In real-life medicine, nothing is ever as it’s written in the textbook.
During my community service year I came across some weird and wonderful patients and cases. Some built me, some broke me. But all taught me something.
I was on call and she walked in. She was obviously in severe pain. She gripped her abdomen in agony and Vomitted a green bile stained fluid repeatedly. I gently pressed on her abdomen and she screamed her head off, while vomitting over my hand. Well at least it’s not urine, i thought to myself.
Okay, A peritonitic abdomen. Textbook case of guarding, rigidity and rebound tenderness. While the causes are vast and never ending, it was important to recognize it and then refer her for an ultrasound or probable urgent surgery. I quickly did an assessment and picked the phone up.
“Hi it’s Dr Moosa from the clinic. I have a peritonitic abdomen id like to refer please. May i discuss the case?”
“peritonitic you say. Ya okay, send the patient” she said through gritted teeth.
Even the overflooded district hospital knew theres no dodging a peritonitic abdomen. They must be sent ASAP. I updated her and watched her face cringe.
I was going through the motions of referring the textbook case and began writing the referral letter while booking the ambulance”.
She heard me on the phone and reached out and snatched the phone out of my hand. I was puzzled.
“I’m not going to the hospital.and I don’t want an operation. I have to go to eastern cape tomorrow for a function”.
I was now more annoyed than confused at 3am. I gently explained how there was something very wrong in her abdomen that probably needs life saving surgery to deal with, without which she could die. in that case the only function she’d be attending is her own funeral.
She groaned and muttered something about “it’s only gas”
“Gas?! Can gas cause this much of pain, i intentionally flickered her abdomen and she jumped up” her pulse climbed.
To my dismay and repeated objection, she left. I wondered how long she would last and where she would end up for damage control.
During the next few days I warned on call teams about a probable peritonitic abdomen that may come in, in septic shock.
As fate would have it, a month later, I saw her again. Alive. I was surprised. I wondered what had happened. Burst appendix sealed itself? Pyelonephritis disappeared?
In fact she was well. Mobile. Alive and complaining. She complained about an uncomplicated heart burn which she was convinced she needed surgery for. The self diagnosis had Google written all over it. “Please refer me now doctor i need to be cut tonight!”
I checked all her vitals i examined her from head to toe. Normal.
I smiled. Opened my own stash of ENO in my bag, gave it to her and said “No”.