Never Dismiss a Faint

There is a wonderfully reassuring feature of ordinary vasovagal fainting.

The patient wakes up. And that is also what makes syncope dangerous. Because once someone is talking normally again, everybody relaxes.

“Gutom lang.”

“Napagod.”

“Mainit kasi.”

“Mababa siguro ang blood pressure.”

Often, they may be right. But as physicians, we must resist diagnosing syncope by reassurance alone.

The heart can produce a dangerous rhythm for only a few seconds and return to normal before anybody records it. Severe structural disease can first reveal itself through exertional collapse. A medication regimen that was appropriate years ago may now cause hypotension in an older, thinner or more frail patient.

At the same time, we should resist the opposite mistake—subjecting every person who faints to an expensive battery of scans and tests.

Good medicine lies between complacency and over-investigation.

Listen carefully.

Ask the witness.

Measure blood pressure standing.

Examine the patient.

Record an ECG.

Then let the evidence determine what comes next. That approach is central to both American and European syncope guidance.

Perhaps the most useful question after someone regains consciousness is therefore not:

“Are you okay now?”

It is:

“Why did this happen?”

Most answers will reassure us.

A few may save a life.