Just a few months short of graduating from The Ohio State University College of Medicine in February 2016, I had an extraordinary opportunity to rotate at the Raleigh Fitkin Memorial (RFM) Hospital in Eswatini (formerly known as Swaziland), an African absolute monarchy mostly landlocked by South Africa and sharing a border with Mozambique.

At the time of my visit, RFM was a 350-bed regional referral and teaching hospital in Manzini, a major metropolitan center. My rotation was sponsored by the OSU Office of Global Health and hosted by the nongovernmental organization MercyAir, run by Dr. Roger Pacholka and Katy Pacholka (a retired emergency physician and nurse couple), who were instrumental in organizing the logistics of the trip.

The flag of the Kingdom of Eswatini. (Image AdobeStock/Alexmak. Click to enlarge.)

Clinically, my main responsibilities at RFM included rotating in the emergency department (ED), surgical ward, labor and delivery department, and outpatient settings. My day would usually begin with a morning conference in any one of those departments, followed by teaching rounds, operating room cases, work in the rural outpatient clinic and HIV/AIDS clinic; of note, adult HIV/AIDS prevalence in Eswatini exceeds 25 percent between the ages of 18-49.¹

During my visit to RFM, their sole CT scanner (aka “the donut of truth”) had recently become dysfunctional. Medical staff knew it was typically unreliable. As a referral hospital, this imposed a significant barrier to physicians’ ability to more effectively diagnose disease. Consequently, if a CT scan was recommended, that patient was asked to obtain the scan at a private imaging center and bring the images to RFM for review. Being able to finance one’s own CT was, of course, cost-prohibitive for most patients; many were unable to travel several miles away to a government-funded hospital that did have a working scanner.

As such, physicians at RFM were adept at making life-altering diagnoses without the usual CT scan. I certainly learned a great deal from my attendings’ clinical decision-making, and two cases come to mind that highlighted the importance of an accurate history and physical exam in a resource-limited setting.

The first case involved a young woman who presented with a several-day history of worsening lower abdominal pain. Her urine hCG was negative, and primary concern was initially for appendicitis. However, after delving deeper, we discovered that she had vaginal discharge, dyspareunia, and a pelvic exam that was notable for cervical motion and adnexal tenderness. A vaginal swab was obtained. Out of an abundance of caution given the lack of CT or transvaginal ultrasound capability, general surgery was consulted, and after performing their evaluation, they agreed with the emergency physician’s diagnosis of pelvic inflammatory disease (PID).

The patient was admitted for antibiotic therapy and observation. Unfortunately, specific data regarding the misdiagnosis of appendicitis and PID in Eswatini is not readily available. It is well documented in the United States that missed appendicitis is one of the top diseases associated with diagnostic error and medical malpractice.² Conversely, one retrospective review showed that 25 percent of South African females who were referred to general surgeons with suspected acute appendicitis were incorrectly diagnosed. In these instances, it was advised that a pelvic exam be performed to help differentiate between appendicitis and PID in resource-limited settings.³

The second case in which I witnessed exceptional clinical expertise involved an elderly woman who was the restrained passenger of a motor vehicle crash from a few weeks prior. Her mobility since the accident had been profoundly limited, secondary to musculoskeletal pain. She subsequently presented to the ED with a several-day history of constipation and a two-day history of nausea, vomiting, abdominal pain, and distension. She had no prior surgical history. She had no rebound or guarding on exam, was not febrile, and did not appear toxic.

Abdominal X-ray was performed and showed diffuse colonic dilatation and scarcity of air fluid levels concerning for Ogilvie’s syndrome (acute colonic pseudo-obstruction). Nasogastric tube and rectal tube were placed, she was admitted and ultimately did well. The gold standard for confirming Ogilvie’s syndrome is a CT of the abdomen and pelvis with contrast, to assess not only for the degree of cecal dilation that could lead to perforation, but also for other pathologies potentially causing mechanical obstruction. Peer review of the literature, CT imaging approaches a sensitivity of 96 percent and a specificity of 93 percent for Ogilvie’s.⁴ Although X-rays are not the most sensitive test, they can be used in stable patients to serially evaluate colonic diameter.⁵

What struck me the most about these two cases was the clinical acumen of the physicians and surgeons. Despite lacking a working CT scanner or other technological adjuncts, they were still able to provide expert medical care to their patients. They remained well-read on the latest emergency medicine and surgical guidelines dictating standard of care and expertly adapted this knowledge to the best of their ability and resources. They relied heavily on their history and physical exam-taking skills to make the bulk of their diagnoses. For me, an emergency physician early in my career, this was the greatest lesson—the donut of truth hasn’t completely killed the physical exam.

Dr. Esteve is an assistant professor of emergency medicine at the University of Texas Health Science Center at San Antonio. Her academic interests include medical education, with a focus on simulation-based learning, violence prevention, and health equity.

References

1. Centers for Disease Control and Prevention. HIV and TB Overview: Eswatini, CDC Public Health. Published June 30, 2025. https://www.cdc.gov/global-hiv-tb/php/where-we-work/eswatini.html#cdc_pir_special_topics_resource-resources
2. Newman-Toker DE, Peterson SM, Badihian S, et al. Diagnostic Errors in the Emergency Department: A Systematic Review. Agency for Healthcare Research and Quality (US); 2022; 22(23)-EHC043.
3. Kariem N. 2023. Misdiagnosis of Appendicitis in Women in a Resource Limited Setting: Lessons from South Africa. Faculty of Health Sciences, Division of General Surgery. Open UCT. Accessible at: http://hdl.handle.net/11427/39575
4. Pereira P, Djeudji F, Leduc P, et al. Ogilvie’s syndrome-acute colonic pseudo-obstruction. J Visc Surg. 2015; 152(2):99-105. doi: 10.1016/j.jviscsurg.2015.02.004. Epub 2015 Mar 11. PMID: 25770746.
5. Ahmed S, Sharman T. Intestinal pseudo-obstruction. [Updated July 3, 2023]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Available at: https://www.ncbi.nlm.nih.gov/books/NBK560669/