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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES Programme no: 9 - Fainting
RADIO 4
TUESDAY 26TH FEBRUARY 2008
PRESENTER: MARK PORTER
REPORTER: CLAUDIA HAMMOND
ADAM FITZPATRICK
RICHARD SUTTON
KIKI MCMANUS
SANJIV PETKAR
MAXINE DODD
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. While I have never actually fainted myself, as a doctor I have had plenty of people keel over in my presence. Nothing to do with any Dr Kildare type aura either - just the needle and syringe in my hand.
And my colleagues here in the Science Department do their fair share of fainting too. Here's one of the Case Notes producers, Helen Sharp, explaining how she came to record her first and only ever blackout.
SHARP
I had to go and record a knee replacement operation and although I have been in theatre many times before and I've never fainted I unfortunately didn't get to see the knee replacement operation and I can remember leaning in to watch what was on the television screen and then I don't remember much else, although I woke up on the floor.
ACTUALITY - OPERATING THEATRE
It's okay alright, it's okay.
PORTER
Although Helen's pride was dented, I am pleased to report that her recording equipment wasn't. But why did she faint? And how can we be sure that her loss of consciousness - or syncope as doctors often call it - wasn't due to something more sinister, like a heart problem, or an epileptic type seizure?
Cardiologist Adam Fitzpatrick runs a pioneering blackout triage service at the Manchester Heart Centre at the Manchester Royal Infirmary. It's basically a one-stop-shop to ensure that people who have passed out receive the right diagnosis and are sent along the right care pathway - which means going home and nothing more for most people like Helen who faint and that's the group we will be concentrating on in this programme.
Everyone attending the clinic has a heart trace or ECG but that's just the beginning of a detailed appraisal.
FITZPATRICK
It depends very much on the age, obviously older patients are more likely to have a degenerative condition which can affect the conducting system or the wiring system of the heart, so not infrequently in the older patients we see something in our routine screening that we go through that suggests to us they may have premature wearing out of their wiring system in the heart and not infrequently those patients go on to earn themselves a pacemaker in due course. In contrast in the younger patients who have the same experience of losing consciousness, in that they often suddenly go out without much warning, it's usually a simple faint or what we like to sometimes term a complex faint. And I think the service, as we provide it, is trying to essentially discriminate between the complex faint, which people may inadvertently mistake for epilepsy and epilepsy itself. So we provide in this triage blackouts clinic a clinical assessment which is structured, we ask all the patients the same questions, trying to tease out the cause of their blackouts and we're specifically looking to exclude any life threatening or high risk condition.
PORTER
What is a simple faint?
FITZPATRICK
Well we don't really under - we understand what is triggered in that we know that the blood pressure collapses abruptly and often the heart rate slows down or even the heart stops for a number of seconds, se we can understand quite easily because we observe what is actually triggered. What we don't know is necessarily how that is triggered and what is the first thing that changes. Why so many of us have the capability of doing it, and it's probably at least half of us who have a faint at some stage during our lives, is unclear. It's obviously a very primitive reflex. There's some suggestion that it's a play dead reflex and that the casual predator, millions of years gone by, would observe the fainted animal and see apparent lifelessness and assume that the individual was dead and wander off having lost interest. So there may be some evolutionary benefit, in terms of survival, from playing dead. It's clear that many people - particularly the witnesses to a faint - what they observe is that their loved one or their spouse or their child appears to have died - we hear this all the time - a great intense pallor, pulselessness, lifelessness. And obviously that is taken extremely seriously, often much more so by the witness than by the patient themselves.
PORTER
And what do we think is the pathway that's responsible for that then, this is due simply to a drop in blood pressure - not enough blood going to the brain - that's why you're getting a loss of consciousness?
FITZPATRICK
Yes. The - what we observe is triggered in the brain stem, which is a relatively - in evolutionary terms - a relatively old part of the brain and there are two centres there which are called - in technical terms - the vasomotor centre and the cardio inhibitory centre - and they're involved in blood pressure regulation and heart rate regulation. And what the vasomotor centre does is opens the floodgates into your muscles, the muscles of the legs, the muscles of the arms, preparing you for exercise by diverting the cardiac output into the exercising muscle. And exactly the same thing happens if you're about to have a fight with somebody - you get ready for that by charging your muscles with energy. The problem is if you're resting but not exercising your cardiac output is not adequate to supply the muscles and the brain and all the other organs at the same time. So if you trigger this reflex when you're essentially not exercising or fighting or fleeing the blood pressure plummets drastically. And secondly we have seen up to one minute of the heart literally stopping beating altogether and then subsequently recovering. We've - particularly with the implantable recorders that we use here in quite large numbers - we've seen patients having 60 or 80 seconds of complete a systolin. And if you count slowly to 60 or 80 you get an idea of just how death like that can be. Some people will faint after exercise, there appears to be a mismatch between the increased cardiac output you expect when you exercise because your heart's going faster and harder and the diversion of blood to the muscles. So during the recovery period the floodgates remain open but the heart's slowing down and the cardiac output is falling, so you can see how you might have sufficient mismatch to inadequately perfuse the brain. We don't understand quite why that happens but we see sometimes in a formal exercise test on a treadmill in a hospital the patient finishes exercise and the blood pressure falls very noticeably for this reason presumably.
PORTER
A story that is all too familiar to Claudia Hammond. Unlike my producer Helen who we heard from earlier, Claudia has never fainted at work, but a new leisure activity has come up with an unexpected side effect.
HAMMOND
Phew, just got home from running and I've been out for about 45 minutes. Now I'm really not a natural runner and when I started out nine months ago I could only do like two minutes running, then one minute walking, two minutes running at a time and so on. Now I can do much longer than that with practice. The problem is when I stop - when I stop moving, like now, I start to feel a bit faint and I've fainted a couple of times now, first I feel slightly dizzy, which I do a bit now so I'm just going to start walking round a bit, then the whole world kind of starts to close in and it goes dark. So now I know when it's about the happen because I've got used to the signs and so I sit down on the ground quickly, so that I don't faint. But it doesn't feel nice and that's hard to do at traffic lights. So while I'm waiting to cross I end up having to jog on the spot for fear of fainting in the street. Now I've got to keep moving now, so that I don't faint now, so I'm going to get my keys out and go up the stairs to my flat.
That's better because as soon as I'm moving again I'm fine, so if I run up the stairs and there's lots of stairs then I'll be alright. Oh see, feeling a bit dizzy again now because I've paused to get my keys out, hopefully I can do it in time. There that's better.
PORTER
We sent Claudia to see Professor Richard Sutton at St Mary's to undergo a tilt case, a procedure designed to bring on a faint to try and clinch the diagnosis.
HAMMOND
If you've got a patient like me who comes to you because they've been fainting say after exercise what's the first step, what would you do?
SUTTON
The first step is usually that I would see you in the outpatients, we call it syncope clinic, could be called blackout clinic. And we'd make an assessment and decide whether a tilt test was going to be helpful in diagnoses or not. So Kiki McManus, one of the nurse specialists, is here, so let's start doing the assessment then.
MCMANUS
When was the first time you experienced this?
HAMMOND
About eight, nine months ago.
MCMANUS
Eight, nine months ago. Did it ever happen to you when you were a young girl?
HAMMOND
No.
MCMANUS
Pre-teens or in your teens...
HAMMOND
No.
MCMANUS
You can't remember any ...
HAMMOND
No I don't think I've ever fainted before that.
MCMANUS
Okay, okay. And explain a little bit to me what you experience. When you've actually lost consciousness have you ever injured yourself?
HAMMOND
No, no.
MCMANUS
Okay, good lovely. And you've been sort of fully conscious in that sense - you know where you are as soon as you come to?
HAMMOND
Yeah, yeah.
MCMANUS
Have you any idea how long you've been out for you think?
HAMMOND
Only a couple of minutes I think at the most.
MCMANUS
So we're going to go through the actual test and I'll explain what we're going to do. We sort of try to bring on a common faint, you're going to be on the bed behind me there, we'll put some ECG stickers on your chest to follow your heartbeat, we're going to put a couple of straps around you, so you'll feel safe.
HAMMOND
So you can't fall off the bed.
MCMANUS
Can't fall off the bed, exactly. And going to let you have a rest for a few minutes, we're going to turn down the lights in the ceiling.
HAMMOND
So I'll just take my boots off there. That's better.
MCMANUS
When we stand you up I want you to keep your legs and your feet as still as possible when you're standing up because what we're trying to do is drain the blood down in your feet, that's basically what happens ... just an ordinary blood pressure cuff around your right arm. That's going to sit there throughout the test. Your left hand's going to be stuck with this cuff around your finger and that needs to be rested by your side at all times. Okay so you're ready? Turn this up quite quickly but I promise I won't tip you over. Just try to relax as much as you can. We'll stop before you get completely upright, so it's an angle of about 60-70 degrees there. And there we stop and then I'm just going to leave you there and wait.
We've done the first bit of the test for 20 minutes, I'm going to give you a little spray underneath your tongue of something called GTN or glyceryl trinitrate and what that does it opens up your blood vessels a little bit so we can get more blood going down in your feet, sort of provoking a little bit more. Just one puff.
HAMMOND
Oh it's very minty.
MCMANUS
Okay, so we'll go 15 minutes from now on, so just keep relaxing, you're doing well there. We're going to put you flat very soon. You're doing really well, not too much further. Still with me there Claudia?
HAMMOND
Yeah just, it feels all hot.
MCMANUS
Just about, things closing in?
HAMMOND
Yeah.
MCMANUS
Still with me? Still with me there Claudia? Claudia, wake up. Claudia, wake up. You just passed out there, very briefly. You're back now with your head a little bit lower than your feet, the blood will be quicker back into your head. So how did that feel like?
HAMMOND
It was like sort of dreamy.
MCMANUS
Let you recover for a couple of minutes there. There's your blood pressure going, and there's your heart rate blue and can you see here it's coming down, about here is when you told me first that you were feeling a little bit funny.
HAMMOND
Oh just it's going a bit higher.
MCMANUS
And then it started to go down, down, down, down, at the bottom there is when you lost consciousness.
SUTTON
From this relatively steady period to this declining period we can say that this is definitely fainting.
HAMMOND
So the pulse going up is the heart trying to compensate, desperately trying to get blood round.
SUTTON
... also a compensatory mechanism and then everything fails.
MCMANUS
So it's really important that you get a lot of fluid into you and you need probably to aim for two to three litres a day of water...
HAMMOND
That's quite a lot isn't it.
MCMANUS
It's quite a lot and especially on those days that you're running you have to make sure that you've drunk quite a lot before you go out running. Another thing to think of is it usually comes on as you stop exercising - you're moving your muscles when you're running and as you stop you don't use your muscles, they relax, so you get a draining - a quicker draining of blood down in your feet. So if you stop to cross a road for example keep moving a little bit or as you stop just stand there and squeeze your buttocks or thigh muscles a little bit or go up on your toes and it's something we call isometric manoeuvres - you flex your muscles fully and hold on to it for a few seconds, relax and do it again, and keep doing that and that gets your blood pressure going a bit better. Then we often advise people to take a little bit of extra salt, especially if you're doing a lot of exercise - you're running, you're sweating, you lose salt.
HAMMOND
Because I never add salt to food to try and be healthy because we know that too much salt is bad for you.
SUTTON
The media's been brilliant at publicising reducing salt and it's good for most people but not for fainters.
PORTER
Back at Manchester Royal Infirmary, Adam Fitzpatrick's team deal with a wide range of different condition in their blackout clinic, but there are three working diagnoses that account for the lion's share of patients referred to the service - fainting, an abnormality of the heart and epilepsy.
FITZPATRICK
We've been trying to highlight the misdiagnosis rate which is significant for some years, we've published some work on it. It's thought that 20-30% of adults have the wrong diagnosis, they probably have a complex fainting syndrome but they've been labelled with epilepsy. And anything of up to 40% of children. So it's a big public health problem that's not been focused on until recently. And the all party parliamentary group on epilepsy in England published a report last year which for the first time recognised that at least 74,000 people in England alone are misdiagnosed with epilepsy.
PORTER
Because one of the problems would be of course that if you're on treatment for your epilepsy, you don't have epilepsy in the first place, it's not going to stop you fainting, so you continue to faint, so the treatment for your epilepsy gets increased or more drugs that you're added, you're in a sort of vicious circle.
FITZPATRICK
Yes you are, I mean I think that there's no substitute for expert review. There is a tendency for the fainting patient to arrive first with the neurologist and if the syndrome is sufficiently uncertain then there may be a trial of epilepsy treatment given. There are two dangers here: the first is that it imprints the label of epilepsy, which has a lot of very important social consequences, in a service economy people don't employ epileptics very readily because if they're manning the front desk and they have a seizure it puts the customers off, there's difficulties with driving, there's difficulties with education and employment, as I've said. The second concern is that the patient has a simple or a complex faint that appears to be epileptic form, they're labelled with epilepsy, they're started on treatment and they may never have another faint and it's assumed that the drugs are working. So the label of epilepsy is maintained for that reason. And again I think there's no substitute, if seizures have resolved, there's no substitute for a thorough specialist review to make sure the diagnosis was right.
PETKAR
Patients who blackout they present to a lot of specialities - to the GP, to the accident and emergency department, physicians, care of the elderly physicians, pulse clinic, the eye clinic and to the neurologist.
PORTER
Dr Sanjiv Petkar is a clinical research fellow working on a web based tool to help Adam Fitzpatrick and his team come to the right diagnosis.
PETKAR
If you look at the - all the literature that is available on the subject of blackouts it is absolutely clear that the diagnosis quite a lot of times rests in listening to the patient.
PORTER
Trying to tell you what's wrong with them, all you've got to do is listen.
PETKAR
Yeah and unfortunately in sort of our world today we're always pressed for time. To take the variability away from the history taking by different medical professions we thought we'd standardise the whole process.
PORTER
So the patients will arrive at the clinic, they'll be seen by one of the specialist nurses who will then go through - show me - we're sitting in front of your laptop here, this has the questionnaire on it.
PETKAR
This has the questionnaire on it and the first page just has the patient demographics on it. The second page basically tells us as to who referred these patients to us. How many previous consultations they had for blackouts because we know that one in three people can blackout over and over again.
PORTER
So if I was a witness, I mean take me to the section, what would you want to know about the attack specifically that might help you work out what was going on?
PETKAR
What I would like to know is what was happening before the attack - was the patient lying down, sitting, standing immediately, standing for a prolonged period of time. Did the attack occur during exercise because that's a bad prognostic feature. Some people can blackout when they're passing water - what were the predisposing factors, was it a warm environment, had they had too much to drink, had they had a late night because the late night and tiredness can precipitate epilepsy.
PORTER
I mean the things that strike me straightaway would be colour changes maybe in the patient but also seizures - convulsions.
PETKAR
The thing is when it comes to basically fainting, as opposed to epilepsy, most of the times there may be a precipitating cause. The patient usually falls to the ground very floppy, the patient can lose colour - will become very pale and sometimes they say that I thought that the patient was dead. They recover pretty fast and in fact one of the features is that if you recover within five minutes then it is likely to be syncope. And if you have abnormal movements, these abnormal movements are not symmetrical, these abnormal movements are just twitchings ...
PORTER
So you can still twitch if you're having a simple faint but they tend to be erratic?
PETKAR
They tend to be erratic, they tend to be brief and they occur usually after the fall. As opposed to that basically with epilepsy usually they go very stiff initially and they start sort of jerking before they fall.
PORTER
Specialist nurse Maxine Dodd uses the computer program to take a detailed history from every patient.
DODD
What I want to do now June is just chat to you about what happens when you have these blackouts. So if you just want to tell me in your own words what happens and your husband that's with you, as well, if he wants to join in. Okay?
JUNE
Well it's usually I don't feel well, it doesn't just happen for no reason.
DODD
Are you doing anything in particular at that time?
JUNE
No, no I can be just sat or doing anything. I get a buzzing in me ears.
DODD
Right, does that happen every time?
JUNE
Every time. And I sweat profusely and then I just faint.
DODD
How long does this happen for?
JUNE
I should imagine it's only seconds.
DODD
So it's just for a few seconds before you actually collapse?
JUNE
Yes.
DODD
And then what happens when you do collapse, do you actually fall down and collapse?
JUNE
No, I'm usually on the floor already.
DODD
So you know it's going to happen and you get yourself on the floor ready?
JUNE
Yeah.
JUNE'S HUSBAND
She says to me she normally feels sick and can I get her upstairs to the toilet. Last time, on New Year's Eve, I got her upstairs on the landing, she just went down then and said I don't feel I can make the toilet. Laid down, she's out for about three or four seconds, then she started to vomit.
DODD
And what happens to her colour, she goes very pale.
JUNE'S HUSBAND
She said she felt very, very hot and she felt cold to the touch.
DODD
Okay and what was happening to her body at that time - did she go floppy or ...?
JUNE'S HUSBAND
She just stayed still.
DODD
Laid still, so there's no twitching movements or anything like that?
JUNE'S HUSBAND
No nothing like that.
PETKAR
We can also show some video clips to witnesses. This is a video clip of syncope.
PORTER
So this is someone who's fainted and they are twitching.
PETKAR
But you can see that the twitching is very brief, they're not very stiff, they're quite sort of limp. There's no real pattern to their twitching.
PORTER
So the witness would be able to watch this and say well yes it's exactly what happened or it wasn't like that. And who are these people here on the video?
PETKAR
They're all volunteers - medical students.
PORTER
I'm intrigued - how do you make them faint?
PETKAR
This is by asking them to squat holding their breath and then suddenly getting up again - it's called a fainting lark or the mess trick.
PORTER
It works very well on medical students by the look of it.
PETKAR
It certainly does work very well on medical students.
PORTER
Looking at your web tool here, I mean it's very detailed, I think we've got 12 pages altogether, but is it an intelligent system in that it's taking the details that you've recorded in the history and deciding which way ...
PETKAR
Not yet because basically this is where we're trialling the questionnaire out, we never had anything to go by in the sense that this was the first thing that we created out of it, there was no model that we could follow.
PORTER
So essentially at the moment it's a bit like having bits of paper to make sure that you ask the right questions or the nurses ask the right questions to help you make the correct diagnosis but you envisage a day where you might use the computing behind it to say ooh this sounds like a stroke, let's go down this pathway?
PETKAR
Yeah, so basically like what we need to do is look back at all our results and see which were the discriminatory features for each of these conditions.
PORTER
So what can be done to help someone who has been given the all clear for a more sinister underlying cause, but is still prone to fainting?
Adam Fitzpatrick again.
FITZPATRICK
The very, very common finding, particularly in young women for some reason, is that the patient simply doesn't like the taste of salt. They've picked up the public health message that salt is bad for you and they avoid it like the plague and this produces typically a history of low blood pressure, occasional or frequent dizziness and blackouts. And the treatment there is to take more salt, not surprisingly.
PORTER
And is fluid intake part of that as well?
FITZPATRICK
If you take a lot of fluid alone you won't retain it because the body has to keep the body fluids at the same, what we call, isotonic level, that is they have the same amount of molecules circulating, otherwise you get very damaging currents between different parts of the body. If you just take fluids, if you just drink a lot of water, it won't help. If that doesn't work then there is a drug which is very effective, it's called Medadrin, it is widely licensed around the world, particularly in Germany where it's perceived that low blood pressure is a major public health problem. Of course we have the opposite problem in the UK that blood pressure's too high. And partly I think for that reason this drug has not got a licence for use in the UK, particularly for this indication, in spite of some of us pushing for it to be licensed. But it is available on a named patient basis, so if your doctor is comfortable prescribing it and stocking it you can get hold of it and we found it to be extremely effective in many cases. There are some people, even young people, who are so troubled by their blackouts, which are due to fainting, with an associated slowing or stopping of the heart, that a pacemaker may be considered a suitable treatment. Typically it will come into pace if the heart rate falls below 50 or 60 beats per minute. And in the patients who are completely a systolic for 10-20 or 60 seconds then the pacemaker will kick in and keep the heart beating, keep the blood flowing and keep the brain perfused when otherwise the patient would have become unconscious.
PORTER
What's the best first aid management of somebody who keels over in front of you, assuming you know it's a faint?
FITZPATRICK
One thing that will always improve the blood supply to the brain is getting the head down below the feet and also possibly raising the feet because you'll transfuse two or three units of fluid from the legs back into the circulation. If these floodgates in the muscles have opened then that will help to improve the blood supply to the brain and restore consciousness.
PORTER
And they should come round pretty quickly.
FITZPATRICK
Essentially yes, in fact the very act of collapsing in most cases is sufficient to cause a faint to recover. Indeed in some instances in history people have died because they couldn't collapse to the ground, in fact this was said to be the cause of death in many people who were shipped from Germany to the concentration camps in train trucks during the war because they were packed in very tightly, a lot of people fainted but they couldn't actually get down to ground level.
PORTER
So their blood pressure couldn't normalise. Because I have seen cases when I've been out and about where people have fainted, people tried to sit them up and give them a drink of water and you can see ashen people with no blood going to their brain, they're propped up and it just gets worse.
FITZPATRICK
Yes, if they're in a chair tip the chair down and make sure that their head's below their feet.
PORTER
And who would you like to be referred to you, I mean let's assume that a GP has a patient that has what sounds like fainting, do you think you should see that person to see, I mean there's an awful lot of people out there, we said 50% of people are prone to faint at some stage, but that means there are a lot of people out there having loss of consciousness, should they all be assessed properly?
FITZPATRICK
I think there are a lot of people but there are also a lot of inappropriate admissions. As we heard earlier a lot of patients with the wrong diagnosis. So we have to be responsive I think and I think the response should in all cases include an ECG, looking for heart rate, rhythm or morphological abnormalities. And any patient with a loss of consciousness should have an ECG because a small but very important set of patients will die the next time.
PORTER
I mean you call the service here triage service, as a GP I see this as a great sort of one-stop-shop if you like to work out what's wrong with people and where they should be going to get their treatment. Is this sort of service replicated across the country?
FITZPATRICK
With a bit of luck and some support, which we hope we're going to get from the Department of Health in this respect, then the methods that we're developing here would be available to be rolled out across the NHS in other centres.
PORTER
Cardiologist Adam Fitzpatrick talking to me at the blackout triage clinic at Manchester Royal Infirmary.
If you'd like more information on the investigation and treatment of blackouts then do visit our website where you'll find lots of useful links. This is the last programme in the current run but we'll be back for a new series at the beginning of April. Until then goodbye.
ENDS
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