Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
31 Oct 2007

THE PERILS OF TRAVEL

            Peggy and I recently took a long-planned trip to China, then to Hong Kong and finally Kathmandu to visit with Stephen Knoble, PA-C, who used to work in the Gettysburg Clinic.  Unfortunately, for all of us, Steve is doing fine in Kathmandu, Nepal and is going to finish out his obligation there for the next two years before coming back to the United States.  Our trip was not a vacation.  Rather, it was an adventure to see a part of the world that is very different than our own.  We should all be very thankful for where we live and the lifestyle that we have. 

            But the topic of this column is really about an observation that I made on this trip.  It lasted 26 days, involving 300 people on a planned tour with a travel company.  I am not sure how the travel company selects the people who will go on these trips but the selection process does not involve any significant or serious physical exam or health profile.  People who could barely walk or barely breathe came on the trip and through heroic effort on their part almost everybody completed it.

            But the one striking feature of the trip was the potential for falls.  Here we are traipsing in and out of airports, all around irregular surfaces in China, up and down boat ramps, in and out of hotels with steps that we aren’t used to.  The number of falls was dramatically few but one of them was very serious.

            It was late in the trip and we were traveling down the Li River in southern China observing some very beautiful hills.  The tour director came to me and said that there was a gentleman downstairs that was unresponsive.  When I arrived at his side, there was already a nurse present who determined that he was diabetic and she was getting sugar lumps into his mouth.  He was chewing the sugar lumps and swallowing them.  After about 15 minutes of watching this, there was still no responsiveness on his part other than to chew a sugar lump in his mouth.  But he would not follow commands and would not speak.  The tour director wanted to know whether I felt the gentleman should be allowed to continue on the trip sitting in his chair on the boat or whether we should get him on to medical attention.  The right answer was we needed to get him on to medical attention.  We subsequently learned that he had had a fall two days before  falling backwards and had struck his head on a concrete floor.  He was not knocked unconscious at that time and recovered and continued on his activities.  He reported to his wife that he had a severe headache the night before the boat trip and the morning that we started but he continued the trip anyway losing consciousness on the boat after we had started. 

            There were absolutely no medical facilities on the boat.  I examined the gentleman and determined that he had a very good pulse and that both arms and both legs were functional.  He would resist movement.  But he would not respond to any inquiry although he would withdraw while we attempted to extend his arms.  Pupils were small, round and equal.  He was not vomiting and he was breathing comfortably.  After about 15 minutes of watching for a response to the sugar lumps, nothing had occurred. 

            Going through the potential problems, it did not appear that his heart was the issue.  He was breathing comfortably, his lungs were not an issue, he had a good strong pulse, blood pressure was not apparently too low but the brain certainly wasn’t working normally.  To that end, he needed to get off of the boat and get medical attention as soon as possible. 

            I instructed the tour director regarding this analysis and the boat dutifully pulled into the nearest village after 15 minutes traveling slowly down the river to reach this place.  Four “safety officers” from the local village came down with a litter and removed him from the boat.  He was taken to a local dispensary no bigger than an 8 x 10 room which was the town’s answer to medical care.  The gentleman’s wife accompanied us.  I conveyed the information to the tour director who spoke to the Chinese doctor in the dispensary. An ambulance was then called. 

            Now imagine this, here you are in the middle of China and the tour director now says we must proceed.  The ambulance will come and take care of this gentleman and his wife.  The tour director and I are directed back to the boat by the “security officers” in the local village.  This wife is left with her unconscious husband in an unknown Chinese village with no language capability between her and the Chinese people there.  I have never felt so helpless.  The tour director did reassure us that one of the tour guides would stay with this couple as an interpreter until he got to the hospital where he would be cared for.  But the regular tour guide and I were not allowed to stay in the village and had to return to the boat.

            The ambulance did arrive, he was taken to the local hospital where he was diagnosed as having a subdural hematoma.  This is a blood clot that occurs between the brain and the skull and causes unconsciousness eventually as happened with this gentleman.  The Chinese neurosurgeon told the gentleman’s wife that he would have to be operated on him immediately and indeed that did happen and he did recover.  Ten days after the surgery was done, he did return back to the United States still not regaining normal function but certainly much better and recovering.

            The lesson from this event is that travel can be very dangerous.  It is absolutely terrifying to have something ugly happen in a foreign country.  Before you embark on a trip like this, you should have your health checked out, carry a copy of any medication prescriptions that you have, and for goodness sake “watch your step”.  Those with heart failure, lung disease, heart disease, insulin requiring diabetes or uncontrolled hypertension will do better to remain in the confines of our wonderful United States of America.  There is really plenty to see here.

This and other columns available at www.macpierre.com.