Vasovagal syncope might be a diagnosis on your list of differentials that seems relatively benign, as there are many more sinister causes for a sudden loss of consciousness. But no one wants a sudden loss of consciousness to happen in front of the whole staff of an operating theatre, or in front of all your peers in the dissection lab.
In a recent episode of Sharp Scratch, we broke down some of the reasons why we might feel faint, strategies we can use to prevent faints, and why there’s no shame in being a frequent fainter—all with the help of expert guest Boon Lim, award winning consultant cardiologist based at Hammersmith Hospital, where he runs one of the busiest syncope services in London
Initially, we asked why people faint and, in turn, why medical students in particular are so prone to it. “Fainting is very, very common, and is seen in up to 50% of patients in their lifetimes,” explained Boon. Lily Copping suggested fainting may be more common in medical students as “we see a lot of gory things,” while Anna Harvey suggested that fainting might have evolutionary roots, where “your body protects itself from potential danger, such as when you see blood.” Boon confirmed this, citing the example of a possum protecting themselves from a predator by becoming bradycardic and playing dead.
Try as medical students might to seem like they are invincible (and much as we might delight in telling our non-medical friends perhaps slightly exaggerated tales of gore), it’s inevitable that at times you might end up feeling a bit funny at the sight of a serious procedure or operation—or even, as some of the panel described, at something totally unexpected. Lily recalled her third year haematology placement, watching a Hickman line removal. She remembered thinking, “Wow, this is so fine! I could be a haematologist, I’m not being squeamish at all!” before seeing the nurse look up at her and ask if she needed to sit down. Next thing Lily knew, she woke up on the floor, surrounded by nurses and wearing an oxygen mask.
Despite fainting being common, no one wants to be known for being the medical student that faints all the time—as host Nikki Nabavi found out on her vascular surgery block, which the panel discussed in the episode. Nikki recalled fainting in theatre on the first day of the block. After she had recovered, an unaware nurse showed Nikki back to theatre, turning to her to share the gossip that “apparently one of the new medical students has already fainted!” This experience resulted in Nikki being increasingly nervous about attending theatres, and these negative associations meant she continued to faint.
Aside from the unexpected causing them to faint, medical students often worry that they may soon become an unexpected topic of conversation, with Nikki musing if there is stigma around being “a fainter.” Lily described one of her fainting experiences as “embarrassing,” and recalled her WhatsApp group chat discussing the rumour that someone in their group had fainted. “There is nothing to be embarrassed about with fainting,” Boon told us, “the only fear I have for the three of you is that you won’t fulfil your full potential and ambitions for fear of fainting.”
Our expert guest had some good news for us and other frequent fainters out there—there’s lots you can do to prevent yourself getting to the point of fainting in the first place. Boon sees hundreds of people who faint frequently every year (including consultant surgeons). He explained that it’s a combination of different factors aligning to cause a faint, and “part of the strategy is to be aware.” He asked us to imagine “you are in the middle of your menstrual cycle, you had a difficult night’s sleep, whether because you had a party or your flatmates were up studying, you also had a tough morning rise to get to your hospital placement on time, you were stressed and missed your breakfast. All these factors make it more likely that you will faint at even the slightest procedure.” He urged us to use this “situational awareness” to decrease the risk of “situational syncope,” and drink plenty of water (3L a day). He also advised us to be aware of our personal prodrome to a faint. Our panellists recalled feeling unwell right before they fainted, and learning to recognise the signs that indicate you might be about to faint can help you avoid “face-planting into a surgeon’s sterile field.”
Boon told us that his advice to patients at his syncope service is to learn the isometric counterpressure maneuver— tensing the muscles in your legs and then relaxing them—with some people describing their gastrocnemius muscle as “the second pump.” Anna recalled being taught similar techniques to prevent feeling woozy while giving blood, and they are experts in stopping people from fainting after a pint of blood has been removed from them.
So, we asked Boon, is it really more common for women to faint than men? It certainly seems a bit of a trope from a Victorian novel, of a lady dramatically passing out and being revived with smelling salts. Boon explained that the complex monthly cycle of hormones can affect the vasculature of those who menstruate, which becomes “more stretchy and compliant,” resulting in more fluid passing down to the lower limbs with gravity. If you are already predisposed to fainting, your monthly period can be one of a combination of factors that results in a fainting episode.
Fainting isn’t always within your control, but there’s plenty you can do to make sure you’re taking care of yourself and reduce the likelihood of having a “funny turn” (even if drinking three litres of water per day might seem a little excessive). Being “squeamish” shouldn’t put you off medical school, and definitely shouldn’t put you off any specific career paths within medicine, such as surgery. It is likely that you feel more embarrassed about fainting than anyone else around you is judging you. Boon encouraged us to “wear compression socks, drink some water…and get into theatre and have a good positive experience, conquer the learned helplessness reflex, and feel emotionally positive about every surgery you get through without fainting. Retrain your brain not to fear it.”
Anna Harvey, medical student, King’s College London and past editorial scholar, The BMJ.
Nikki Nabavi, editorial scholar, The BMJ, and medical student, University of Manchester.
|The Sharp Scratch Panel:
Nikki Nabavi, The BMJ, University of Manchester
Anna Harvey, King’s College London
Lily Copping, Barts and The London School of Medicine and Dentistry
Fainting episode guests:
Boon Lim, consultant cardiologist and electrophysiologist, clinical lead for Imperial Syncope Diagnostic Unit
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