East Timor Medical Elective - Week 4 (Part 4 / 6)

“MATEUS” (APPENDICITIS)

I clerked “Mateus” in another afternoon (this time on medication) with Natalya and another student watching me, but apparently he was waiting for nearly ~6 hours since being admitted this morning. I didn't recall seeing him in the morning Ward Rounds, so he probably arrived just after we left the Baixa (Gen Med) ward. 

I looked at Dr. Dan's mini-notes: “RLQ pain - ?Appendicitis ?Ascaris”.

Oooooh, a potential Appendicitis case, I thought.

I asked Mateus what his problem was, and he said that he's been having pain that started in the RLQ last night, and later spread towards his RUQ and Epigastric area.

It sounded strange. I recalled the textbooks stating that Appendicitis initially starts in the centre of the Abdomen (around the belly button), and then migrates towards the RLQ, and then causes diffuse Peritonitis if not treated fast enough. Mateus' abdominal pain didn't sound like the textbook, but I was still worried.

 After asking enough questions about his Abdo pain and gross (basic) Systems Review, I decided to “jump” to the Physical Exam.

His bowel sounds were still present. I lightly palpated his Abdomen, and he winced as I examined his RUQ and RLQ. I then percussed, and was internally pleased when he felt pain from this. Omg, Percussion Tenderness is present! He could really have Appendicitis.

I then gently pressed on the left half of his Abdomen, which wasn't painful, but I let go after a few seconds, and he winced again, saying it hurts the right side of his Abdomen.

OMG he has Rovsing's Sign! I was so delighted upon seeing this for the first time, but didn't smile about this in front of the others. I became very excited and concerned.

“I think he has Appendicitis, I need to tell Karl immediately,” I said.

Karl soon came and I presented the case, with Appendicitis being my most likely differential, in which he agreed, and continued him on the empirical antibiotics.

I felt so proud of myself on having “diagnosed” Appendicitis within 15 minutes, but knew that I had a hint from Dr. Dan's mini-notes, so could take a targeted history and physical exam much more easily. If I had no hints to begin with, my clerking would be more time-consuming, and that will only improve with practice and feedback. But I was also happy to see in person, how a patient doesn't necessarily present themselves perfectly as per the textbook descriptions.

He was monitored overnight and was to be transferred to the ED of GVNH, for admission to have an Appendicectomy.

I knew that the overall standards of Healthcare in Developing countries were lower than in Developed countries, but it was still shocking to see the differences in person.

I spoke in my slow, “formal” English accent to one of the ED Drs, who wrote notes based on what I said, including Physical Exam findings, including the Rovsing's Sign. I was surprised. Isn't the ED Dr supposed to examine the Pt himself?!

For some reason, it was another ED Dr that ended up physically examining Mateus. Ok, at least he's been examined by someone now. Bloods were to be taken next.

Next was the jaw-dropping moment. The Dr used a glove to tie around Mateus' arm as the “tourniquet”, and with his bare hands (unwashed), started inserting the needle into Mateus' vein. Mateus' arm wasn't even swabbed with Alcohol!!! Internally, I was gasping and horrified, but still maintained my Flat Affect on the outside. Oh how I dearly wished to have taken a photo of the Dr taking Mateus' blood, and get away with it!!! I'd be very interested in seeing the infection rates from Venepunctures and Cannulas in East Timorese patients secondary to poorer hygiene practices.

"The Scream", by Edvard Munch.

I left after the bloods were taken, as he then had to wait until 2 PM (it was now ~12:30 PM) to have an Abdo Ultrasound done as the radiographers were still on their lunch break. In fact, the majority of the hospital staff (doctors, nurses, lab staff) have a lunch break from 12 – 2 PM. Things go to a halt. 

It baffled me as to why GVNH doesn't roster their staff in a way, so there's at least 1 person working at any time of the day, or that staff take turns working during lunchtime. I suspect a strong factor was the near absence of Litigation. Then again, on their relatively “peanut” wages (apparently ~$US 700 / month for Interns at GVNH), if the Medico-Legal pressure was present akin to Australia, I bet 90+% (if not 100%) of the Drs would try to jump ship to another Country, or another Career altogether. Anyhow I'd hate to be an acutely ill patient arriving at the ED at 12:05 PM... : S

Note: I visited Mateus a few days later and it turned out he eventually had an Appendicectomy done, and was recovering with no post-op complications (yet?!).