Wednesday, February 11, 2009

Syncope

I started fainting at a young age - I think I was only six when I had my first of fourteen teeth pulled.  According to my dentist, I had too many teeth and not enough space in my mouth - an unfortunate Mendelian roll of the dice that dealt me much pain in my formative years.  I still remember the first time - the procedure was already over and I was standing in the waiting area next to the child-sized table and chairs with a big bear painted on it, my mouth full of gauze, reaching into the treasure chest to pick out a small plastic prize for having tolerated the procedure.  When I woke up, I was lying on the couch, surrounded by concerned adults.

This pattern repeated itself throughout my childhood and teenage years, mostly in the dental chair.  Once, at about 16, I had to have an irregular-shaped, oddly colored macular lesion removed from my right arm.  When I woke up after having passed out, I was mortified and embarrassed, but my family doctor reassured me with a story I was sure he had told to many people before myself, one that I like to use today when my patients succumb to the vasovagal response.  He said that my response to pain was a survival instinct left over from the battlefield long ago.  Soldiers who "played dead" at the first sight of pain woke up intact long after the battle was over and got to return home to their families.  So I was the genetic legacy of the wimp that survived, somewhat, but not entirely, reassuring.

I kept fainting from pain:  getting my braces in high school, getting a belly ring in college, donating blood.  When I decided to go to med school, sort of by default, parents and friends worried.  "But you always pass out at the sight of blood!"  Well, that was my own blood.  I was pretty sure I could learn to tolerate blood and guts, as long as it was somebody else's.

When we had our blood draw lab at the end of the second year of medical school, I was alarmed to learn that we had to practice on each other.  I teamed up with a guy in my class, and volunteered to go first; he was clearly uncomfortable.  I got him easy on the first stick, and I passed off the variously colored tubes of blood I collected to the clinical laboratory volunteers; they used the second year med students yearly as a large normal lab value cohort.  When it was his turn to do me, I took a deep breath and gritted my teeth.  He missed the first time, and then he began to sweat.  I watched the shaky needle approaching my antecubital vein uncertainly.  I don't remember the rest, except for being the subject of my classmate's gentle ridicule for the next few weeks.

After that, I began to take precautions.  I had heard stories of med students fainting in the OR.  It is one thing to go unconscious when there are lots of sympathetic people around to deal with it, and quite another to risk a sterile environment and require the attention of the already understaffed operating suite when there was a much more critical patient on the table.  The kiss of death, as far as reputation goes.  I learned that if you tank up on sugar in the early morning, you are less likely to get woozy at the sight of blood.  Based on my past history, it was a safe bet that I was at considerable risk in the OR.

So I started stocking juice boxes, m&m's, and candy bars in my backpack.  Once I found myself sugarless at 5:30 a.m. before a big ortho case at the Children's Hospital - I knew there would probably be a lot of big hardware involved with screws and pliers, and this particular attending really enjoyed testing me to see whether or not I had the strength to cut various metal rods with massive pliers after they had already been inserted into the child's body.  I began to frantically search for a sugar source in an area of the hospital that I was not familiar with at all, and still remember the enormous relief I felt when I saw that I could afford some Lifesavers (I just realized the irony here) in an old, ill-used vending machine tucked into a corner outside the dressing rooms.

When I got into pathology, I got over it.  Autopsies became routine, and I eventually stopped loading up on sugar.  I had to get my blood drawn a lot during my two pregnancies in residency, and tolerated that well, except for one unfortunate incident when the phlebotomy novice nervously crushed the blood tube in her hands, spilling my blood and broken glass all over my arm and the floor.  But that was the exception.

So I was surprised, on my first day at the crime lab, when I got woozy.  When I walked in the basement morgue for the first time it was a Monday.  Monday is the busiest day at the crime lab; many crimes happen over the weekend, when people are bored and indulging in drugs and alcohol.  At our crime lab, the pathologists don't work weekends, so there are often twenty to thirty bodies laid out on metal tables on Monday morning.  We all round together, and I listened to the story of each death.  By the time we got to the third or fourth one, I started zoning out to buzz of blowflies and fluorescent lights in attempt to dissociate from my surroundings and save my reputation. I suddenly realized I wasn't going to make it unless I got some sugar.  I pulled one of the dieners aside and asked if anyone had an m&m or candy bar stash somewhere.  He said he didn't know of any candy, but thought he had seen some peanut butter and crackers somewhere.  I must have looked ghostly and desperate, because he quickly ran back to some cabinets and returned with an open package.  I sat down and ate them all, fortunately saving myself from embarrassment, and tried to return to rounds as unobtrusively as possible.

So I am living testament to the fact that you can experience chronic syncope, and go into medicine successfully.  It takes an enormous amount of exposure, precaution, and discipline.  The mind will eventually adapt, and gain control over the psychosomatically-induced vasovagal response consisting of dilated arteries, plummeting heart rate, and the rapid draining of blood from the central nervous system that renders one unconscious.

What to do if you see someone faint or become woozy:  Place a cool cloth on their forehead, and quickly place them in a supine position, feet elevated.  Feed them some candy or Sprite, if they are or when they become conscious.  








2 comments:

christie said...

If I had been a fly on the wall, I just would have assumed that dead bodies made you hungry! I love the evolutionary explanation for pain-induced passing out. I read that section to Chris, who has zero pain tolerance. I think it made him feel a bit smug. He too would have survived the battlefield!

Gizabeth Shyder said...

Hmmm . . . I should have thought of that before I exposed my weaknesses! Blood and guts make me CRAVE food. An interesting pathological spin.