Island Practice (6 page)

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.

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 operation,” 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.

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.”