The airport security posters telling you that liquids of more than 100ml are prohibited, actually apply to bottled fluids rather than bodily fluids.  But my stomach was no longer able to cope with this kind of subtlety.  So there I was, on my knees in the transit lounge security queue at Hong Kong airport, vomiting copiously into an airline sickie bag, to the horror of my watching children.  “Mummy, stop that!” my eight year old daughter instructed anxiously.  If only. 

A security official regarded me distastefully and radioed for assistance.  Another uniformed official approached and studied me, from a safe distance, as I continued to fill my sickie bag.  “You take care of yourself, okay?” he said, then wandered off.  My stomach finally emptied of water and bile, I stood up again.  The first official gestured to indicate that I should place my well-used bag in the security bin by the door, along with the outsized shampoo bottles, nail scissors and other potential threats to airline security.  About 300ml of vomit, by my guess.  Clearly a security breach.

So there I was, standing woozily in the security screening queue with my two kids, no water to rinse the bile out of my mouth and an urgent need to swallow some hydrocortisone.  I stuck a 10mg tablet in my mouth and let it crumble on my tongue, the bitterness an easy match for the taste of bile.

The young lady on the scanner eagerly identified the sports bottles in my carry-on bag: you have water! she said.  I have empty bottles, I clarified, which I intend to refill as soon as we are on the plane.  Empty plastic bottles are indeed okay, and the injection kit in my handbag was left unremarked on this, as all previous occasions.  My stomach upset may have constituted a biological hazard, but not a security threat; we were allowed through to the departure gate. 

Here I was able to lie down on the floor for 20 minutes, to the indifference of the check-in attendants, who gestured me to move out of the way a couple of times.  Then we boarded the plane.  The effort of standing in the boarding queue had me dry-retching, much to my small son’s excitement – “You’re being sick!  Can I see?” I left a small deposit of bile in another sickie bag by the aircraft door.  Then we were on the plane and I dozed in my seat. 

Actually, I had started vomiting about four hours earlier, on the previous leg of the flight from Auckland.  I was fine when I got on the plane: ate a light supper, went to sleep.  But woke up several hours later feeling like I had the hangover from hell – thumping headache and dehydrated – and threw up not long after swallowing some extra hydrocortisone.  Even then it had been just a mix of water and bile, which the cognoscenti among you will recognise as being easier on the throat and milder-smelling than your average stomach contents.  I had promptly taken my injection kit down to the toilet and lined up an intra-muscular injection.  Aircraft toilets have a convenient shelf, good lighting, and are not bad places to inject yourself in the thigh, turbulence and cleanliness permitting.  On reflection, I decided not to deposit my used needle and syringe in the bin.  Then I returned to my seat to sip water from my sports bottle, hoping that would be the end of it. 

When my stomach emptied itself for a second time, not long before we reached Hong Kong, I had to say ‘bugger’ in front of the kids. Mostly because I missed the sickie bag on the second heave – turbulence! – and covered my trousers instead. I managed to rinse most of it off in the toilets, leaving just some yellowish, not too odiferous stains.  We were the last ones off the plane, an officious hostess watching me collect up a further clutch of sickie bags, but failing to ask if I needed any help. I was getting bleary and light-headed by now, hoping that the intra-muscular hydrocortisone would carry me through. 

With the benefit of experience, I should have asked the officious hostess for assistance before staggering off the plane at Hong Kong, kids in tow.  Which is what I finally did towards the end of the flight from Hong Kong to London. About an hour into the flight, I had tottered down to the toilet to give myself a further injection.  Then I collapsed back in my seat in a haze of nausea, leaving the kids to fend for themselves on the movie channels.  I dozed for the first ten hours, feeling like death warmed up – as one does – and sipping a little water each time I stirred.  I also swallowed a 10mg tablet every few hours.  Then I woke up enough to realise that, although I had not thrown up for 10 hours, my blood pressure was pretty low.  Even adjusting the seatback to upright gave me a headache.  Making it through the immigration queue was going to be a problem. 

So I pressed the call buzzer and waited.  A nice young steward answered it, and I hesitatingly asked if I could get a wheelchair or some medical assistance off the plane.  He looked me in the eye: of course, he said.  Would you like some oxygen as well, he suggested.  I nearly cried with relief. I had no idea I looked that bad.  I agreed to try the oxygen, and he reappeared with a small green canister and a yellow rubber mask just like the ones in the security demonstration.  I dozed for 15 minutes, breathing in the rubbery air, and it did make me feel more alert.  The steward told me I had more colour in my cheeks afterwards.

By now I was alert enough to realise that I needed to do something about my fluid levels, to try and get my blood pressure in better shape. I got the water bottles refilled, collected all the sugar and salt sachets off our family meal trays and prepared a self-help rehydration mix: equal parts salt and sugar. By the time we got off the plane I had nearly half a litre of this in my stomach, which made a real difference.

Just as well, because I miscalculated badly about the wheelchair getting off the plane.  When I told the cheery young stewardess at the plane door that I could make it over the bridge to the transport buggy without a wheelchair, I didn’t realise I would also lose the chair and assistant at the other end for the immigration queue.  But we made it through immigration, with me sitting on the floor most of the way up the queue, and then down to the baggage hall, where we all perched uncomfortably on the luggage trolleys.  I had enough strength to haul our cases off the carousel, although I could probably have asked one of the fitter-looking men in the crowd to do this for me. My sturdy children pushed the trolleys through customs to meet daddy on the other side of the barricades.  We had made it!

If there is a lesson to this story, it is to always ask for help. Joining the mile-high, thigh-high club was as easy as pie: self-injection in the aircraft toilets was the most straightforward part of the whole experience, making me stable enough to last through 24 hours long-haul air travel with a gastric infection. 

However, staying on my feet through the airport queues for security and immigration was a far bigger problem, because I was weakened by fluid loss and low blood pressure.   It was on the ground, in transit, that I really needed help.  But I wasn’t thinking clearly enough to ask for it.   Which is why I ended up on my knees, vomiting, in front of strangers who had no idea how to respond.  When I finally did ask for help, the air crew did everything they could.

Looking back, the main thing that troubles me is the burden of responsibility I placed on my young children by failing to ask for help early on.  The intra-muscular hydrocortisone meant I was unlikely to slip into adrenal crisis, but I could still have blacked out through low blood pressure.  Then it would have been up to my eight-year old daughter to try and communicate my condition to others.  She knows that I have a MedicAlert bracelet because I have Addison’s.  I hope I never have to put her to this test.

Ruth

September 2008

The mile-high, thigh-high club - The doctor’s view

Ruth is to be admired for her courage and tenacity in getting through this harrowing experience relatively unscathed. Her in-flight use of her intra-muscular hydrocortisone injection – twice - demonstrates clearly the value of this emergency intervention.  It was fortunate that Ruth had ample supplies of Efcortesol with her, as she could easily have dropped a vial if there had been any turbulence while she was preparing the injection. 

The vomiting was most likely to have been precipitated by a gastric infection, but once adrenal insufficiency is established, nausea and vomiting are exacerbated and a vicious cycle ensues. In this situation, even if vomiting is not continuous, it is likely that normal stomach emptying is impaired so that the absorption of hydrocortisone tablets will be unreliable.

Ruth clearly had quite severe fluid loss with circulating volume depletion, as evidenced by her “wooziness” when standing.  This persisted so that she felt less well when sitting upright on the final leg of her journey.

As always, it is easiest to advise in retrospect and one recognises the desire to complete the journey, especially with children in her care. Nonetheless, the course of events confirms the importance of receiving skilled medical support as soon as possible after it has proven necessary to take intra-muscular hydrocortisone because of vomiting.

In Ruth’s case this should have resulted in an emergency admission to hospital in Hong Kong, where medical standards are high.

Oral fluids are a poor substitute for intravenous rehydration in this type of situation - all the more so with the current security restrictions described in Ruth’s account.

For long-haul international travellers, who might find themselves needing emergency treatment at some time in the future, the most sensible course of action would be:

• Make sure you have a full five-vial packet of Efcortesol plus two needles and syringes, ADSHG emergency card and a spare copy of the emergency treatment instructions in your carry-on luggage.

• Stabilise your condition immediately after vomiting by using your intra-muscular hydrocortisone injection.
   

• Then show the flight attendant your ADSHG red emergency card/treatment instructions.  Explain that you will need hospital treatment as soon as the flight lands, but that you should be able to complete your onward journey 24 - 48 hours later once you have received intravenous fluids and medical monitoring.

• Allow the airline to make the necessary arrangements to collect your bags and forward them to the hospital.

In this instance, Ruth was not thinking clearly enough to seek medical assistance while in transit in Hong Kong.  She was fortunate that her use of the intra-muscular injection meant her condition did not deteriorate during the onward leg of her journey.  If she had deteriorated markedly, it might have been necessary to divert the plane for an emergency landing. However, she and her children made it home and all is well that ends well.

Professor John Monson

St Bartholomew’s Hospital, London

UK

September 2008