Nantucket Cottage Hospital -July 2011

100 Years Strong

by: Joshua Balling

“The increasingly higher value placed on human life is an infallible indication of higher civilization. To conserve human life on this isolated island, it is imperative that the conditions under which medicine and surgery are practiced, must be superseded by more modern ones.”

Those words were spoken by Dr. John S. Grouard in April 1911, on the need for Nantucket to have its own hospital, a little over two years before his dream would become a reality in a former home on West Chester Street.

At the time, Nantucketers took to their beds when ill, piled on the blankets and hoped to get better. Medical procedures were performed on kitchen tables, and babies were born at home.

Today, as Nantucket Cottage Hospital celebrates its centennial, Dr. Grouard’s words continue to ring true. The facility is the second-largest employer on the island, occupies a sprawling campus between Prospect Street and Vesper Lane, and utilizes the latest in state-of-the art equipment to treat thousands of patients a year. Yet its challenges are much the same as those faced by Dr. Grouard and the small group of Nantucketers who first saw the need for an island 30 miles out to sea to have its own hospital, chief among them the financial hurdles of an ever-changing healthcare landscape.

The commitment however, remains as strong as it ever did.

“I think the hospital has a unique place in the fabric of life on this island that cannot be over-estimated. It has that quiet presence that is counted on so much that you almost don’t see it after a while. Ideally, you just know it’s there,” said hospital president and CEO Margot Hartmann, who joined NCH as an emergency-room physician in 1999, and was named its top administrator in September 2010.

“If you think of all the other things that happen in this sophisticated way we live improbably 30 miles out to sea, none of that could happen without a healthcare facility,” she said.

HUMBLE BEGINNINGS

The seeds of Nantucket Cottage Hospital were planted on April 4, 1911, when Grouard invited a group of 18 interested townspeople to his home at the foot of North Street Hill, according to “Nantucket Cottage Hospital, A History of the Institution From the Time it was Established in 1913,” by former Inquirer and Mirror editor and island historian Edouard Stackpole.

He spoke passionately about the importance of a hospital, and a week later, the Nantucket Hospital Association was formed, with Alanson S. Barney elected its first president.

“It was originally planned to operate a small hospital unit for the summer months, when it would be most needed,” Stackpole wrote. In order to begin, money had to be raised from islanders as well as summer residents. By July, only 82 people had contributed, but the group pressed on.

On Aug. 7, others joined the cause following a wellattended meeting at the Methodist Church, including Dr. Benjamin Sharp, “a distinguished scientist and man who had become identified with many of the island’s worthy enterprises,” and Dr. S.H. Dickson, a prominent summer resident.

Shortly after, the Nantucket Hospital Corporation was formed, and a board of trustees elected. Its charter reads, in part, “for the purpose of establishing and maintaining a hospital, visiting nurses, or any kind of work connected with illness, in any form whatever, for the benefit of all persons, regardless of race or creed, the same to be free, as far as the means permit for those unable to pay. Patients able to pay will be charged reasonable rates ...”

Grace Gilman, the island’s first visiting nurse, served until April 1912 at a salary of $100 a month, when the trustees voted to discontinue her services due to the expense involved. In November, it was decided to again hire a visiting nurse, at a salary of $65 a month. Emma Woodworth was hired, but resigned in February 1913.

A PERMANENT HOME

In December 1912, the Charles Este house on West Chester Street was purchased for $6,000 for the new hospital. “It was a sturdy old Nantucket dwelling, built by Perez Jenkins and deeded in 1800 to Baker Turner, son of Thomas Turner, who had died on board the Bon Homme Richard while fighting under John Paul Jones,” Stackpole wrote.

“Plans for transforming the building were quickly drawn, and workmen began the job early in 1913. The main entrance was in the middle of the street front. On the left was a large room that took in the whole side of the house. This was the first ward ... What afterwards became the emergency room was the dining room, with a small china closet and a kitchen behind it. The stairs went up opposite and very close to the front door. There was no X-ray room or laboratory. A small room off the back served as the important operating room. A nursery was impossible and babies were kept in the kitchen in baskets, near the warm stove. A private patient was sometimes put in an upstairs room. Later, three beds in the attic provided nurses’ quarters, while the cook slept in a small room over the kitchen.”

THE EARLY YEARS

On Aug. 12, 1913, the hospital opened. Its first patient was a woman staying in one of the island’s hotels. In the first month, before it closed for the season, three patients were received, and an operation for appendicitis was performed by Dr. William P. Graves.

Annie C. Ayers, one of the early hospital workers, described the first years in Stackpole’s history: “In those pioneer days, if we were without a cook, we would get the meals until we found someone, and in the wards and private rooms, we helped with the nursing under the supervision of a trained nurse. We painted, cleaned house, did anything to keep going ...”

In 1915-1916 the hospital was open practically year-round. “The islanders had now become hospital-concious. There were patients waiting to be

admitted,” Stackpole wrote. “The patients increased steadily, until it was found necessary to refuse admittance. The least number of patients a day was two, the most nine. For the year ending May 31, 1916, the hospital was open 10 months. In that time, there were 71 patients admitted, 35 surgical cases, 31 medical, and five obstetrical ... During this first ‘all-year-round’ maintenance, 11 physicians availed themselves of the privileges offered by the hospital.”

The facility suffered growing pains in 1916-17, with 100 patients cared for. “So overcrowded was the hospital that the nurses off duty had no private rooms in which to rest and sleep. Mrs. Eugenia Snelling, one of the trustees, remarked at the time, ‘The faithful housekeeper made chicken broth

Opposite page, from top: Four nurses at the hospital on West Chester Street in June 1920; Milly Lou Gardiner in bed in the solarium of the original hospital in 1929; The “Nantucket Home Hygiene Nursing Class for Health and Home” in the 1940s; A nurse holding a baby in the hospital’s nursery during the summer of 1950.

with one hand and quieted three brand-new babies with the other, at the same time’.”

In 1918, an addition was built, a gift of the Underwood family in memory of Jennie Cushing Underwood, and “its coming was most timely, for that year saw the active entry of this country into the world war, the establishment of a large Naval reserve here, and numerous other changes.”

In the early winter of 1918, an influenza epidemic struck, and the hospital treated 337 cases of the flu. Only nine deaths were attributed to the disease on the island.

Just as today, fundraising was a key component of the hospital’s survival in the early days. During the summer of 1920, the forerunner of the Hospital Thrift Shop was organized by Mrs. Raynor M. Gardiner in the form of a Benefit Shop on lower Main Street. A two-day event called “Hospital Days” took place in August 1920, at the Barnes boathouse on Commercial Wharf, and the Flanagan family’s Moors End estate, where a garden fete was held. The events raised about $2,500 for the hospital. The first of many popular Main Street fetes was held Aug. 18, 1921, and raised over $10,000.

Over the next two decades, the hospital continued to serve a vital role in the community, adding equipment and space to its West Chester Street facility, but still feeling the financial pinch. Fundraising was necessary to make ends meet, and the Main Street fetes, perhaps the

early-20th-century equivalent of today’s Boston Pops concerts that benefit the hospital, went a long way toward closing the gap.

In 1926, a motorized ambulance replaced the previous horse-drawn vehicle, and in 1929, the hospital thrift store opened, and a new wing was added to the hospital, a gift of the Gray family. It contained five rooms and two bathrooms.

All 58 babies born on Nantucket in 1937 were born in the hospital, and a new ambulance was purchased in 1938.

In 1940, the last major addition to the West Chester Street hospital was completed prior to its move to its current campus on Prospect Street. The Crosby Memorial Wing added six private rooms, a kitchen, bath and utility room in a completely new unit.

THE BIG MOVE

The hospital continued to serve the community well, but was outgrowing its location. A major campaign was started to raise over $1 million to build an entirely new facility, and in May 1957, the new Nantucket Cottage Hospital, situated between Prospect Street and Vesper Lane, opened its doors. A year later, a 15-bed nurses’ dormitory was built adjacent to the main hospital building. The new facility had three emergency and accident rooms, 52 beds, a physical-therapy room, physicians’ offices, a laboratory and X-ray department.

In 1969, a new wing containing 10 beds for extended-care patients was built on the second floor, with increased office space and five rentable doctors’ offices below.

Hospital officials again asked the community for help in meeting operating deficits, and turned to a pair of islanders, Murray’s Toggery Shop owner Philip Murray and Alexander “Sandy” Craig, for help when a professional fundraiser was less than successful. The two men created the Life Line Campaign, with a goal of $5 million to establish a hospital endowment, and by the time they were finished, had raised over $8 million.

“The hospital was very important to him. He did work diligently on the Life Line campaign,” said Murray’s widow Elizabeth. “He was involved in many things in the community, but the hospital was the one he cared the most about. He felt that it was the most important institution on the island. He had grown up on West Chester Street next to the old hospital, and it meant something to him.”

THE MODERN ERA

Over the next four decades, the hospital continued to move forward, keeping up with the advances and changes in healthcare while always working to remain on stable financial footing.

In 1981 additional physicians’ space was added, and a year later the emergency department was renovated and expanded. The same year, Nantucket Hospice was established to provide palliative and supportive care. In 1985, the hospital partnered with Boston MedFlight and the U.S. Coast Guard to transport patients to mainland hospitals for specialized treatment and care.

In 1992, a chemotherapy unit was opened, and CT scanning technology offered in 1995. In 1996, Lucille Giddings was named the hospital’s first woman CEO. A year later, the first Boston Pops concert to benefit the hospital was held, and raised nearly $600,000. It has raised in the neighborhood of $1 million a year ever since.

A renovation of the obstetrical department, named The Birthplace, was completed in 2001, offering labor, delivery, recovery and postpartum suites. In 2003, four duplexes for hospital-employee housing were completed, the same year a telemedicine program was established for dermatology. It has since expanded to include stroke and pediatric services. NCH also established a popular “swing-bed” program, providing patients who’ve had surgery in a mainland hospital the ability to recuperate and rehabilitate on-island.

In 2007, faced with an ever-changing healthcare landscape, Nantucket Cottage Hospital affiliated with Massachusetts General Hospital and Partners HealthCare, a relationship that continues to evolve for both sides.

THE HOSPITAL TODAY

Hartmann, a 12-year veteran of the hospital’s emergency department, was named president and CEO in September 2010, replacing Sylvia Gettman.

“I feel in awe of the trail of continuity throughout all the vagaries of history from the last century into this century, that the hospital has survived and served. It gives those of us who work here, and are charged with its continued health, a sense of stewardship, a sense of confidence in a way, in the unquestioned need, in the fact that it has to survive and deliver quality care in a remote island setting,” she said.

The hospital currently employs approximately 130 full-time, 40 part-time and more than 20 seasonal employees, making it the second-largest employer on the island. With Hartmann’s move into administration, the medical staff is made up of six year-round physicians: surgeon Tim Lepore, orthopedic surgeon Raymond “Rocco” Monto, family practitioners George Butterworth, Greg Hinson and Margaret “Mimi” Koehm, and internal-medicine specialist Diane Pearl.

“I don’t think we could attract the level of tourists and second homeowners that we do without a major hospital on the island,” said former Jared Coffin House owner and hospital trustee Phil Read. “My hotel guests always felt good knowing there was a hospital here. Hopefully they wouldn’t have to use it, but if they did, it was good to know it was there. It’s a nice comfort factor.”

Trustee Margaretta Andrews agreed.

“Any isolated community deserves a full-service medical facility, but given how isolated we can become with weather challenges, it is not only important it is essential,” she said.

And costly. Hospital officials have had to make some tough choices in recent years to address budget deficits that last year topped $4 million, including a reduction in staff, the closing of its kitchen and elimination of its visitingnurses program, whose services are now provided by the Vineyard Visiting Nurses Association.

“The hospital has struggled with cyclical finances, and the cyclical nature of business onisland for all its life. It’s no different today, and the healthcare pie is even smaller,” Hartmann said.

The challenges facing NCH today are threefold in Hartmann’s mind: Decreased patient volume, decreased insurance reimbursement and an aging facility.

“It’s pretty clear that a sustainable model going forward is going to have to include new facilities, and we’re actively working to figure out what that should look like. We intend to be sustainable, and we need to be here. It’s a very easy case to make. It’s really not primarily about money, but about a belief in the institution, a loyalty to its existence, and the relationship with our patients and potential patients that we value,” she said.

To stay viable, the hospital needs to become “smarter and better,” Hartmann continued.

“We’ve been here this long, but we have to get smarter and better as the healthcare environment shifts. The hospital is in an urgent situation. It needs the community, and the community needs the hospital. It’s just that simple. But we can’t continue business as usual. We need to keep our eye on quality, but find a better way to marry the business of medicine with the art and craft of medicine. We need to get better at giving everything its due, no more, no less. Don’t overreact, don’t under-react. Find the appropriate response to everybody’s story that we’re privileged they share with us when they bring us their healthcare problem. They figured it out these last 100 years. We can figure it out the next 100 years. It gives us hope, but it’s daunting.”

A DIFFERENT BREED

One thing that hasn’t changed over the years is the commitment of the staff, Hartmann said. They continue to provide the care – and the inspiration. But it take a special breed to be a doctor or a nurse on Nantucket.

“Medicine on the mainland is more and more and more specialized. What works out here is someone who can do many things, has generalist expertise,” she said. “We’re really two different hospitals, Columbus Day to Memorial Day, and then Memorial Day to Columbus Day. That’s always been the challenge here.”

The hospital hires about 30 board-certified physicians, along with a handful of lab technicians, nurses and physical therapists each summer to treat the influx of seasonal visitors.

And they have to be ready for anything, just as their year-round counterparts do.

“On a quiet February day in the emergency department, we may see 12 patients in 24 hours. At our peak, when the island is really hopping, we can see 105 or 110 patients in 24 hours on a Fourth of July weekend,” Hartmann said.

“It takes a very unique and talented professional to deliver remote island medicine. It’s its own specialty. What that means is that you have to be ready to improvise in a way you don’t have to do in a large medical center, where you have huge breadth and depth of roles. Here you have to wear lots of hats, work outside your job description sometimes, and always keep your eye on the ball of patient care. Everybody who loves practicing medicine here has that quality.

“The island is not for everybody. But if it gets under your skin, you realize that the quality of life that it brings far outweighs any inconvenience, and it’s this hospital that brings that together. The quality of life we’ve all chosen is made possible by this hospital,” she said.

Stephen Anderson, chairman of the hospital’s board of trustees, agreed.

“The doctors here love doing it all. There are no fellows or residents or interns between them and the patient. They like that, the ability to get back to rolling up the sleeves and practicing medicine.”

Dr. Tim Lepore arrived on Nantucket Jan. 1, 1983, on the noon boat. He entered a hospital with 55 beds. Today it has 19, and is a much different facility. But in many ways, it’s a much improved one, he said.

“I see a small hospital that has moved ahead tremendously,” Lepore said. “Yet we’re always in this awkward position of what do we do, and what do we send off-island? We can do anything if we have to, but if a seriously-ill patient comes in, we don’t have, nor should we invest, in sophisticated monitoring equipment, when the patient is better served in Boston, and we’re not going to use it.

“It still amazes me when people ask if we do surgery, or deliver babies. Of course we do. It’s a real hospital that was just shrunk. We do an excellent job taking care of seriously-ill patients. Our surgical-site infection rate is tremendous. It’s less than 1 percent. You won’t see that in Boston, and you won’t see it at a bigger hospital,” Lepore said.

“We are carrying on the tradition that was started in the cottages over on West Chester Street. We’re doing what we should do, and transporting when we should. But we can do anything if it gets foggy.”

Lepore couldn’t imagine being anywhere else.

“I came from an academic, surgical background, and find this hospital and community very much to my liking. I grew up in what was then a small community in central Massachusetts. I’m a Whaler by acclimation, if not by birth. This is my home, and this is my hospital, and I’ll do everything I can to meet the needs of the community we serve.”

Working in such a close-knit environment – and by extension living in such a small community – make some of the decisions Hartmann and other hospital leaders have had to make that much more difficult.

“It’s never easy to help an organization through massive change, whether it’s downsizing, or right-sizing, whatever euphemism you want to use, but it is an opportunity to do things in a better way. It’s patronizing and too insular to think that none of the rules apply to us. Reality hits us just like everybody else,” she said.

And while there have been growing pains, the affiliation with Partners and Mass General will be valuable moving forward into the hospital’s next century, Hartmann said.

“Living on an island, one of the reasons we do is we don’t like or trust the way things are done on the other side. While that’s true, we all deserve and expect we’ll have the best of what’s available on the other side, delivered in a Nantucket way. That’s the challenge to the hospital, and it’s a wonderful challenge,” she said.

The affiliation can make that happen, Hartmann said.

“Without the affiliation, we would be in a more precarious place than we are right now. We wouldn’t have as rich a future, with the clinical opportunities that have been, and will continue to be, brought to the island. In a way, it’s having your cake and eating it too. On Nantucket, we can have local care delivered by islanders with the quality of nursing that you really don’t get in a big major teaching hospital, and you can have a direct link to the finest medicine in the world. That’s potentially the best combination.”

The hospital must still work to stay viable in a new healthcare world, however.

“Nobody’s writing us a blank check, nor would we want them to,” Hartmann said. “If somebody’s paying for what we should be paying for ourselves, we will be losing the independence of doing things in an island way. We don’t want to lose that, but still have access to the best. Like any relationship, we’re still figuring that out,” she said.

For all the challenges, it’s never boring, Hartmann said.

“When I said I was going to come out here 12 years ago, my colleagues told me I was going to be bored, that I’d see nothing but tick bites and sunburn. But it’s never boring. You see anything that can happen to any population of people, not only the severity, but also the volume, because we’re small, and don’t have layers and layers, although we do have systems in place to deal with that,” she said, citing this spring’s treatment of more than a dozen people from the same home for carbonmonoxide poisoning as an example of the success of those systems.

“You never know what’s going to walk in the door. We may see a case of malaria, not that we have it here, but our population potentially travels everywhere. Then we have the hardy Nantucketers, who won’t come in until they have to crawl in. It’s definitely not boring.”

As hospital leaders look ahead to the next 100 years, they acknowledge there are potentially daunting hurdles to overcome, but they remain committed to keeping the doors open, and providing the healthcare that Nantucketers have come to expect – and rely on – especially when the boats aren’t running and the planes aren’t flying.

“This hospital is absolutely critical and essential, without a doubt. People need care,

but what is so unique to us is our isolation, 30 miles out to sea. We have weather. MedFlights can only get off under certain circumstances. There are situations where we have to have a very highly-skilled emergency department to stabilize people, acute-care beds if someone can’t get off, or if the best care for that person is here. Not everyone has to go to a Boston hospital for critical care. We can provide it here too,” Anderson said.

“The centennial provides a wonderful opportunity in the midst of hard times to step back and look at what the hospital means. It allows me to get my head out of the weeds of the day-to-day struggle to put the hospital on a good footing for going forward, and realize its place in this community, and its place in the history of this island. It reminds me and redoubles my commitment that we have to find a way to make it healthy and keep it healthy for at least another 100 years,” Hartmann said.

Joshua Balling is the associate editor of Nantucket Today, and the assistant editor of The Inquirer and Mirror, Nantucket’s newspaper since 1821.






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