Royal and famous patients 3. A royal stone
This story starts with a phone call in May 1994 from the embassy of an oil-rich country in the Middle East. “We want you to come and treat an important person. I have arranged for a plane to collect you tomorrow. Bring any assistants and equipment that you need. Would that be convenient?”
Hell no, it could not be less so. The call came just before “Digestive Diseases Week”, our main annual professional conference, at which I had numerous commitments. And for the week following I had rented a house at the beach for friends and family, and 2 weeks later we were due to relocate to Charleston. The embassy man was not sympathetic, and would not divulge any more information, let alone the name of the patient. Eventually I was allowed to speak to one of the local caring physicians who made it clear that the patient could not be more mportant, and that he needed one of my ERCP procedures to treat a problem in the royal bile duct, and very soon.
After much negotiation I left a week later with my trusted nursing colleague (Marilyn Schaffner), with lots of equipment and even more trepidation. I told the embassy that I planned to visit the hospital on arrival, to do the procedure next morning, and to leave 24 hours later. They had other plans. We arrived on time and were met nicely on the runway with a big black car. Our passports were taken for early clearance—but not returned. This was the first sign that we were not totally in control of our destiny or schedule. We did go to the hospital that afternoon with a cardiologist who seemed to be in charge, and found charming staff ready to provide anything we wished at short notice. It turned out that an ERCP had been attempted a few weeks before. The king had not wished any publicity, so they had built an entire procedure room with full x-ray facilities in the Palace. Unfortunately, the x-ray equipment failed to function appropriately, and the procedure was not successful.
We returned to our hotel suites (about 10 rooms each) ready to do the deed on the following morning. However, a call came to say that the patient was not yet ready and thought it desirable for us to be more rested before embarking on the procedure. We were taken to a beach resort and told to relax. I remember a tasty “slipper” lobster.
The next day dawned with similar comments. The patient was not quite ready, but we should go to the hospital in the early afternoon, which we did and waited with increasing anxiety. He arrived eventually at about 10 pm with a retinue of Princes and staff. The medical details certainly suggested the presence of biliary obstruction, and the need for ERCP. He cut short my usual discussion of informed consent, with a gesture of trust which I found slightly menacing, backed up as it was by a chorus of rippling Korans in the background. Everyone crowded into the room, and we got started at about midnight with the expert help of an Irish Anesthesiologist.
As I passed the instrument around into the second part of duodenum where the bile duct enters, I was delighted to see pus draining from orifice of the bile duct. This was a good sign, because it suggested the presence of a stone rather than a tumor. I had been very concerned that—had I found a tumor—we would have been trapped in that country for a long time whilst organizing appropriate treatment, with the potential for a bad outcome for all involved. Stone removal, however, is pretty straightforward, and was indeed successful within a few minutes. There was a huge outpouring of excited relief (not least from myself) and much kissing, even by the half-sedated patient. I told the retinue that we would return to see him at 9 o’clock in the morning, and that, assuming that he was doing well, we would like to leave town shortly afterwards.
Marilyn and I and several local physicians returned to the hotel, prepared to celebrate our relief, only to realize, of course, that alcohol was not available. I had not been asleep for long when the phone rang at around 5 am. I was told that a car was waiting to take me urgently to the hospital. This sounded very, very bad, and I could envisage emergency bleeding, confusion, incrimations and significant retribution. Happily, the patient looked surprisingly well when we entered his suite, and it turned out that he simply wished to thank me and ask permission to eat. I left carrying a large envelope full of negotiable (American) currency. We were booked on the next flight home through Paris and were enormously relieved when the plane took off (and alcohol became available). We transferred in Paris to the Concorde, just for fun, and got home safely.
Marilyn certainly remembers the trip:“It was a very foreign place. Immediately on arrival, I was taken to a shopping area where I was fitted for an Abaya (a large, black cloak worn loose and flowing) and a Boshiya (veil). I chose a beautiful and probably very expensive outfit.
I soon ran up against other cultural differences, that I would call prejudice, like having to walk 5 paces behind Peter. I am not a shrinking violet, and my staff back home at Duke were worried that I would start a women’s revolt, but I chose not to impose my views. However, one night I came back to the hotel, and could not get into my large suite on the top floor. The front desk told me that my suite was being given to someone more important. They assured me that I would have a comparable room in another building. I pulled off my veil, leaned over the counter and assertively (and boldly) stated that unless the room was exactly the same, they needed to give me another key. I got my suite back but did not sleep well that night for fear of retribution”.
I am grateful to Marilyn for allowing me to include her reminiscence, and photos, but ever more so for her always cheerful partnership and mentoring over many years as we worked together at Duke and MUSC. Far from walking 5 paces behind me, she was always several steps ahead. She taught ne a great deal.
This story does have sequels. The royal physician minders got the impression that I was a medical expert and continued to call me for illnesses in the family, mostly outside my small area of expertise. Some years after my visit, however, the King again developed biliary-type pain and fevers, and I was invited to attend again as a matter of urgency. On the phone the symptoms sounded like inflammation of the gallbladder, which had not been removed, despite my advice, largely because the local physicians were scared to recommend anything at all risky in their valued (and elderly) patient. I suggested that a surgical team should attend and recommended two of my most trusted surgical colleagues, from London and from Duke University. When I arrived at the palace, I found that both had been summoned, along with another surgeon from the United States, and a group from Germany who proposed shockwave lithotripsy treatment. Thus began several long and contentious meetings involving 20 or so fairly distinguished physicians of various types. We were given hourly updates on the patient’s condition (and effluents), along with daily CT scans, which were initially rather unrevealing.
Whilst we were discussing the issues, the situation was brought to a head with more pain and fever, and a CT scan showed evidence of gallbladder perforation. How and why this happened is still a mystery, but clearly demanded treatment. Fortunately, there was a local interventional radiologist who was able to drain the gallbladder, to everyone’s relief, including the patient. There followed further discussions, which I was invited to chair, about the best timing and place for the surgery needed to remove the gallbladder.
The health minister was extremely uncomfortable, not wanting anything bad to happen on his territory, but was also outraged when the surgeons all recommended that the patient must be transferred to their home country, to their own treating environments. When asked why this was necessary, they all said that they needed their usual staff, anesthesiologists, intensivists, equipment, etc., whereupon they were invited to bring all of them. Eventually, that is what happened, and with a good result.
And, 4 years later, a call came about one of the royal mothers……
All part of life’s rich tapestry