I was sitting in the lineup at Nine Palms, Baja California Sur, early in the morning. Matt (name changed) had just paddled out, an experienced surfer, 60 years of age.
Soon I overheard him say to his friend: “I am not feeling well!” His friend asked what’s wrong. “I have a terrible headache and my neck hurts.” Although his friend suggested that Matt might just be exhausted from the long surf session the night before he agreed to paddle out with him. But Matt said “I can’t. My arms and legs are feeling weird. “Lie down on your board I will pull you.” “I can’t lie down!”
I paddled over to them. So there was a surfer with head and neck pain and weird feelings in his extremities. No wipeout, no other surfer close to him that might have hit him. He hadn’t even caught a wave yet. His friend started pulling him towards the beach while Matt was sitting on his board. I knew Matt because I had checked his ears the night before. While I helped escorting him to shore I asked him a few questions. Except for the fact that he had surfed extensively the day before and did not have breakfast before coming out in the morning I got nothing worth mentioning out of him. No diabetes, no allergies, no heart condition, not even high blood pressure. “I think I will pass out.”
Nine Palms is a pretty mellow point break but treacherous. You have to navigate around some serious rocks. That day a long period swell brought overhead sets. Pulling the sitting surfer was really challenging. The three of us were slow, silently I wished Matt would simply lie down, I am sure his friend felt the same. Miraculously, no set rolled in – until we were about 20 meters from the beach. Then, Matt got hit by his friends SUP board, the result was a small bruise on his forehead and some damage to his board. Finally, we made it to shore and helped Matt out of the water. He was able to walk with our help but seemed weak and confused.
When I asked him he knew his name and where we were. The physical exam did not show any neurological deficit, Matt’s pupils were equal. He had no signs of injury except for a minor bruise on his forehead. His neck felt soft, the pulse was well palpable but with a pretty low rate of around 40, the capillary refill was good. His symptoms were the same as in the water: head and neck pain, general weakness. Matt said he was thirsty. His breath smelled a bit weird. What was the matter with him?
On the beach people were surrounding us trying to help. Matt’s friend, a retired firefighter captain, and I both knew that he had to get to a hospital. There is no cellphone reception in Nine Palms and no point really in calling an ambulance either. 40 minutes on a bumpy dirt track separate the spot from the next town. While the firefighter went to get his truck I stayed with Matt on the beach.
He vomited and buried his hurting head in the sand.
People around us started giving advice. One wanted to give Matt something to drink, others wanted to lift his legs up or brought some painkillers to give to him. I still didn’t know what he had, the symptoms didn’t fit any common cluster. The lack of breakfast, his thirst, and his weird smelling breath let a hypoglycemia seem most likely. Low blood sugar can cause a broad spectrum of symptoms including neurological ones and does occur pretty often. I had seen it in the hospital many times before. There the blood sugar is easy to check. It only takes one little drop of blood and 30 seconds to find out if somebody is hypoglycemic. On the beach there was no way to find out. I asked around if anyone was diabetic so I could use their blood sugar measuring device. No one.
Also, the acute onset and the low heart rate didn’t really fit the picture. My other theory involved a neurological condition. The sudden pain let me think of a subarachnoid hemorrhage. But I had never seen a case before. Both conditions, the hypoglycemia and the bleeding in the brain, can be immediately life threatening.
In case of hypoglycemia you can actually save somebody’s life with some sugar and water. But if my patient on the beach had any neurological condition giving him food or drink could be fatal because he might pass out and suffocate.
Because of the long ride into town I decided to give him some honey. Matt said it made him feel better. As the truck pulled up on the beach I helped Matt into the passenger seat. Just before they drove off I could see his left eyelid was drooping. I checked his eye movements and detected a paresis of the abducens nerve on the left side.
Even though the honey had lifted his spirits I was sure now that Matt didn’t have hypoglycemia.
It turned out that he had indeed a subarachnoid hemorrhage. The scan in the hospital showed an aneurysm. A neurosurgeon was flown in for the surgery. I heard from Matt a week later and I was very relieved, he made it. Many don’t survive a bleeding like that. Experiencing it at such a remote place definitely doesn’t help.
What to learn of this case:
The patient is the boss. We could have made it way faster to the beach if we had told Matt to lie down. I am glad we did not. A head down position increases the pressure on the vessels. It can cause a deterioration and actually kill the patient.
Lifting up the legs is not always good: On the beach people wanted to do exactly that. I told them not to. I could feel Matt’s pulse at his wrist, it was strong and the capillary refill was good. The circulation wasn’t the problem. I did not know it was that important not to lift his legs up though.
A blood sugar measuring device can come in handy: Giving Matt honey was not necessary and actually judging with my knowledge now not good. But since there was no way to know for sure if he was hypoglycemic on the beach and he had a long drive to the hospital ahead of him I think it was ok I gave it to him.
What to improve as a surfdoc: In a perfect scenario we could have been faster. I could have sent somebody from the lineup to paddle ahead and organize the transport. And If I had handled the people on the beach better we could have saved another few minutes. Does this make a difference? You never know. The odds that I will witness another bleeding like this on the beach are really low. But maybe somebody who reads this will. If you do: Good luck!