarity with the procedure and trouble finding a vein in which to insert Monagle’s IV. In first the left, then the right, Lepore made an incision that ran from Monagle’s arm pit to her elbow. He pinned down the excess fatty skin with clamps, then cut it off. He removed a pound and a half of skin on each side, and Monagle imposed only one condition: that the excised skin not be “jerkied and given to Ajax,” Lepore’s red-tailed hawk.

  Afterwards, Lepore was so proud of his handiwork that he had staff from all over the hospital come look. Monagle was overjoyed. “It’s hard to find a surgeon that you trust. I love that man.”

  Still, about six months later, when Monagle decided to move to Florida and asked if Lepore would perform an abdominoplasty or tummy tuck to reduce her excess belly fat, he said no, at least not until Monagle lost some more weight. “Otherwise it won’t look right,” he told her. So Monagle left but planned to return for the procedure, rather than have another surgeon perform it. “I’ll take a break from wherever I am and come back to have Dr. L do my abdominoplasty.”

  Lepore does not try everything. He usually declines, for example, to perform laparoscopic surgery, the less invasive form of operating in which a surgeon, guided by images projected from a scope onto a video screen, works through small incisions, using tools to manipulate the tissue. Laparoscopic su
rgery is becoming popular because it leaves less scarring and usually involves less recovery time. But it requires surgeons to use long-handled instruments instead of their hands and be good at judging how much pressure they are applying.

  Lepore knows how to perform surgery laparoscopically—he took his first course in it in 1977—and he has the equipment. The problem is that he can’t do it as regularly as he would like.

  “Laparoscopic is fraught with problems. You have to be doing it again and again and again, and I don’t have that number of cases. It’s different enough that I don’t think I could do it safely. Laparoscopic is sort of like putting your arm behind your back as you do it. The view on the scope can be very misleading. It’s like working with chopsticks.”

  Lepore knows that not being able to offer laparoscopic puts him “at a disadvantage.” But to feel confident, he would first want to assist on scores of laparoscopic surgeries performed by experts. And for that, he’d have to go off-island. He would feel guilty leaving Nantucket so frequently.

  So when a fifteen-year-old girl came in with a perforated gastric ulcer, Lepore sent her for laparoscopic surgery at Children’s Hospital Boston. “I could have done it here, but it would have been a big incision, and she would have had a six-inch scar. Now all she has is a little incision in her belly button.”

  Koehler, a laparoscopic surgeon to whom Lepore sometimes sends cases, says, “A regular surgeon would just say, ‘Hey, you know what? You don’t need a laparoscopic.’ He’s very, very honest and has very, very good judgment.”

  Lepore is acutely aware of the degree to which patients on the island must rely on his judgment. As he once told Hartmann: “You wake up in the middle of the night, and they’re all around the bed, and you know who they are.”

  In fact, Lepore remembers not only his patients but their pathologies. It was nearly thirty years ago that he saved Doug Kenward from his stab wound to the heart, prompting what Detective Steve Tornovish says was an island-wide joke: “If you come home late, you damn well better have a bag of russets with you.” (Kenward’s wife received a suspended sentence in the case, Tornovish says.) But Lepore recalls much more than the joke; a veritable anatomical atlas of that case is indelibly imprinted on his brain.

  And that turned out to be a lucky thing in March 2009, when Scott Bernard, a house painter, was found dead on Cato Lane.

  Tornovish says police officers called to the scene couldn’t tell how Bernard had been killed. “People thought he was hit by a car.” But when “Tim and I were together looking at the body, Tim said, ‘This is exactly what Kenward had.’”

  That told police they had a murder on their hands, then only the second killing on Nantucket in a quarter-century. But who was the killer? Tornovish turned to Lepore again: How far would Bernard have been able to walk after being stabbed? “With that wound? Seventy-five yards,” Lepore replied. “And he was aspirating blood the whole time.”

  The police returned to the spot on the shoulder of Cato Lane where the body was found. “We literally tracked the blood back about seventy-five yards, around a corner to a driveway, and right to the guy’s front door.” They arrested Thomas Ryan, another house painter, who pleaded guilty to the killing.

  Another job had been added to Lepore’s résumé: homicide detective. “He may be crazy all day long,” Tornovish asserts. “But he is almost always right.”

  CHAPTER 4

  Moby-Tick

  Out of the corner of his eye, Lepore spots something: a faraway pickup truck, the driver wearing orange. Lepore’s eyes light up behind his wire-rimmed glasses.

  “A hunter—maybe he bagged a deer. Hey, I know that guy. It’s Ronnie Conway. He works for the electric company. He’s also a patient.”

  He whirls his boxy, green Honda Element into a U-turn and races down a looping island road toward Conway’s house. He can’t believe his good fortune. Inside Conway’s garage, hanging upside down from triangular hooks: five slaughtered deer.

  Lepore grins. “Can I?” Conway nods.

  Lepore squats by one blood-dribbled head, placing his bare hands on the scruff of the neck almost tenderly, as if petting it. The deer were gutted in the field, so their rib cages splay open, and Conway has placed buckets under their mouths so blood doesn’t splash all over. “After two or three days, we’ll skin and quarter them,” Conway enthuses, and a hunting buddy, son of the meat manager at Stop & Shop, will cut them into venison steaks.

  Combing through the deer hide, Lepore hits pay dirt: a thick, round, black tick, then two, then three. He pinches them off with his fingers, beaming through his brush mustache.

  Fishing in his pocket, he pulls out a glass vial with an orange top; he always keeps some handy. He pops in the squirming creatures, swollen from the deer’s blood, and moves on to Conway’s other carcasses. Soon Lepore’s vials with their wriggling eight-legged captives will be winging their way to the mainland via Federal Express. There, they’ll be sliced, diced, and tested for a rogues’ gallery of diseases, diseases that have become all too familiar on Lepore’s island.

  “Not that it’s going to get me the Nobel Prize,” Lepore smirks. “I’m not going to meet the king of Sweden.” But that’s beside the point. This afternoon, Ronnie Conway’s garage has become a beachhead in what, to Lepore, is a struggle of epic proportions: Homo sapiens versus Ixodes scapularis—man versus tick.

  Like a certain fictional ship’s captain obsessed with a great white whale, Lepore is out to conquer another of nature’s leviathans: the wily tick. His style is somewhat different, of course. Lepore isn’t the raging megalomaniac Captain Ahab was. He’s more what you would expect if Ahab was played by Robin Williams. But make no mistake: Tim Lepore has a tick fixation.

  Given the slightest provocation, or not, he will expound on the three main tick-borne diseases: Lyme disease and the less well known but potentially deadly babesiosis and anaplasmosis. Or one can read the squeamish details in Lepore’s delightful color brochure: “The breeze blowing, the sun shining . . . the tick crawling up your leg . . .”

  Lepore, who has been bitten but never infected, tracks Nantucket’s tick cases with meticulous religiosity. He can list celebrities and demi-celebrities who’ve had tick diseases. And among his tick-themed paraphernalia are a cell-phone ring tone based on Brad Paisley’s country song “Ticks” and a parody of the famous gray T-shirt from Martha’s Vineyard’s Black Dog tavern—Lepore’s says “The Black Tick” and has a bug silhouette.

  An acknowledged expert, he gets calls from doctors and researchers around the country. Some patients bring him deer they’ve killed so he can siphon off ticks in his own backyard.

  “He has this obscene interest in it, and everybody gives him credit for that,” says Jim Lentowski, who runs the Nantucket Conservation Foundation. But on Nantucket, Lepore is also controversial in his outspokenness about a highly charged topic: He believes the only way to prevent tick diseases is to kill more of the island’s deer. “He really understands and is so passionate that he turns a lot of people off because they just think he’s being a nut about it. He’s a high-profile person on that point, and he wears a lot of people down.”

  On the same December day of the Ronnie Conway bonanza, Lepore is waging his tick crusade on other fronts too. It happens to be the Saturday of the Christmas Stroll, the biggest—well, pretty much the only—tourist event of the off-season, so most year-round Nantucketers are downtown reopening shops they had otherwise mothballed for the winter or helping run tourist activities.

  Ferries from the mainland are filled to the gills with giddy landlubbers. On the island, they promenade in red hats and jingle bell necklaces, mink vests and Prada high-heeled boots (perhaps not optimal footgear for Nantucket’s cobblestoned streets, but some folks are too well-heeled to care). As Victorian-costumed carolers sing, visitors tour gussied-up Georgian Revival mansions, imbibe generous goblets of eggnog, and fill their bags with trinkets like Christmas ornaments from the Cold Noses boutique, featuring a silho
uette of any breed of dog personalized with your pet’s name.

  Lepore is having none of it. He has more important things to do: staking out the waste water treatment plant, for one.

  The plant is drab and dank, its interior a mass of gigantic tanks and labyrinthine pipes, festooned with perky signs like “Anionic Polymer—Caution.” But Lepore isn’t there for the ambiance or the sewage. He is lying in wait for ticks.

  During the weeklong deer-hunting season in November and December, the plant becomes a check-in station. Hunters haul in freshly killed deer and heave them onto a wooden scale, warped and reddened with years of deer blood. James Cardoza, a retired state wildlife biologist, records each deer’s weight, sex, and age. Then Lepore swoops down and pores over the dead animal, scooping up blood-bloated ticks with his hands.

  Hunters, usually eager to cart their deer home, can be taken aback by the bald, bespectacled man gleefully picking ticks off their conquests. But Lepore persists: “Jim lends me an aura of officialdom.” Anything to get his hands on the island’s prime promoter of ticks—in his view, a devil disguised as Bambi.

  “The deer basically is the taxi cab for the ticks” is how Lentowski puts it. And on Nantucket, ticks have no trouble hailing a cab. Where are deer going to go, after all? They stay on-island and multiply, so that, state biologists say, there may be sixty white-tailed deer per square mile on Nantucket, the highest concentration in the state, where most counties have about ten to twenty per square mile.

  Deer scamper through backyards and driveways, are spotted around Main Street and the hospital parking lot. The deer furnish adult ticks with a “blood meal,” Dracula-style. The blood meal is critical to allowing ticks to reproduce. Filled with blood, a tiny tick can swell to the size of a grape and lay 2,000 eggs. “A deer could literally cause tick reproduction so that everybody would be up to their necks in ticks,” says Sam Telford III, an associate professor of infectious disease at the Tufts School of Veterinary Medicine and the guy who receives Lepore’s FedEx packages of neatly bottled arachnids.