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Michael McLeod
Jim: thought you'd enjoy this.
From the ny times - An on the spot diagnosis
By Jay Wellons
Dr. Wellons is a pediatric neurosurgeon.
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Credit...Tim Lahan
Last year I was invited to give a lecture at a college in Vermont. It was to be a quick 36-hour trip — flight to Burlington, fancy dinner the first night and the lecture and some meetings the next day, then back home to Nashville.
Years ago, I was a light traveler. I had toured Ireland with only a change of clothes and a school backpack. But as I aged, the inner Boy Scout in me gradually took over, and my suitcases grew burdened with things I would almost certainly never need. Who knows, there may be a pool nearby and I would be bereft without my swim goggles. I might actually need both black and brown shoes, right? This time I vowed to return to my roots. No extra stuff. I put on a suit, threw a lightweight backpack over my shoulder and headed for the plane.
What else could I possibly need, I thought, fighting off a hint of anxiety and a faint longing for my swim goggles.
Soon after, I settled into my seat on the plane and we took off. I carefully folded my suit jacket, placed it on the empty seat next to me and began to drift off to sleep. I was jolted awake as a flight attendant walked swiftly past, heading toward the front of the airplane. Soon after came the inevitable announcement asking if there were medical personnel on board.
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Two lights came on. Mine and one two rows in front of me, at the seat of a young woman. The flight attendants made it to both of us simultaneously.
“I’ve got a brain surgeon here,” said mine.
“A nurse practitioner here,” said the other, perhaps a hint of disappointment in her voice.
All eyes turned to me.
“All hands on deck is my rule,” I quickly said to the nurse, who warmly smiled back. We introduced ourselves to one another. I learned that her name was Susan and that she worked in a primary care clinic — which was excellent news for everyone involved.
We made our way to the back of the half-empty plane. There on the next to last row was a middle-aged man covered in blood. He held a cantaloupe-size wad of tissue under his nose from which blood was pouring out as if a spigot had been opened. He had a deep laceration on the top of his nose but the blood was coming from inside.
I would like to say that I immediately began to assess his medical situation. Instead, my thoughts went to my shirt and suit as the only articles of clothing that I had for the next 36 hours.
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I tucked my tie in my shirt. One of the flight attendants handed us latex gloves and I leaned in to pinch the bridge of the man’s nose and ask what had happened. He remained silent but the flight attendant spoke up, “He said he hit it on a counter as he bent over to pick up his briefcase this morning.”
The man took over: “It had stopped bleeding before I got on the plane but it wasn’t coming from the inside until a few minutes ago.” I asked him the usual questions about being on aspirin or other blood thinners. Was he a free bleeder or had any problems with bleeding in the past? No, no and no.
Classic first aid teaching says to pinch the cartilage of the bridge of the nose to stop a nosebleed. I did this, but nothing happened. The blood continued to pour out of his nose. I looked to Susan and said, “This may not be so easy.” She nodded and began to rifle through her purse.
“He did just have vodka right before it started,” the flight attendant volunteered, pointing to the small empty bottle lying on the seat next to him. Susan and I looked at one another knowingly. Alcohol can raise the blood pressure acutely in some people, particularly those with high blood pressure already.
“Do you take blood pressure medicine?” I asked him. “Do you have any on the plane?”
“Yes,” he answered, “and no.” He turned away, the blood still flowing. Suddenly, I began to piece it all together as a severe disruption of the plexus of blood vessels in the mucosa underneath the bridge of the nose, possibly worsened by elevated blood pressure. I had neurosurgery partners at home who would treat intractable nosebleeds by snaking a tiny microcatheter up from the groin into the arteries of the nose to inject a type of glue directly into the vessels. Invariably, that would stop this type of hemorrhage.
None of that and none of them, however, were with us at 15,000 feet.
“Anyone have any nasal spray?” I asked. “Afrin specifically?” Afrin is basically neosynephrine, a potent vasoconstrictor, and would be ideal to put on a tissue stuffed deeply in the nose.
“And a tampon?” Susan added, holding up a tampon from her purse and smiling. Multiple eyes turned toward her.
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“Brilliant,” I said, turning to the flight attendant. “Can you make an announcement calling for Afrin nasal spray and a tampon?” Quick enough, the overhead rang out. The man behind us handed up a bottle of Afrin.
“It’s used,” he said.
“Ooooooo, gross,” another passenger added.
I took the bottle and wiped the tip down with what was left of the vodka, trying to make a show of it to all around. I looked up and saw several female hands in the air. Within seconds we had our choice of tampons: small, medium, large, extra-absorbent, all different types were available. There were even some disposable pads, with and without wings.
We settled on medium, extra absorbent. We doused it in Afrin and quickly shoved it up the man’s nose as far as we could. By shove I mean that I put my hand behind his head to keep him from pulling away while Susan removed blood-soaked tissue. On the count of three, we put that tampon as far as humanly possible into an orifice entirely different than the one it was designed for.
His bucking during the first insertion was nowhere near as dramatic as it was during the second. By then, he knew what was coming and his eyes widened as we hovered over him a second time and counted. Afterward, to his credit, he calmed down quickly, even mouthing, “thank you” to us and giving a thumbs up.
It was soon evident that this procedure had actually worked. The blood flow had essentially stopped. I did keep up the external pressure, though, switching on and off with Susan the last 30 minutes of the flight. During landing, I stood in the row behind him, pinching his nose from behind. Susan sat next to him monitoring his pulse, calming him. I peered down to see no spattering of blood on my shirt, no bloody tissue sitting on my pants cuff. I breathed a sigh of relief, slightly guilty for being concerned about such a thing.
After landing, the plane went straight to the gate where two emergency medical technicians awaited with a gurney, medical supplies, and a smirk about the “emergency nose bleed.” They came on board as soon as the airplane door opened and found the patient in seat 24B with two bloodstained tampons sticking out of both sides of his nose, the strings hanging down toward his shirt. He managed to give another thumbs up to the EMTs and a smile.
As the technicians loaded him up on the gurney, it dawned on me that my proud, newly revisited days of packing light were gone forever. And that a well-placed tampon in an emergency was way more useful on a flight than a pair of swim goggles.
Jay Wellons, M.D., is a professor and chief of pediatric neurosurgery
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