173. Primum Non Nocere, Part One

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.