She Thought It Was Just Bloating
This case involved a female patient whom I had treated previously for various conditions. She was a long-term patient, and because of that, a strong level of trust had already developed between us.
The reason this case has remained vivid in my memory is not because I diagnosed an ectopic pregnancy.
In fact, I did not know what the diagnosis was at the time.
What I knew with certainty was that something was seriously wrong.
And it was definitely not a condition that should be managed with acupuncture or simple observation.
One morning, shortly after I started work, I received a text message from her. I was busy seeing patients and forgot to reply. Around one o’clock that afternoon, I suddenly remembered and asked her to come to the clinic.
She told me that the pain had started during the previous night and had continued for hours. She had barely slept.
She believed she had eaten something that disagreed with her.
She described abdominal bloating, discomfort, and frequent passing of gas. Each time she passed gas, the symptoms seemed to improve slightly.
Because of this, she assumed it was a digestive problem rather than anything serious.
When she first contacted me, she was even asking whether there were any acupuncture points she could press herself at home.
Her expectation was simple.
She thought acupuncture might make the pain go away.
Something Felt Wrong the Moment She Walked In
As soon as she entered the treatment room, I sensed that something was not right.
She walked slowly.
Every movement appeared cautious.
Even lying down on the examination table required significant effort.
She explained that the pain was concentrated in the right lower abdomen.
More importantly, the pain was beginning to radiate toward her right shoulder.
That immediately caught my attention.
Ordinary bloating, indigestion, or common abdominal discomfort does not usually produce shoulder pain.
What concerned me even more was her overall appearance.
She looked pale.
She looked exhausted.
She was clearly distressed.
Her entire presentation felt different from that of a typical patient with digestive complaints.
I Did Not Know the Diagnosis, But I Knew It Was Not Normal
Physical examination revealed marked tenderness in the right lower abdomen.
There was also rebound tenderness.
The abdominal wall was beginning to become rigid.
She was sweating because of the pain.
At that point, the possibility of an acute abdomen immediately came to mind.
To be honest, I did not know the exact diagnosis.
Could it be appendicitis?
Could it be bowel obstruction?
Could it be a gynaecological emergency?
Could it be an ectopic pregnancy?
I simply did not know.
But one thing was absolutely clear.
This was not a patient who should continue with acupuncture treatment and observation.
She Wanted Acupuncture, But I Refused
The patient trusted me.
She repeatedly asked:
“Can you just do some acupuncture first?”
“Maybe it will settle the pain.”
She had previously received acupuncture treatment from me for abdominal complaints, so her request was understandable.
But that day, I refused.
And I refused firmly.
I told her:
Do not have acupuncture.
Go directly to Auckland Hospital Emergency Department.
Get investigated first.
Get a diagnosis first.
If everything is normal, then come back later and we can discuss treatment options.
I still remember that she was somewhat reluctant.
She had come looking for help.
Yet I was sending her away without treatment.
But I knew that the priority was not treatment.
The priority was safety.
The Text Message That Gave Me the Answer
The next morning, I found myself thinking about her again.
I sent a message asking how she was doing.
Her reply arrived shortly afterward.
“Bleeding ectopic pregnancy. Surgery last night. About 1.5 litres of blood removed.”
The moment I read that message, I felt relieved.
Not because I had diagnosed the condition correctly.
But because the management decision had been correct.
I later replied:
“I didn’t realise it was bleeding, but the abdominal rigidity made me think this was an acute abdomen.”
Looking Back, It Could Have Ended Very Differently
Afterward, I thought about the case many times.
What if I had simply followed the patient’s request?
What if I had performed acupuncture?
Perhaps the pain would have eased temporarily.
Perhaps she would have felt better and gone home.
Meanwhile, the internal bleeding could have continued.
What would have happened then?
No one can know for certain.
But it almost certainly would not have been safer than immediate hospital treatment.
Progressive blood loss.
Hypotension.
Shock.
Potentially life-threatening consequences.
These were all very real possibilities.
Every time I think about this case, I am grateful that I chose not to treat her that day.
The Real Lesson from This Case
The most important part of this case is not that an ectopic pregnancy was eventually diagnosed.
I did not diagnose the ectopic pregnancy.
The real lesson is that I recognised it was not behaving like an ordinary condition.
Over the years, I have become increasingly convinced that patient outcomes are often determined long before the final diagnosis is reached.
What matters is recognising when something does not fit.
At the time, I did not know the cause.
But I knew that continuing acupuncture was unsafe.
I knew that waiting was unsafe.
I knew that further investigation was urgently required.
Sometimes, that is enough.
Important Red Flags
Several important warning signs were present in this case:
- Severe pain causing sweating
- Marked abdominal tenderness
- Rebound tenderness
- Abdominal guarding and rigidity
- Significant deterioration in general condition
- Referred pain to the shoulder
- A clinical picture inconsistent with simple gastrointestinal discomfort
Together, these findings strongly suggested an acute abdominal emergency.
Dr Huang’s Clinical Reflection
This case reinforced one of the most important lessons in clinical practice.
A doctor does not always need to know the final diagnosis.
But a doctor must recognise when a condition is dangerous.
Many serious illnesses initially appear ordinary.
The real danger is not failing to identify the exact disease immediately.
The real danger is continuing routine treatment when the situation is clearly abnormal.
Sometimes the most responsible treatment is not treatment at all.
Sometimes it is recognising that the patient needs emergency care.
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