Have you ever woken up under the operating table or in a crumpled heap in a corner of day surgery or spent most of an amniocentesis with your head between your knees? Jessica Whitworth used to...
Fainting was a common occurrence in my student life, and a little informal research leads me to believe that I am not alone in hitting the floor at the most inappropriate times.
The first time was as a first year on one of my seven day long "this is what a patient looks like" attachments. I was invited to watch a pleural tap; I lasted until the venflon pierced an artery, and blood hit the curtain. A kind nurse escorted me, ashen faced, with my blood pressure in my boots, to a nearby chair and cheerily told me that I would get used to it. Two years on, I had not.
The mere thought of watching an operation set my pulse racing--the preoperative anticipatory "fight or flight" response--and then soon after entering theatre by a profound intraoperative bradycardia, the usually final vasovagal event.
The slightly odd thing was that if the patient was under general anaesthetic, I was unperturbed and able to observe every slice and prod of the surgeon's hand. And the dissecting room posed no problems. But if the barbarians chose to use local anaesthetic, and the patient was lying there, commenting on the weather, his rheumatic joints, and the price of bread, while they separated the strap muscles of his neck hunting for an elusive lump, I was out. Especially when the patient flinched as the instruments ventured beyond the anaesthetised field.
I became increasingly anxious about my condition at the beginning of the fourth year. Colleagues, sympathetic nurses, and amused doctors simply told me it would pass. It was getting worse: I could think myself into a vasovagal.
I decided to consult the professionals. I went to student support services and, with great embarrassment, explained the situation to a counsellor. She was very kind, never showed surprise or alarm, did not ask once about my relationship with my parents, and did not make me draw a picture to represent how I felt about the future. She even promised repeatedly that she would not tell the medical school, and she referred me to a psychologist.
I told my woeful tale again. The psychologist was fascinated--especially by the general or local anaesthetic aspect--which was gratifying. He said that we would use some behavioural and cognitive therapy techniques.
Distraction
Distraction is similar to part of the mental state exam, so some of you may not be able to do it. Count serial sevens in reverse order from 100--that is, 100, 93, 86, 79... It sounds silly, but it requires a certain degree of concentration and takes your mind off current events. It helps to get through short moments of stress, but is not ideal when you're trying to understand the operation. This technique is worth trying at the first symptoms of a vasovagal.
Disassociation
Disregarding all attitudes and manners so painstakingly cultivated throughout medical school, such as "this is a person, not a neck lump" and "we treat the whole person, not the illness" can help. Well, if I have to get through the operation to care for the person afterwards, I may have to consider only the lump during the operation.
An example of commentary going through my head is: "Ooh, look, he's sliced open that piece of flesh. Is that subcutaneous fat I see? And look, muscles there now. That must be the sternocleidomastoid and he's dividing the two heads. Who is that person talking about the price of bread? I'll block out that voice completely and concentrate on the procedure at hand. How exciting: a nerve." I attempt to fill my head with "data" so that the dreaded thoughts cannot enter. This is effective.
Rationalise
Being rational: "This person is under anaesthetic and can't feel a thing and we have to do this. It's for his own good. How silly to be upset by it. He can't feel a thing. Really? Not a thing, OK? Nothing?"
Face the beast
Before theatre, I undertake a mental scrub-up: "Here I am going into an operation. Isn't that interesting? I wonder if I'll get those fainting feelings again. It's odd that I do. I think I just won't bother with them today."
I go into theatre, humming to myself, "This is a pleasant way to spend a morning. La la la. I do like it here. I'm so relaxed. Oh look, there is a person on the table. Bet he likes it here too. Everyone is happy and calm. This is no big deal."
The operation commences, "Is that a tingling in my fingers? Oh yes, I always get that before fainting. Surely I am not going to faint? How entirely unnecessary. And now my pulse is slowing. Here we go again. Oh come on, pull yourself together. This is fun, everyone is happy. Go on heart, speed things up..."
The aim is to break the vicious cycle of anxiety about fainting that compounds the problem. I try to convince myself that there is nothing to get worked up about. This is usually pretty effective.
And finally...
You may be a bit embarrassed about seeking help, but believe me, there are plenty of others who do. It is out there: all medical schools should provide some form of student support.
I cannot say that my sessions with the psychologist "cured" me, but they did give me tools for dealing with the problem. They also showed me a different perspective on it and gave me the hope that I don't have to be a victim of these psychological responses that make me faint. I cope a lot better now and it is such a great boost to my confidence when I get through a whole procedure without feeling faint. Don't wallow in your anxiety and embarrassment: seek help.
