Island Practice

by Pam Belluck

  The antlers hanging in his office are “sheds” that he found on the ground after deer sloughed them off. Sometimes when Lepore is out in the moors looking for antlers, he wanders completely off the deer trails into thick, nearly impenetrable brush. As darkness falls, Lepore calls Cathy: “I’m lost—come find me. Go someplace high, and turn on the lights and honk the horn.” Before her friend Pam Michelsen moved off-island, she and Cathy developed a system: Drive out to the middle of the moors and climb up Altar Rock, the island’s second-highest point at all of 108 feet above sea level. Then blow a whistle. Keep on blowing until the doctor finds his way out of the woods.

  Once, with forty-five minutes to spare before the wedding of one of his longtime nurses, Lepore decided to scout out a new hunting spot. He drove to Hidden Forest, bumping along dirt roads until the dirt became mud and the car got stuck. He called Cathy, who was livid and sent Chris Fraker to the rescue. But the car was so mired they had to wait for a professional tow. Lepore missed the wedding.

  “Hunting—this is the best way I can put it—it’s very different from going for a walk in the woods,” Lepore muses. “You’re more alive to everything around you, to the wind, to sounds, to looking to see things.”

  Besides, whatever gets injured on a hunt, it’s a game animal, not a patient. “I haven’t tried to fix anything I’ve shot,” Lepore says, and maybe that’s part of it. In hunting, it’s okay to let things die.

  CHAPTER 8

  WE CAN HANDLE WEIRD

  Alexandra McLaughlin could see them and hear them: people buzzing around her, anxiously wondering what to do. She had just gone out for a walk with her dog. But suddenly she was sprawled on the ground, face down.

  Passersby seeing her in the dirt panicked and called 911. Someone, perhaps thinking she was having a seizure and might bite her tongue, said, “Let’s shove a wallet in her mouth.” But McLaughlin wasn’t having a seizure or a heart attack or a fainting spell. She wished she could explain what was going on, but, although fully conscious, she couldn’t move or utter a sound. She could only lie there, humiliated.

  “My face,” she recalls, “was right next to a dog turd.”

  McLaughlin was the ultimate medical enigma. For more than two decades, since she was about ten, no one could determine what was wrong with her. Many doctors had tried. They suggested thyroid problems, renal problems, Lyme disease. One doctor proposed postural orthostatic tachycardia syndrome, POTS, in which the heart rate revs when people stand up. Brain cancer was tossed around. Depression? Bipolar?

  “I kept getting misdiagnosed.” And she kept getting worse. Falling down had been a rare symptom for most of her life, but since moving to Nantucket in 2009, she was collapsing constantly—face down on the street, on the beach, in stores. “People find me on the ground all the time. It looks like I’m dead.” She’s had surgery on her knee, wrist, ankle, and fingers, and “I had to give up horseback riding, which I love, because I would fall off.”

  McLaughlin’s symptoms can be triggered when she’s startled, even “when people honk to say hello to me” on the street. And “whenever I have a strong emotion, I can’t move my arms,” or her knees buckle, and she turns to Jell-O.

  “When I’m really, really happy, I know it’s going to happen. So I start thinking of something awful: dead puppies in a washing machine or something. When I get really angry, I can’t move my head, and my jaw goes slack. I have to think of the funniest YouTube videos I’ve ever seen.”

  Once on the beach, McLaughlin saw a mother playfully chasing after her daughter with sunscreen, the girl squealing: “I’m a princess, and princesses don’t get burned.” It was so “funny and delightful” that “I was doomed,” McLaughlin says. “I fell right down.”

  Glancing at photographs of close family or friends can make her “high five the table with my face” without warning. And watch out “if I’m talking to somebody I’m madly in love with. I don’t look him in the eye.”

  McLaughlin’s condition could cause her to hallucinate, seeing spiders where there were none, for instance. She was also experiencing sudden onsets of fatigue and “could nod off to sleep and not realize that I’ve slept. I was unable to get out of bed, unable to drive my car, can’t work, can’t do anything.”

  McLaughlin moved to Nantucket when she was thirty-one because the island, where her family had summered, seemed a good place to reboot after her marriage broke up. (She asked to be identified by her birth surname instead of her married surname.) Soon after arriving on-island, she began landing in the emergency room. She inquired about primary care physicians. “Dr. Lepore may be the only doctor taking new patients,” she was told. “He doesn’t turn anybody away.” Lepore was not only available. He was fascinated.

  “With him I could be more honest about what would happen to me. I had this huge history of symptoms that just never made sense. I couldn’t tell that to anybody because it sounds crazy. He said, ‘Oh that sounds really interesting.’”

  McLaughlin, it turned out, had stumbled on a medical marriage made, if not in heaven, then on Nantucket. Lepore loves odd or inscrutable cases, and Nantucket has provided him with more than his share.

  In the summer of 2006, Rob McMullen actually crawled into Lepore’s office. It was an extraordinary predicament for McMullen, a ship’s captain who has plied Nantucket’s waters for almost two decades. He lives alone on his sailboat, The Snowy Egret, drives a small cruise boat taking tourists from town to an upscale inn on the island’s northeast point, and was used to shrugging off ailments without any medical help.

  But McMullen, then forty-four, was having strange symptoms. He got hot flashes and then chills so extreme that he was piling on sweaters and blankets in July. His legs began crumbling beneath him. “I really couldn’t walk.”

  To get to his job, “I would crawl to the edge of the sailboat, pull myself up on the deck, pour myself into my dinghy, and then row it over to my work boat,” the Wauwinet Lady. There McMullen would “kind of prop myself up” while steering and making safety announcements. When he got to the inn, The Wauwinet, where he usually ate meals, “I couldn’t walk up to the hotel, so I would convince someone to buy me a turkey sandwich, and I would live on that for a few days. I was too proud, and I didn’t want to stay in bed or go to the hospital. I think it was kind of messing with my head.”

  Finally, McMullen contacted Lepore, who zeroed in on what McMullen called “twin puncture wounds on my neck that looked like I’d been bitten by a vampire.” Near the wounds was a raised lymph node that resembled skin cancer, but there was something atypical about it. “He wouldn’t give up,” McMullen recalls. “He wanted to figure out what it was.”

  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 Lep
ore 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 calle
d 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.