any time (so don't get caught out)

the usual story. gunshot abdomen. his father apparently took one in the chest and had already been whisked off to theater, bled out and not doing too well. my guy, however was stable.

on examination, the bullet had passed very laterally through his abdomen on the right hand side just below the ribs. in fact it was so lateral that i wondered if it had in fact even entered the abdomen at all. the left side of his abdomen was soft and seemed unaffected. however the right iliac fossa region was exquisitely tender, suitably far from the tractus of the bullet to convince me there was something amiss inside.

so off to theater for a routine exploration of a common or garden gunshot abdomen.

i opened in the midline. is there any other way with a gunshot wound?
what i found inside was surprising to say the least and downright confusing to be more specific. lateral to the peritoneum there was extraperitoneal bruising, but no penetration of the actual peritoneal cavity. to be very sure i mobilized the colon and confirmed an uninjured retroperitoneal ascending colon. but what i did find was a severely inflamed appendix!?!?!

what the hell!!! i thought. but of course all i said was "hmmm?" and whipped it out in double quick time. (it's quite easy when the abdomen is splayed open like the pages of an old book)

obviously i started trying to explain this to myself. had the appendix been just next to where the bullet passed the peritoneal cavity and had been injured by the shock wave? but then why was the rest of the bowel totally normal? and why was the inflammation so well established? i mean it wasn't as if i had tarried for a week or so in getting him to theater.
in the end all i could do was close and move on.

post operatively the patient recovered very well. the next day i struck up a conversation.
"was there anything wrong with your abdomen before the incident?"
"well now that you mention it doc, there had been this constant pain here on my right" indicating mcburney's point, "but it seems to be gone now. i even got some antibiotics from the chemist two days before the gunshot incident, but they didn't seem to help"

the guy had appendicitis at the time he got shot!!! so don't get caught out! appendicitis can in fact happen to anyone at any time! who would have thunk? looking back now, i wonder if i could have approached the history in any other way. can you imagine the strange looks i would get if i asked my gunshot abdomen patients from now on:-
"and when exactly did this pain start?"