Island Practice (20 page)

Then one night, “it dawned on me,” Lepore says. “Ulceroglandular tularemia. I’d read about it but never seen a case.”

Only about a hundred to two hundred cases of tularemia are reported in the United States each year. It can cause skin ulcers, pneumonia, diarrhea, and swollen lymph glands, and can be fatal if untreated. “It’s a great bio weapon,” Lepore notes.

Sometimes called “rabbit fever” because it is carried by rabbits and rodents, tularemia can be transmitted to people if they handle infected animals, eat something contaminated with the bacteria, breathe it in, or are bitten by an infected insect, like a greenhead fly. On Nantucket, rabbits are nonnative animals, brought over from the Midwest in the 1930s so hunters had something for hounds to chase. But as rabbits do, their numbers have long since multiplied.

The greenhead flies that Lepore traps and sends to Sam Telford at Tufts for testing have never shown traces of tularemia, but Lepore knew that the nearby island of Martha’s Vineyard had a small cluster of a different strain several years earlier. He called McMullen in, stuck a needle in the lymph node, sucked out fluid, and FedExed it to Telford. Sure enough, he told McMullen, it was “red hot for tularemia.”

For a month, Lepore saw McMullen at least every other day, but since McMullen did not have insurance for such care, he says Lepore treated him “practically for free,” charging only $440. Lepore tried three antibiotics before finding one that worked. “It was pretty powerful stuff,” recalls McMullen. “It made my fingernails turn black.”

Tularemia is the kind of obscure condition more likely to arise on Nantucket because the natural ingredients are there. But other characteristics contribute to a variety of medical problems. The population may be small, but it is hardly homogeneous.

As a summer resort community, Nantucket has visitors and natives who are highly traveled, sometimes to exotic places. A bride returned from her Caribbean honeymoon with a maggot wriggling out from between her shoulder blades. Another woman’s vacation souvenir from Jamaica was a delightful hookworm called “creeping eruption.”

And in a probable sushi-related incident, a lady from Greenwich, Connecticut, came in with a specimen: a fish tapeworm as long as a chinchilla—and the worm’s other half still inside her. “I always say the only thing worse than finding a worm in your apple,” Lepore told her, “is finding half a worm.”

The population that supports Nantucket’s summer community is increasingly diverse, with immigrants from Bulgaria, Cambodia, El Salvador, Haiti, Nepal, Latvia. Some immigrants visit the doctor only when their illnesses have become serious, like a man with “a canteloupe-sized scrotum with four to five feet of small bowel trapped in it.” Some immigrants bring not only foreign maladies but foreign remedies—treatments like cupping, in which a hot cup is placed on the skin to suck blood to a certain spot, and medicines that have not been approved or studied in the United States.

“It’s a very multicultural experience to practice medicine here,” notes Margot Hartmann, the hospital’s CEO. “You have to kind of understand from an infectious disease perspective what they might have been exposed to.”

Other types of bizarre cases could happen anywhere, but Lepore believes he may see somewhat more of them because of the island’s diversity and vacation atmosphere. There is, for instance, a subcategory, or perhaps a sub rosa category, of patient whose interests in unconventional erotica go comically, or tragically, awry.

One morning in August 2009, a twenty-eight-year-old tourist from Cambridge showed up at the hospital complaining of acute pain in his abdomen. He turned out to have a big tear in his rectum, a perforated colon, and a bad infection.

Lepore urged the man to explain, and he finally came out with the story. “He and his girlfriend were having some sex play, and he got a toilet plunger stuck up his butt. One could ask why, but I suppose there’s no good answer.”

The tourist told Lepore the injury had occurred around 4 or 5 AM, but Lepore thought it was “a lot older than he told me.” Maybe he believed he could recover on his own, or embarrassment kept him from seeking help earlier. The damage was profound, and Lepore was concerned because the patient was developing sepsis, his bloodstream overwhelmed with bacteria. After all, of all the things one could insert in one’s body, plungers are probably not the most sanitary.

Lepore pumped the man with intravenous fluids and antibiotics. The weather was bad, and the MedFlight helicopter was not planning to fly. But the man needed major care—the removal of a piece of large intestine and ultimately reconstruction of his bowel.

“I have done it,” Lepore says. “But when you don’t have the staffing and the other medical resources, and you start dealing with a patient that seriously ill, that’s not a patient who should be on Nantucket.” Fortunately, as Lepore was preparing to operate, MedFlight decided to fly.

The choice of a plunger might have been innovative, but, in Lepore’s experience, the motivation for using it is not. One patient arrived with a cucumber in the same location. Another man had a vibrator there, insisting his wife was responsible, although she said she had nothing to do with it. Another man was vacuuming naked when his genitals got caught in the fan blades, suffering “a certain amount of destruction,” as Lepore puts it.

One night in the fall of 2011, a Nantucketer in his twenties came into the ER with a predicament Lepore describes this way: “Picture a penis.
There’s some loose skin by the corona at the head of the penis. The guy had put two very powerful magnets there on either side. They were pressing into the skin because they’re attracted to each other. I wish I’d taken a picture. He was in a great deal of pain, and then he was in a great deal of embarrassment.”

Nurses and a physician assistant were unable to pry the magnets off because “every time they pulled one, the other would pull it back.” So Lepore anesthetized the area with lidocaine and used hemostatic forceps to dislodge them. “I really don’t want to know what you were up to,” Lepore told the man, sensing the moment was right for a proverb: “Idle hands are the devil’s workshop.”

Lepore was a little less diplomatic to the man who introduced himself by saying, “Doc, I think I have a ballpoint pen up my penis.” How could Lepore not be charmed?

“You’re a dumb bastard,” Lepore told him.

“I didn’t come here to be insulted,” the man responded, doubly hurt.

“Look, you’re forty years old and you
think
you have a ballpoint pen up your penis?” Lepore asked, amazed. “That’s sort of black and white. There isn’t a lot of gray in there.”

Lepore had to operate to remove said pen by making an incision in the bladder so he could pull it out from below. The episode ended gentlemanly enough, however. “These cases,” Lepore observes, “if you don’t have testosterone, you don’t understand it.”

Lepore has seen a few cases involving the opposite sex, but most have been accidents, like the woman with a chunk of soap lost in her vagina, who had been trying to get clean, not trying to get off. Lepore removed the soap. On the patient discharge sheet he could not refrain from giving advice: “Soap on a rope could forestall this problem.”

Lepore cannot fix some erotic experiments. “Death, rectal paintbrush, and penis ring” was the way Lepore characterized one case in an email. It occurred out on the water in the cabin of a small sailboat. The man, a summer restaurant worker, was found naked, kneeling, with a paintbrush
stuck into his rear end and a noose around his neck connected to a penis ring. It was an arrangement the man had engineered himself, trying for “a little bit of strangulation because partial asphyxiation causes an erection,” Lepore explained. A salacious video had been playing on his computer, and he had been smoking a small amount of marijuana.

“A friend of his discovered him, then called one of the restaurant owners, who then called the sheriff, who then called the police, who then called the Coast Guard, who then called me,” Lepore said. Partial asphyxiation had turned into total asphyxiation, and Lepore went out to the boat to pronounce the man dead, see if an autopsy was required, and dispatch the body to the medical examiner’s office in Boston.

“It wasn’t,” Lepore summed up, “a good picture.”

While Lepore’s black comic sensibility appreciates such gallows humor, it is the medical mysteries that really get his blood flowing. His diagnostic acumen is something of a legend among patients.

In 1994, Lepore knew John Gardner as a “tough-as-a-two-dollar-steak” defensive back on the football team, small in size but so determined that “if I said to John, ‘I want you to run through the wall,’ he would run through the wall.”

So when Gardner at fourteen started losing coordination, speed, and strength, even though he was training five days a week, Lepore knew something was up. Gardner was having headaches and feeling dizzy but tried to shrug it off until simply hitting a tackling dummy caused an intense jolt of pain in his neck. Lepore sent him for an MRI, got the results on a Sunday morning, and immediately decided that “the kid’s got to know what’s going on.”

Gardner was off-island, though, heading to the Patriots’ opening game with his father and other relatives. They’d just stopped to eat breakfast at the Country Kitchen in Hyannis on Cape Cod when a police
officer entered and called out the name Gardner. Lepore had tracked him down. From a pay phone, Gardner called Lepore, who told it to him straight: “John, looks like you have a brain tumor.”

Lepore sent him immediately to Massachusetts General Hospital, where his tumor, which was not cancerous, was removed. But after the surgery, he experienced repeated puzzling setbacks, each of which Lepore helped diagnose: meningitis, a spinal tumor, leaking spinal fluid, and arachnoiditis—inflammation of a membrane that covers spinal nerves. “Doc was constantly trying to figure out what exactly was wrong,” recalls Gardner, who had to have surgery three more times. “I always had the feeling that if I needed something, he was going to get it done.”

Gardner could never play football again and for a while had to lie on the floor in class because he couldn’t hold his head up and look at the blackboard. But Lepore pushed him to get back in shape, monitoring his exercise plan of walking to the end of first his driveway, then his street. “He was taking great care to make sure I was progressing. He was matter-of-fact. I asked him a question, and he didn’t sugarcoat it. That, I appreciated.”

Lepore considers his approach axiomatic. “You got to spend time. You can’t be on a six-minute schedule. You got to ask the right questions.”

Sometimes even before you actually see the patient. When Marilyn Bailey came from San Diego to visit her daughter, Carolyn Condon, who had just had a baby, Bailey’s hip was in pain. As her son-in-law helped her upstairs, her hip “snapped in his arms,” Condon recalls. In the emergency room, a visiting doctor who happened to be a bone specialist examined Bailey.

Bailey told the doctor she thought she had a groin pull, and without ordering an X-ray, he concurred, gave her painkillers, and sent her home. But Bailey’s pain persisted, keeping the family up all night. Next morning, Condon, in tears, burst into the office of her own doctor.

“Dr. Lepore, what do I do?”

“How old is your mother?” Lepore asked.

“Sixty-nine.”

“I’m calling 911; she’s coming in. There’s no way a sixty-nine-year-old pulled her groin muscle.”

Lepore got Bailey to the hospital and sent Condon home to rest, calling her several hours later. “The pain that your mother has endured is amazing,” Lepore told her. Her hip was completely broken, and Lepore had discovered that Bailey was having a recurrence of breast cancer she’d had years earlier. The cancer had metastasized to her hip and was spreading throughout her body. Lepore helicoptered her to Boston.

“Dr. Lepore just took the bull by the horns and said, ‘This is what we’re doing,’” says Condon, who runs a heating and cooling business with her husband. Later, the bone doctor called Condon, apologizing profusely. “He was beside himself. He was just blown out of the water.”

Margot Hartmann thinks one key to Lepore’s diagnostic success is that he is good at hearing what patients are saying and not saying. “People are self-selecting in the information they give you, out of their own effort to make sense of it and maybe because of where they want to lead you. You have to keep lots of differential diagnoses in play, while not assuming it is any one thing. You don’t want to miss the subtle clue.”

Clues like that are what Lepore lives for, Hartman says. “He loves to crack open those books” and read about cutting-edge treatments and oddball cases.

In 2010, when Eva Blathe was two months old, her mother, Michelle Whelan, changed the baby’s diaper, dressed her in footie pajamas, and set her down for a nap. A couple of hours later, several of Eva’s toes were turning purple, and one was bleeding.

“It was absolutely horrifying,” Whelan recalls. “I was in hysterics. I knew the danger was that her toe would fall off.”