Thursday, January 28, 2010

Timber


I was doing a spinal for a patient seated in front of me on an operating table. In front of her, facing me, her nurse was holding her steady; behind me, a tall, young nursing student stood observing.

Three minutes passed between the time I prepped the skin with sterile solution and the moment I injected anesthetic into my patient's spinal canal. "You're all done," I said cheerfully and withdrew needle and syringe out of her back in one motion. "We'll have you lie down in just a second."

All of a sudden the nurse's eyes widened and she said in a firm voice, "Sit down. Sit down right now. Right now, sit down, RIGHT NOW." She was gazing past me. I put my hands on the patient's shoulders and turned my head to glance over my shoulder in time to see the nursing student teetering on her feet trying to make her way to the nearest wall. With me now in charge of holding our patient, the nurse rushed around the operating table toward the student and arrived just in time to support her crumpling body before it hit the floor.

Vasovagal syncope is a very real concern and not uncommon in bystanders observing procedures that involve the insertion of sharp objects into patients. I once saw a tall adolescent male fall back unconscious because of an I.V. In a case that would fill any conscientious anesthesiologist with dread, the husband of a woman who was getting an epidural for labor fell, hit his head, and DIED of an intracranial hemorrhage. This page has an interesting comparison of legal cases brought against hospitals on behalf of people who have fainted while observing medical procedures.

I don't think it's fair to assign blame for fainting. People can't help their physiologic reactions, which can sometimes be unpredictable. Different people have different triggers. Some can't stand needles; others, blood or fractures or internal organs; my Achilles heel is the drainage of pus. Even just thinking about that can provoke that unpleasant, pre-vomit tickle in my throat. Needles commonly seem to be problematic for the toughest-looking individuals, so I try not to judge by appearances. But it can be tricky, this business of trying to be mindful of observers' needs when all we really want to do is put 100% of our focus on our patients.

I hope that student is okay.

13 comments:

Jo said...

Eeeep - I hope the student is ok!

My cousin once fell and needed a few stitches in her knee. My uncle took her to hospital, watched them put the first stitch in, fainted, and needed about ten stitches to close the gash in his head!

QuietusLeo said...

In our delivery room we don't allow the fathers present during performance of the epidural puntcture. In my previous hospital, we did, and there were more than a few gentleman who mopped the floor with their tongues. I made the following observation. Taller and more muscles is a positive predictive factor for syncope.
As the old adage says: "The bigger they are, the harder they fall."

fenwayguy said...

I was curious about the Passalaqua suit. The parties settled it. No surprise there, I guess.

Old MD Girl said...

I vagaled after standing motionless for 4 hours during a surgery. Of course they all made fun of me, saying I must have been afraid of the blood or something. Actually the problem was I hadn't had anything to drink in 10 hours.

Meaghan said...

I had a friend who took me to the ER faint on me when he was watching me get my finger stitched up. It was hilarious how quickly he became the patient! (He was ok though)

Pax Arcana said...

A few months ago I passed out while having blood drawn. I had had blood drawn at the exact same lab two weeks earlier, and have never experienced any problems in my 30+ years of being poked. The only difference this time was that the nurse asked repeatedly if I was feeling woozy -- at least three or four times before even pulling all the blood she needed. I submit that she underestimated the power of psychological suggestion.

Albinoblackbear said...

The last two times I almost hit the floor was observing an autopsy (strangely NOT when they were sawing the skull open but in fact when he put the heart on the scale) and when I was providing traction for a tibial fracture reduction on a 5 year old (the crepitus....ohhhhh the crepitus).

Funny how it is sometimes hard to predict what will send you down the vagal rabbit hole! :)

Kathleen said...

My daughter's friend had a vagal response when he got his ears pierced. He didn't look so cool on the floor at a kiosk in the mall.

Teaching special ed, my "gotcha" is watching or helping someone brush their teeth. Makes me gag everytime-- with my kids at home, watching it on TV as well as here at school.

Glad you are blogging again!

Anali said...

Eeek! I almost passed out doing a fetal pig dissection. That's when I realized that I could or would at least never voluntarily dissect anything bigger than that.

To this day, I've never fainted though. Hopefully I never will!

Varsha said...

I fainted when I first pricked my own finger with a 21 G needle to draw a sample for a physiology experiment to estimate Hb. And next when I witnessed the autopsy of a neonate who died some 3 hours after birth. After that never. Not even brains spilling out of cracked skulls in the trauma ward.........

Dragonfly said...

I was close to vagal after 4 hours in one of those moon suits that orthopods do joint replacements in. Turned out the band holding the helmet on my head was done up far too tight - when I took it off the welt took over half an hour to subside. Of course being the female student on ortho it was awful but the female anaesthetic reg came and checked on me. Love.

speducatorlvc said...

I've never fainted. I may have come close once after slamming and dislocating two fingers in the door of my 70-something Ford, but it's never actually happened. I'm not saying this to brag; quite the opposite, I think what makes me odd is that I've always secretly wanted to...just to know what the experience is like.

ChingChuan Chiu said...

Well, it's definitely not a nice experience ;). It does have advantages, however, now I'll forever remember the signs/symptoms of vasovagal collaps...

I fainted during my primary care internship - the doctor was going to remove a piece of someone's nail and all of a sudden, I felt a bit sick, then it seemed as though my head was covered with a pillow - and it was only then that I thought, well, perhaps there's something wrong.
Fortunately, I made it to a chair before I fell. The weirdest thing was, I heard this really loud buzzing/beeping noise, which took several minutes to disappear.

For me, it wasn't the blood or anything, it was because the patient was slightly uncomfortable (even after several administrations of local anesthetic, she still felt a bit of pain. The doctor decided to get on with it, as he was nearly finished). I watched her nonverbal responses and then I started to feel queasy.

I'd never fainted before so it was indeed a very interesting and enlighting experience - though I'd rather not repeat it.

Very nice post, by the way ;).