On Sunday, September 11, Hillary Clinton was reported to abruptly leave a 9/11 anniversary ceremony. Video shows Clinton being assisted into a van stumbling. It was later reported that she was dehydrated and has a new diagnosis of pneumonia.
In my response area, which includes a lot of churches and geriatric parishioners, we anticipated the diagnosis ‘Sunday syncope’ when we were called out for an “elderly female who fainted during church service.”
With limited information available, my intent isn’t to diagnosis a patient I didn’t assess or treat. Rather, I think Clinton’s case presents an interesting opportunity to review a common call type. As you consider the incident, ask yourself or discuss with your partner, company or squad the following questions about general weakness and syncope:
1. What are the anticipated patient problems?
Enroute to any call, EMS providers should be anticipating potential patient problems based on the dispatch information. If responding to a call for a 68-year-old who reports sudden weakness and possibly witnessed stumbling or fainting, what is on your anticipated problem list and what additional information do you want to have?
A cautious practitioner prioritizes likely problems from most severe or critical to least stable. At the top of my list for general weakness in a geriatric or close to geriatric patient is myocardial infarction or stroke. Midway down the list, I include hypovolemia and hyperglycemia. A simple — if there is such a thing — fainting episode is at the bottom of the list, but I am not sure if fainting can ever be idiopathic.
The anticipated problem list launches the patient assessment process before patient contact is ever made. New providers can use this enroute mental preparation to review associated signs and pertinent negatives, as well as the questions to most quickly reduce the number of anticipated problems to a working diagnosis. Also, make equipment decisions — what you carry to the patient — based on the dispatch information and the anticipated problem list.
2. How do you manage the treatment location?
More often than not, the church service kept going after the patient fainted in the pews. We either arrived to find our patient in the rear of the church or being tended to in the pew as the praying and singing continued around them. Our usual practice was to quickly assist awake patients out of the church and then begin treatment. If the patient is pulseless and/or apneic, treat them where you find them.
It seems reasonable that a dignitary like Clinton would leave the memorial service to receive assessment and treatment in a different location. A presidential nominee, like all patients, deserves privacy and protection from the watchful eye of professional and citizen journalists. Always keep in mind that moving the patient, even partially toward the receiving hospital, is part of the treatment process.
3. What is the patient’s history?
Use the SAMPLE history to narrow the anticipated problem list. A churchgoer often had a recent history of standing up quickly from a sitting position. Be a detective and dig deeper to find out other history that might have contributed to the sudden loss of consciousness.
- Is the patient taking any medications for heart or blood pressure problems?
- What are the patient’s most recent food and fluid consumption?
- Does the patient have recent history of cough, fever, diarrhea or vomiting?
On Sunday evening, Clinton’s pneumonia diagnosis was reported. Fatigue from poor sleep — almost always a complication of pneumonia — persistent coughing and the malaise from being ill is consistent with her reported presentation as she was helped into a van.
Many of my ‘Sunday syncope’ patients, after a series of probing questions, usually had a recent history of not feeling well and had not had their usual breakfast before church. Some ended up having more serious signs and symptoms, like confusion, fever, hypotension and tachypnea leading us towards a diagnosis of sepsis.
What is your experience assessing and treating Sunday syncope? Add your suggestions for assessment and care in the comments.
