Graphic by Margaret Farrell

Not for the Faint of Heart

by Jill McDonnell

You’re a third year medical student watching open-heart surgery. A stream of blood jumps out of the chest and suddenly you feel a tingling sensation in your arms. Your vision is getting blurry. Is it hot in here? Before you know it, a nurse catches you right before you hit the floor.

Syncope, the medical term for fainting, is not an uncommon event in the operating room, yet the topic is hard to explore. According to a survey at the University of Nottingham School of Medicine in England, 12 percent of medical students have had a near or actual operating room syncopal episode. This transient event can have serious physical and emotional consequences. The student may become injured if they fall onto the floor in the wrong position or, at the very least, is often left extremely embarrassed. More importantly, a student may fall into the sterile field on other members of the surgical team, or even the patient.

Contrary to popular belief, students are not the only ones who experience syncope. A survey from Poland finds that 4.7 percent of nurses and doctors have actually fainted and 14.8 percent have experienced pre-syncope, a condition where one becomes light-headed and weak, but never actually faints. Patrick Varley, MD, a surgical resident at UPMC, states that it is not uncommon for an attending or nurse to have symptoms during surgery. Nurse anesthetist Kelly Morreale has seen it mostly in younger female nursing students. She further notes that syncope is more prevalent in the summer months, as that is when the new batches of residents start training.

However, despite the prevalence of syncope, not a lot of research has been done on this topic, and the data that does exist can be inconsistent. For instance, medical students may be embarrassed or ashamed to truthfully report syncope or pre-syncope. Studies must consider the gender of survey participants as well. As it turns out, women in general are more likely to faint in their lifetime, and female students also may be more willing to report their episodes. Varley predicts that the lack of research on this topic comes from its recurring nature, given the fact that “it happens so often that people don’t give much thought to it.” Some students and doctors even consider it a rite of passage.

Recalling my own first experience of observing an operation, I was shocked when I fell victim to syncope. On similar future occasions, I even had to sit down during procedures to avoid it from recurring. While I am rarely squeamish and have a passion for surgery, it made me think whether there are other contributing factors for this phenomenon.

In reality, family history, age, gender, heart conditions and the number of previous fainting episodes can all influence the risk of syncope. Specifically for surgical staff, things like lower body weight, longer and more invasive procedures and decreased food and water intake increase the risk of syncope. Contrary to what people believe, watching surgery on a full belly is the smart choice. An empty stomach may lead to low blood sugar, which in turn exacerbates the risk of fainting. UPMC surgical resident Julie Goswami, MD, notes, “students don’t realize that even if you’re headed to the hospital at 4 a.m., you need to eat a large breakfast.” Dehydration and standing for long periods of time can also cause fainting as the blood pools in the legs, leaving the brain with inadequate blood flow.           

Some surgery-specific factors play a huge role in medical student syncope. Working under the intense lights for hours under multiple layers of scrubs and lead X-ray shields can warm you up quite a bit, which can lead to fainting. Surgical masks can likewise create a sense of suffocation and additionally let in the smells of antiseptics and burned tissue, which can often heighten nausea.

During highly invasive procedures, when students are more likely to see something disturbing, they have a greater risk of experiencing syncope. As an example, gynecological procedures are most likely to cause fainting, followed by colorectal and vascular surgery. This phenomenon is a feature of the vasovagal response. When under extreme emotional stress, such as the sight of blood or exposed tissue, the brainstem withdraws the sympathetic nervous system and enhances the parasympathetic nervous system. This results in a drop in both blood pressure and heart rate, which then leads to reduced blood flow to the brain, causing fainting. Goswami points out that it is not one particular factor that will cause syncope, but rather the total overwhelming experience of momentary shock, bodily stress and potentially unpleasant sights and smells.

Episodes of syncope can greatly influence a student’s choice in specialty as well. The University of Nottingham study reported that 16 percent of students who fainted were driven away from surgery. Some studies also suggest that this may be why fewer surgeons are females. Kim Ferrero, a research scientist in the Department of Surgery at UPMC, explains, “If you know surgery is absolutely what you want to do, you’ll figure out a way around it. It’s a learning curve.”

My personal tips to reduce the risk of syncope include eating a large meal before the procedure and drinking a lot of water the night before. I keep my legs moving, sit down or take breaks if I need to, and I tie my surgical mask loosely to increase oxygen intake. Finding out the length and content of the procedure ahead of time helps me prepare accordingly. If I feel squeamish or light headed, I try to look away for a minute or think of something else. If my symptoms get worse, I make sure to tell someone. Surgical teams see this happen all the time, so they are more than willing to help.

However, none of this should stop a pre-health student from pursuing their career. Varley comments that it is not so much getting used to the experience but learning how to manage it. Morreale thinks the challenge is a mental one: “Once you take control back and calm yourself down, you’ll be fine.” The occurrence of such symptoms and events will eventually stop, so it is up to students to persevere towards their goals.

Have confidence in your abilities, and you will eventually be able to walk into that operating room with confidence and determination.