Well, we made it to Singapore. By arrival, his blood pressure had decreased slightly, to about 219/118, and his oxygen saturation level remained at 100%.
A medical team was waiting for us, but initially couldn't even make it up the aisle because the minute the plane stopped, passengers filled the aisle, pulling down suitcases, ignoring the flight attendant's timid request to remain seated. So I stood up and very loudly (but not to the yelling state) said, "Everyone please sit down to make room for the medical team. This is a medical emergency." That did the trick.
The medical team had three people, with a stretcher and a medical bag. A young man in an impressively neat, tailored white shirt and tie, presumably the equivalent of a paramedic, was clearly in charge. I told him what I knew, and he proceeded with an initial assessment of heart and lungs then quickly inserted an IV (just like in the movies).
Then he opened up the defibrillator kit (which can provide an electric shock to convert arrhythmic heart patterns to normal rhythms, arrhythmia a common consequence and/or cause of cardiac arrest). But wait: he has a normal pulse, is breathing regularly, and is fully oxygenated (so clearly the heart and lungs are doing their jobs). So why the defib? The defib routine begins with electrodes that are placed on the chest to provide an analysis of the heart's rhythm. Though skeptical of the need for this (why delay the transport?), I grant that uncommonly an arrhythmia might be present but undetected by a stethoscope exam (not that he asked for my opinion).
If the defib machine were to pick up an arrhythmia, it would verbally prompt the medical attendant to push a button to administer a shock. In this case, with a normal heart rhythm demonstrated, the verbal prompt instead said, "begin chest compressions." Having just confirmed a normal heart beat, why would the machine's algorithm do that? Anyway, the paramedic knew more than the machine--that the patient's oxygen levels were normal. But he followed the machine's instructions and started chest compressions. Chest compressions are not harmless since ribs can be broken, and of course the continued delay.
Fortunately, he soon gave up on this and the patient was put on a stretcher and taken to a hospital, where he probably received a head MRI--when I later talked to an ER doc in my clinic, asking what he would have done, he just said, a head MRI, as soon as possible.
I headed for the terminal, wondering, as is my nature, if I could have done anything different.
First work, then play, right? Maybe not.
We thought play as we left Bagio for Bali, flying over the South China Sea, with anticipation of tropical waterfalls and coral reef snorkeling, when the an overhead announcement asked if there were any medical personnel on board. Though not eager to volunteer--unless of course a baby has decided that time's up--I did catch the eye of an attendant. A Filipino nurse also raised her hand. No one else.
An elderly Filipino man had become unconscious. I noted normal respirations and a strong, steady pulse in the 80's. Family members thought he took medicine for high blood pressure, but did not think he was diabetic. He was already being given oxygen through nasal tubes. The plane's medical kit produced a pulse oximeter which attaches to a finger and measures oxygen levels (anything over 90% is okay). His level was 100%.
We also found a wrist blood pressure cuff: 220/119, suggesting an hypertensive crisis which could cause a rupture of cerebral blood vessels, aka hemorrhagic stroke, leading to unconsciousness. Concerned about the accuracy of the blood pressure, I measured my own: 140/90, more than my usual, but considering the stress of the moment, it seemed to confirm the accuracy of the device. I remeasured his BP: 228/122. A normal variation or an accelerating, possibly deadly hypertensive crisis?
Other common causes of unconsciousness: drug overdose, seizure, cardiac arrest, and either hyper- or hypoglycemia. Hyperglycemia from uncontrolled diabetes, hypoglycemia from accidental insulin overdose. The history, setting, and elevated BP all point to stroke.
The nurse knew how to use the glucometer also found in the medical kit; it showed a normal blood sugar level. I didn't really think he had blood sugar issues, either extreme value would not likely be associated with increased BP.
The kit also contained a number of medications, including some that could be used for hypertension; many with unfamiliar (non-American) names, but I did recognized one: nifedipine, occasionally used for gestational hypertension. He can't swallow and I didn't have the resources to monitor intravenous medications, but nifedipine can be given sublingually
We were 90 minutes from the nearest airport: Singapore, which was the destination of the flight. Attempts were being made to contact an ER in Singapore, but no immediate response.
Should I give him an hypertensive agent, possibly preventing further stroke damage, but risking a sudden drop in BP which could lead to cardiac and cerebral ischemia as the body becomes unable to deliver oxygen to vital organs?
First do no harm.
