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Medical Information

When you want, or need, to know more than the superficial, such as when you are

where there is no access to a physician.

Prototypically: Medicine at Sea

Comments/Disclaimer

This medical information is provided for education purposes only. I am making no attempt to practice medicine over the internet. This is being written to give some basic knowledge for those that are physically isolated from access to professional medical care, such as sailors at sea. This is to help in deciding whether an emergent medical condition exists, how to initially deal with it, and whether evacuation is needed. It is by no means exhaustive or meant to replace personal medical attention. Please do not contact me regarding your personal condition. Over the years I have received many emails from people asking for help with their personal chest pain, or whatever. Sometimes they write during acute pain. This is ridiculous. You can't practice medicine over the internet. If I find their email, after it has been filtered by my spam filter, it may be days or weeks later. My response, if any, will be to contact their regular provider. Even a bad doctor in person is better than an email. Please use this information in the spirit in which it is intended.

Sincerely, Mark R. Anderson, M.D.

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Appendicitis at Sea

Mark R. Anderson, M.D. 2000

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Also see: The Evaluation of Acute Abdominal Pain

Anyone with an opportunity should read Wm. Robinson's bout with appendicitis in "Voyage to Galapagos". This was written in the 30's, so it was before the days of antibiotics.

Appendicitis is, along with Syphilus, one of the Great Masqueraders in medicine. So here's a quick course in recognizing it. Be forewarned though, that it's considered difficult enough to diagnose that 15-20% of those taken to surgery for it, don't have it. This is to avoid missing one. Missing appendicitis is in the top 5, perhaps 3, causes for a successful malpractice suit against ER physicians. More importantly to the patient, being sent home with early appendicitis, only to be forced to have surgery after it has ruptured, is fraught with considerably greater risk, and a much longer recovery time.

There is a typical "classical" presentation. A dull poorly localized, steady pain develops vaguely located in the area around the navel. Some hours later, (often more than a day), the pain localizes to the right lower quarter of the belly. Sometime in this course, appetite is almost invariably lost. There will be little or no fever. There will be little or no diarrhea. Nausea will likely develop, but if vomiting occurs before pain, it's almost certainly something else. The pain hurts more with movement. The patient wants to lie still. Jarring the patient, walking, coughing and other movement hurts. The abdomen becomes tender to the touch. (Separate in your mind whether an area just hurts, vs. hurts specifically to press on it. True tenderness is generally more important than pain without tenderness.) Most reliably it's maximally tender at McBurney's Point which is 1/3 of the way along a line from the top front corner of the pelvis rim, (hip), to the navel. Rebound tenderness develops at this area, probably even before the patient realizes that he/she is hurting in the RLQ (Right lower quadrant). Rebound means that it briefly hurts more when pressure is suddenly released on that area. I.e. press slowly at McB's point and then suddenly raise your hand. The patient winces. True rebound tenderness anywhere in the abdomen is a sign of peritonitis and is always significant. (Separate true rebound from the startle response that some give with sudden release of pressure.) Other signs of a significant process is "guarding", i.e. the pt's abdomen tenses in response to pain as pressure is applied. Even more indicative of peritonitis, (which can be localized or generalized) is rigidity. The abdomen is then always tense, perhaps even boardlike. With rigidity, it cannot be voluntarily relaxed. The abdominal exam should be performed with the pt. warm, (no shivering), and comfortable. The examiner's hands should be warm. It helps to flex the knees and hips to relax the belly. True rigidity won't relax. If the patient is ticklish, his/her hand should be placed on top of the examiner's hand and pressed down. You can't tickle yourself. The pain with movement is a sign of peritonitis, so a gentle tap can be painful, or thumping the bottom of a foot, or jostling the bed. If you listen to the belly, (your ear directly in contact), with well established peritonitis the bowel rumblings will stop. Listen for at least 3 minutes to be sure. Bowel sounds are often still present in early appendicitis.

Appendicitis usually develops over at least 24 hrs. before it clearly declares itself, and some say you've got about 3 days from first symptoms to rupture. Ah, but not everyone reads the book and I've seen cases develop much more quickly. Some people just may not be attending to their body well enough to notice the early symptoms. In any event, at least recognize that it doesn't develop over only a few hours or less. When the appendix ruptures, generally after at least 24 hrs. of pain, the pain will likely subside for a while, only to come back over the entire abdomen along with signs of generalized peritonitis, and a sicker person, who'll develop a significant fever. OK, so a person that has brief pain or pain longer than a few days, no true tenderness, is hungry, and has a soft belly doesn't have appendicitis. Generally true. But remember the masquerade. I once had an adolescent boy with a ruptured appendix that was hungry, no fever, normal blood count, soft abdomen, no definite rebound, and normal bowel sounds, but did have localized RLQ tenderness. He didn't read the book. If the appy is not in it's typical anatomic position, if the patient is old, pregnant, immune suppressed, stoic, or just a curmudgeon, the symptoms may be different. The pain could be in the back, genitals, left sided, painful to breath, or whatever. Nevertheless, the most consistent findings are 1) loss of apetite, 2) tenderness in the RLQ, 3) rebound. Women, being generally higher maintainance, have a number of gynecological possibilities that can confuse the issue.

If you're at sea and you're suspecting appendicitis, start sooner, rather than later, to get medical assistance. First try to get advice to help you decide whether evacuation is necessary.

Email: capn-shanghai@comcast.net

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