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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP Programme 1. - Fainting
RADIO 4
THURSDAY 28TH FEBRUARY 2008
PRESENTER: BARBARA MYERS
CONTRIBUTORS: RICHARD SUTTON
PRODUCER: DEBORAH COHEN
NOT CHECKED AS BROADCAST
MYERS
Hello and it's very good to be back with a new series and today a new subject, which is fainting. Now people have been known to faint in a variety of situations - after standing too long, or standing too quickly, after going to the toilet, coughing or famously at the sight of blood. There all quite common triggers, as are dehydration and certain medications. If you don't know what's causing you to faint or to feel faint your doctor may offer a tilt table test - we may hear more about that later. Or you might be given other investigations to see if you have a heart problem - abnormal heart rhythms are a less common cause of fainting but they may need treating. So if you are prone to sudden unexplained albeit brief blackouts do call us now for expert advice from my guest today, he's Richard Sutton, professor of cardiology at St Mary's Hospital in London.
Our first caller is on the line, she's Elizabeth Lee, she's in London but she is prone to fainting on an aeroplane. Feeling faint or actually fainting Elizabeth?
LEE
Well the first time it happened I actually fainted because it was a bit surprising, I wasn't expecting it and I was out for 10 minutes.
MYERS
Mmm. And has it happened again?
LEE
Yes several times, about half a dozen times.
MYERS
And so your question is what to do about it or what's causing it?
LEE
My question is really two fold. First of all is there something about the health environment of an aeroplane that might make someone faint? I say that because the first time I fainted the cabin staff told me that the air was better in their quarters than it was in the rest of the plane and I should stay there. And the last time I fainted they told me that they were sometimes affected as well. That's the only evidence I've got. Now the other question was - there's nobody else fainting on the plane except me, I'm the only one, so why am I doing it and no one else?
MYERS
Two very good questions - is it down to air quality on the plane and are you unusual. That one first Richard - is Elizabeth unusual to faint on an aeroplane?
SUTTON
No. Fainting is the commonest medical emergency on aeroplanes. So you're not unusual. And I have been on an aeroplane when two people have fainted, fortunately not at the same time.
MYERS
And you were the doctor on the plane.
SUTTON
Yes.
MYERS
And so can you say anymore then about what's causing it - is it something to do with the altitude, is it something to do, as Elizabeth was perhaps suggesting, with the air quality?
SUTTON
It's a little bit to do with the altitude because you are pressurised to about 6,000 feet and that's quite high still and there is a tendency for water to accumulate in the legs, you may have appreciated a little swelling of the feet or legs during a flight. So that's an unloading of the central blood volume into the legs. So that's a feature but all people on the aeroplane are getting that. Anxiety is definitely a factor, we know that adrenaline rises in the overture to a faint and anxiety is to do with adrenaline. And unfortunately you're a fainter, you've declared this by doing it several times.
LEE
Well all I'd like to say about that is I have never fainted in any other circumstances. So I'm not exactly a fainter. My feet and legs don't swell and actually I'm not anxious about flying on planes at all.
SUTTON
Well I'm glad to hear that but in order to prevent it, because I don't agree with you you're not a fainter, you need to drink a lot of water and you need to take extra salt.
LEE
Drink water and take salt.
SUTTON
Yes.
MYERS
Do you want to say a bit more about the - why that would help and a little bit more, Richard, at the start of our programme, about the mechanisms of fainting - whether you happen to be on an aeroplane or whether you might be standing in a crowded train or whether you might be walking on the road, what's actually going on when we faint?
SUTTON
Well it's a very complicated body reaction and we haven't really got time to go into it in huge detail. But one of the consistent features is that there's a loss of central blood volume; that is the blood in the heart, lungs and brain. This loss is into the legs so that when the legs are dangling, as we sit or standing, and the other loss is into the abdominal cavity where there are a lot of veins which open up and receive blood. And it's not available for the central circulation.
MYERS
And the faint then is to make sure that we're on a level where the brain can get its supply of blood quickly and therefore its supply of oxygen to bring us round again?
SUTTON
Yes, I mean fainters collapse, this is actually good because when they lie on the ground and they get a transfusion from their legs, which resolves the problem. Sometimes not very quickly but usually so.
MYERS
And this business, just to wrap up with Elizabeth if we may for a moment, of possibility of perhaps compromised air quality, I mean you often feel as though you need air when you feel faint but is that rather psychological, do you need good air?
SUTTON
I think that the air quality is adequate and that this is not the cause but there are respiratory changes which occur before fainting. The tendency is for breathing to get slower and deeper and this can be perceived by the patient who thinks that there is a lack of air.
MYERS
So the answer you've given is more liquid, more water, to keep up the blood volume so that there's more available...
SUTTON
More salt to hold it in the central area.
MYERS
And more salt to hold it into the central area. Thank you very much. Elizabeth we will move on to another caller, thanks for that call from you though. And to Bexhill-on-Sea where Roseanne is worrying about fainting and she is a fainter, self-declared fainter, regular fainter then Roseanne?
ROSEANNE
Yes.
MYERS
In what sort of circumstances?
ROSEANNE
Well the first time I fainted I was a baby, I'm 58 years of age now and I was being nursed on my mother's knee and the leg came off the chair on which she was sitting so she fell and I fell and the next thing was I gave a couple of gasps and went into a faint and the colour drained from my face...
MYERS
This is a family story I guess is it?
ROSEANNE
Pardon?
MYERS
This has become part of the family history?
ROSEANNE
Absolutely and after that if anything upset me, such as if my sisters took a doll from me when I was a little toddler, I would faint. The same thing would happen - I would give a couple of gasps and down I'd go and the colour would drain from my face. And then when I went to school, I went to a convent school, and one of the nuns gave me a slap one time which was common I think in those days and I fainted.
MYERS
Alright, well let's ...
ROSEANNE
None of the nuns ever touched me again.
MYERS
Let's put your point across to our expert today, this is also quite a curious and interesting history and a long one at that, what would you say Richard's going on here and perhaps what advice might you offer to Roseanne?
SUTTON
It does sound like fainting, the classical or common faint. That it began as a baby is unusual but not unheard of. And that it's persisted all your life is also a little unusual. There tends to be a peak around teenage into the 20s and then many decades of being not a fainter, fainting may come back over 60.
ROSEANNE
I see, well it has followed me all my life, as I grew up sort of teenage years, particularly when I used to go to mass, in those days we had to fast from midnight before going to holy communion and ...
SUTTON
So you had a lack of water.
ROSEANNE
And a lack of water, and I would very frequently faint at mass which was quite a long drawn out affair. But I would always regain consciousness, it was always the same symptoms - just become deathly pale, give a gasp and fall down and - but other than that I would say I'm a very healthy person.
MYERS
Have you ever sought any help for this?
ROSEANNE
Not really, my parents and my mother was very concerned at the time initially and had all sorts of tests carried out and everything proved inconclusive and the doctors generally said oh don't worry she'll grow up and she'll grow out of it. But I'm 58 now and the last time I fainted - I'm a blood donor, a regular blood donor and I have frequently fainted after giving blood...
SUTTON
This doesn't surprise me at all, I'm not sure that you should really do this.
ROSEANNE
Well I just give the - they always ask me to stay on the bed a little bit longer after giving blood, it doesn't always happen but ...
MYERS
Okay, let's just try and pick out from that this business about fainting in relation to pain, in relation to blood and in relation to something physiological like, for example, not having eaten or drunk. Richard, are all of those things relevant to different people at different times and why?
SUTTON
People tend to have a pattern of fainting that is reproduced. So for some people it's a smell, for some it's a sight - often blood - for some it's pain and they can overlap. But it tends to be the same sort of pattern in an individual patient.
MYERS
And something like seeing someone in distress - how could that cause you to have a lowered blood pressure all of a sudden, what's the mechanism for that, is it psychological?
SUTTON
Well we talked earlier about the mal-distribution of fluids in the body. Then there are other parts of a faint which we understand a little, that there is a rise in adrenaline which probably is happening in this case. And there's also the vegas nerve, which is one of those pairs of nerves coming from the lower brain which deals with the control systems. And this nerve is connected to lungs, heart, guts and it can change respiratory pattern, it can slow the heart and it can cause acid secretion in the stomach and increased gastric motility. So people vomit after fainting - that's the reason. People gasp or have slow deep breathing - that's the reason. And sometimes in faints the heart even stops.
MYERS
Does that make a faint life threatening in that case?
SUTTON
No, providing the patient isn't kept upright because then the situation that's brought about the faint persists. If the patient is lying down then the transfusion comes from the legs and the vegas nerve appreciates this and it's switched off.
MYERS
So the body really knows what to do.
SUTTON
So this is something that we get, I think, from animals and the playing dead behaviour and we've - many of us have persisted in having this. It's useless, it's a nuisance but if we have it constitutional we have to live with it.
MYERS
Well I think Margaret Dean who calls us now from Exeter is another fainter, constitutionally a fainter, what triggers it for you Margaret?
DEAN
Probably just about everything really - standing up too long, heat - but mostly it seems over the years it's been a combination of heat and words - and words more than anything else, just a description - a very simple description of somebody telling me about an operation and then I'll suddenly be on the floor.
MYERS
So this is being squeamish, to use the lay term?
DEAN
Yes but not in a physical way, I'm perfectly okay when it comes to a physical situation like somebody with a wound or blood pouring from either my own body or from somebody else's body. None of that makes any sense. But I've fainted twice watching fictional hospital programmes, in particular ER, even though I know it's unreal, it's fiction, people are acting out a situation and I've found myself on the floor and slumped in a chair on two occasions. And that is also a question of words plus the visual action as well. But mostly it's words.
MYERS
We always learn something new on this programme, that is very interesting and Richard, you deal with people who faint and you've met many of them, have you met others where a word or a description about something like a hospital treatment can affect them even though if they had the hospital treatment they wouldn't be too bothered?
SUTTON
Well I think that this is the interesting thing to me about your problem, is that you have a vivid imagination and when the words are spoken you imagine things that are perhaps worse than seeing the real thing.
DEAN
Yes, that's possible, yes.
MYERS
And the blood pressure just plummets.
SUTTON
Yeah, then all of those things we've discussed already start happening and it can be very quick.
MYERS
Do you worry about it Margaret, do you need to do anything about it or are you just telling us for interest?
DEAN
I worry about it on several times in several different situations but I doubt if there's anything I can do about it, it's been going on ...
SUTTON
There are some things you can do about it. You could aim to drink three litres - that's six pints - of water a day, you could - assuming that your blood pressure's normal - you could take more salt and when you feel a bit squeamish, such as there's somebody speaking to you about something you don't like the sound of, you could link your fingers and pull apart strongly without letting go.
DEAN
Oh that's interesting, I've never come across that before but generally it's my own fault because I actually provoke the reaction in some ways because I tell people how are you, they say something and they start to tell me and it's my own fault because I feel I should know in advance.
MYERS
Well what's interesting here that even though it's your fault, as you've put it, you can do something about it and Richard, would that be the case for anyone if they feel faint, for whatever trigger, these are some of the things they could do - increase the volume of liquid they take?
SUTTON
Liquid and salt. And reducing the amount of caffeine taken, I mean caffeine is a diuretic and it reduces the central blood volume and this is not a good thing for fainters.
MYERS
Even though people might think the caffeine would perk them up if they're feeling faint?
SUTTON
Yeah it's a small element of that but the diuretic effect I think dominates.
MYERS
And this isometric exercise again to what raise the blood pressure?
SUTTON
This raises the blood pressure a lot, so if you do that well you'll raise the blood pressure 30 points which takes you from a symptomatic level - 70 or 80 systolic blood pressure - to a 110 which is normal.
MYERS
Let's go to Michael Hunter in Manchester who faints at night. Under what sort of circumstances - in bed, out of bed, getting ready for bed?
HUNTER
Yes thanks for hearing me.
MYERS
A pleasure.
HUNTER
I started fainting about two years ago. Now this has only happened about three, four times over the past two years. I'm coming up to being 50 years old and two years ago I got out of bed, I wasn't feeling too well, I walked about two metres and just collapsed in a heap. My wife woke me up and I got up and then started collapsing again. I then got in bed and felt - recovered the next morning. The doctor came round and he told me I had very low blood pressure and he said to me take more salt. So I did - I started to increase the salt. But then it happened again about a year ago, pretty much the same thing, and then again about two months ago, pretty much the same thing.
MYERS
So you're still obviously concerned and - although you appear to have done the right thing in relation to taking salt and so on it's recurring. There's an interesting little tune being played in the background, I don't know if that's one of your family members practising there. But let's see what Richard has to say about this, what would you advise, does Michael need a little bit more investigation would you say?
SUTTON
Well first of all you're known to have low blood pressure, what you perhaps don't know is that when you're asleep your blood pressure's even lower and when you get up your blood pressure doesn't come up sufficiently fast for you to adopt the standing position. And these are all things that are not disease but you can deal with them better. And we've talked about fluid, we've talked about salt - you perhaps don't do enough of either. But when you get up in the night presumably you're going to pass urine and so you get up and you sit on the side of the bed and wait, at least a minute, to give the body a chance to get the blood pressure up a bit. And you could also, if you find you - this isn't enough, you could drink a half a glass of cold water and then wait another minute. And then you'll be much better.
HUNTER
Thanks Richard.
SUTTON
Cold water is very good for raising the blood pressure.
HUNTER
Right. Richard, could you just advise me here - how much salt is it safe to take then when you've got this kind of problem?
SUTTON
Well the media has been very good at telling people to reduce their salt consumption, and rightly, because many of us are at risk for high blood pressure. You are not one of them. So you could even cover your plate for your main dish in salt and you wouldn't be taking enough - you wouldn't be taking too much.
HUNTER
Right so you could do that three times a day?
SUTTON
You could almost do it three times a day and if you go to your GP and check your blood pressure or you buy your own machine and check it you will see when you're taking too much.
MYERS
Michael, good luck with that, thank you very much for raising the question. We'll go to another man - Peter in Shaftesbury in Dorset - who has fainted or fallen over, again what were the circumstances Peter?
PETER
Oh good afternoon, good afternoon Richard. I didn't actually fall over, I was out jogging at about nine o'clock in the morning and stupidly kicked the kerb and went smack down and banged my head. I got myself up and home and went and saw the doctor, luckily got to see him in the early afternoon and he gave me a checking over and said everything was fine. And then in the evening, about half past seven, I was just sitting quietly, which is unusual, listening to the radio, and I began to feel a bit odd - I've never fainted before in my life and it transpired that I just went - fainted completely off, by the time I got into the other room to sit on an easy chair I was going right out - panting for breath and losing consciousness. My wife called the paramedics, who came very quickly, thank goodness and they discovered all my vital signs were about - well getting towards zero, you know, blood pressure, heart rate - everything like that. And my question is: Did the bang on the head, on the front of the head, have anything to do with the subsequent fainting event? They carted me off to hospital and I was cleared, they sent me back home after about six hours waiting, testing, the service was very good. And there was another slight thing - I have had actual fibrillation in the past but I don't really get it much at the moment.
SUTTON
And you didn't have it then?
PETER
No.
SUTTON
No. So probably the bang on the head was a part of it, exactly how the mechanism is I can't explain. But little things that seem little in life can be triggers for fainting.
PETER
I've heard that from the other people, all the things that cause their problems.
SUTTON
You did need to have all those things because you just possibly could have been a bleed round the brain or a bleed in the brain and all that was checked for when you went to the hospital and wasn't found.
PETER
So they x-rayed and goodness knows what else yes.
SUTTON
So hopefully you won't faint again.
PETER
Oh I hope not, I sincerely hope not.
SUTTON
If you've been listening to the rest of the programme you'll have some idea how to avoid it.
PETER
Well it's made me feel a lot better compared to some of the other people I must say.
MYERS
Well thank you, I'm glad we've made you feel better Peter. There was just a mention there, in passing, of atrial fibrillation and I know we have mentioned in our trails and so on that sometimes arrhythmias - heart arrhythmias - can be a cause of fainting and may need treatment if they are. Can you just briefly say something about that Richard and what the connection is?
SUTTON
Well this is a less common cause of fainting, it may have subtle differences in the faint from the things we've been discussing on this programme. But these might not be evident to the sufferer, so if fainting, for example, occurs during the night or during exercise and I really mean actually exercising, then it's likely to be important and needs investigation and this may turn out to show our heart cause.
MYERS
And can I throw in another quick e-mail which is from someone who's interested to know why fainting is made to look romantic, this is Lesley, who says that when she faints she usually feels terrible. Why is it portrayed as being romantic and should you really feel terrible when you do faint?
SUTTON
Feeling terrible is expected because your brain has had too little blood supply, too little oxygen and headaches and fairly unpleasant things can follow. So that's not a surprise. Romantic - I don't think. But of course swoons were common in 19th Century writings and these were probably things that were developed by people who had fainted.
MYERS
Okay, there we were going to have to leave it, as always far more information than we have time to get across. Thanks to all our callers and our e-mailers and I hope we have been able to answer some of your questions. There are more sources of information on our website, you can download this programme as a podcast, you can call our helpline - 0800 044 044.
Join me next week, we'll be taking your questions on late onset Type 2 diabetes.
ENDS
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