Island Practice (8 page)

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.

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 surgery 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.”