The call came just after breakfast on a Saturday. A patient of one of my partners was hoping I could do him and his employer, Bates College, a favor and see a woman who was not a patient in our practice. She was visiting from out of town to see her grand nephew graduate on Sunday but had taken ill, and was reluctant to visit the ED.
I agreed to meet them in the office after morning rounds at the hospital, something that seemed quite natural at that time but would be difficult now with the multiple added layers of bureaucracy, some imposed by third party payors and some associated with our transition from independent practice to a member of a hospital-owned group.
When I got to the office, they were waiting for me in the parking lot. I unlocked the office, got a pad of paper and clipboard at the front desk and recorded her name and date of birth, and brought her into Exam Room 10, stopping along the way at the nurse’s station to get her vital signs.
(I remember the room because of the framed document. My grandfather, Herr Doktor Professor Herbert Elias, had been a well-respected physician in Vienna before the War, with both a large practice and a teaching position. As Viennese anti-Semitism grow stronger and more public, his position there became more tenuous and in 1938 he was quite lucky to be able to escape not long after Kristallnacht via Belgrade and then Turkey to New York City, where he practiced and taught for many more years. By the time he had left Vienna, he was not allowed to care for patients in the hospital or enter the University, and had been ‘excused’ from membership in the Vienna Society for Internal Medicine. I knew ‘Opa’ as a tall and serious man, distant to the point of being forbiddingly reserved, and without a smile. He was classically educated with what seemed an unlimited intellect, and with the highest ethical and academic standards. After he died in 1976, I accompanied my father on several trips to his apartment, going through his effects. We found, stowed in the back of a closet, a box of some papers and letters. Included in this was a carelessly folded and partially torn certificate from the Internal Medicine Society of Vienna naming him as an honorary special member in recognition of his great scientific and humanitarian service. Accompanying this were copies of a correspondence that he had had after the War with officials at the University of Vienna medical school. They were trying to reconstitute their decimated faculty, having expelled or killed anyone with any Jewish heritage, replacing them with Nazis many of whom were now disgraced or imprisoned. They had contacted him with a request that he return and serve as Chief of Medicine. The fragmentary correspondence reflected his reluctance based on their long history of anti-Semitism in thought and deed. He requested some specific actions before he would consider accepting, but no agreement was ever reached and he remained in New York City until he retired. The certificate was in serious disrepair and my father was going to discard it, but I asked to have it. It sat in my genealogical papers for years before I took it to a local framing shop to have it repaired and then archivally matted and framed. Then it sat in a closet at home for several years before I brought it to the office.)
Ms R was an elderly woman, uncomfortable but not toxic. She was articulate, obviously well educated, with a vague but unplaceable accent that suggested middle Europe, and shoes and bearing reminiscent of my grandmother, Ilse. She described intermittent episodes of abdominal pain for months, often following large meals, associated with nausea and sometimes vomiting, and usually lasting one or two hours. By restricting her diet and avoiding fat she had been able to minimize her symptoms, but traveling to Maine for the graduation had made it difficult. This episode of pain had now lasted 18 hours. She had no fever and had tolerated liquids that morning in small quantities, but had no appetite. Her abdomen was somewhat distended with marked right upper quadrant tenderness and a (+) Murphy sign, but she had bowel sounds and was not jaundiced. The remainder of her history and exam did not add much. The clinical picture was consistent with intermittent biliary colic from gall stones, with a stone now stuck and obstructing the gall bladder.
Impacted stones will sometimes spontaneously dislodge, but the longer the symptoms persist, and the more local inflammation there is in the duct, the less likely spontaneous resolution becomes. Worse, prolonged obstruction sets the stage for infection in the gall bladder - septic cholangitis - which is a life threatening illness and surgical emergency. Patients with a prolonged impacted stone are generally hospitalized, stabilized with fluids and antibiotics, evaluated for other potentially complicating factors, followed semi-urgently by surgery. This was what I outlined to her as my plan, indicating I would admit her and arrange to have her seen by a surgeon within the hour in anticipation of possible surgery in the next 12 hours.
She would have none of this. She had travelled a long distance, alone and with great effort despite her age, because she wanted to see her grand nephew graduate. That was what she was planning to do. Until after the graduation the next day, she was willing to take pills but nothing more. A frank discussion of possible outcomes, including that she could die in the next 48 hours, did nothing to weaken her resolve. I started her on antibiotics and prescribed a small amount of pain medication, explained to her and the Bates administrator who had accompanied her how to reach me over the weekend, and asked that she call me after the graduation was completed.
As she thanked me and stood up to leave, she paused, nodded toward the framed document with my grandfather’s name, and asked: “What do you know about Herr Professor Elias?” She pronounced it in the correct European manner, as ‘Eh-lee-us’ rather than ‘Eee-lie-us’ as it is pronounced here in the States.
Puzzled, I replied, “He was my grandfather. Why do you ask?”
“He was my physician when I was a little girl growing up in Vienna.”
She had left Vienna for Prague with her family in the mid 1930s to escape Viennese anti-Semitism. Most of her family had perished during the war, but a brother had survived and emigrated after the war to the US where started a family. He had died years earlier and she never saw him or any of his family after he left Europe. She had come to the States to see her grand-nephew’s graduation and meet some of her late brother’s family.
I was far more impressed with the serendipity than she. I commented in awe about the amazing string of coincidences: her grand nephew happened to be graduating from a College in my town, the Bates staffer had contacted our practice rather than any of the other practices in town, I had happened to be the physician on call that weekend, I saw her in the office rather than the ED, I put her in Room 10 rather than any of the other rooms, and I had hung the certificate barely 2 months earlier after it had sat at home for a year. She said quietly: “Yes, things happen.” And smiled.
She followed my medical advice carefully. (I suspect my connection to Herr Doktor provided credibility I would not have otherwise had.) She called on Sunday afternoon after the graduation and we made arrangements for her to go to New York City where my father (at that time a partially retired internist) arranged for her to be admitted by a colleague. She had an uneventful cholecystectomy before returning to Europe, and we exchanged holiday greeting cards for nearly a decade before I stopped hearing from her and having my cards returned as undeliverable.
The certificate remains in the exam room in my office. Periodically a patient asks about it, and I can never resist talking about the magic it represents for me, though it always means I fall behind in my schedule. And every time I look at it, I can hear her quiet voice, accepting of fate but still full of confidence: “Yes, things happen.”