Hillary Clinton left early from the 9/11 commemoration in New York as she felt “overheated.”  This video of her leaving the event shows Mrs. Clinton leaning against a concrete post and then her legs appear to buckle under her as she is helped into the car.

 

 

What happened?

The medical term for fainting is syncope. Syncope is the temporary loss of consciousness and posture and due to a temporary insufficient flow of blood (and hence oxygen) to the brain. If the feeling of faintness and light-headedness and weakness comes but there is no loss of consciousness the event is called near syncope.

The video above shows what appears to be near syncope or an “amost faint.” Unless one was with Mrs. Clinton in the van one could not say if she fainted. As a doctor I see near syncope and syncope routinely as it happens during and after procedures. With near syncope it is pretty easy to intervene, as Mrs. Clinton’s team did, and prevent the faint.

Why do people faint or almost faint?

The lack of blood flow to the brain that triggers fainting can be caused be a wide variety of thing, from anxiety or eating a massive meal all the way to very serious heart problems.

Her’s a pretty definitive list from a nice review article:screen-shot-2016-09-11-at-9-43-08-am

The CliffsNotes of the above is that fainting is either due to the nervous system, blood volume, or the heart. Neurally or nervous system-mediated syncope happens when the autonomic nervous system gets twitchy and messes up vascular tone or heart rate causing blood to pool in the legs. It’s a reflex gone awry. The nervous system has all kinds of reflexes to control heart rate and blood pressure that are constantly fine tuning the vascular system behind the scenes and sometimes the signals get messed up. This is the most common cause of fainting for someone of Clinton’s age.

Orthostatic hypotension is another common cause of syncope and it is basically the opposite of neurally-mediated syncope because it is a sign of sluggish or impaired autonomic reflexes. This can happen when there isn’t enough volume in the system (dehydration) or it can be due to medications or medications (diuretics, anti-hypertensive therapy), especially when superimposed upon the natiral aging-related changes in autonomic reflexes.

Cardiac problems can also lead to fainting, for example and irregular rhythm or a structural cause.

What does this mean for Mrs. Clinton’s health?

Mrs. Clinton is under the care of a physician and had a thorough work up when she fainted in 2012 and a documented annual exam in 2015 so we can exclude every heart condition as a cause.

Using the San Francisco Syncope Rule Mrs. Clinton is likely at low risk from this event:

Screen Shot 2016-09-11 at 10.19.57 AM.png (please note the line at the bottom indicating the vast majority of syncope is benign).

I chose “no” for shortness of breath as I am pretty confident that if Mrs. Clinton did have shortness of breath she would have been taken to a hospital. What was her blood pressure? Heard to know, but as she recovered quickly it was not likely below 90 mmHg.

We can exclude congestive heart failure and a low hemocorit (low blood count) based on her doctor’s letter in 2015:

Screen Shot 2016-09-11 at 10.30.22 AM.png

A witnessed almost-syncope or syncopal event provides a lot of information because we know what was happening at the time. She was standing in the heat in a suit. If she was wearing Kevlar that would have obviously contributed to the heat. Based on what was happening at the time and her medical history Mrs. Clinton’s near-syncopal event is almost certainly the result of prolonged standing in one position and heat and possibly dehydration and not due to some secret sinister illness.

Fainting is scary and dramatic, but it’s often “nothing.” Really. 

Even when patients faint at home and are brought in by ambulance and no one can tell you what happened 20-50% of the time no cause for the fainting is found.

In this witnessed situation with an unconcerning medical history with a prompt recovery there is no medical cause to sound an alarm.

This quote from a review article in American Family Physician sums it up nicely:

Patients at low risk of adverse events (i.e., those with symptoms consistent with vasovagal or orthostatic syncope, no history of heart disease, no family history of sudden cardiac death, normal electrocardiographic findings, unremarkable examination, and younger patients) may be safely followed without further intervention or treatment.

Think about the last time you knelt for too long then stood up quickly and felt woozy and had to grab something. That was near-syncope. It happened because the blood pooled in your legs and then when you stood up quickly for some reason it didn’t get back to your heart fast enough and your brain was temporaily short changed. It doesn’t mean you are on death’s door it means you knelt for too long and stood up too quickly.

In reality the most common serious consequence of syncope and near-syncope is injury from a fall due to loss of consciousness. This happened to Mrs. Clinton back in 2012.

If Hillary Clinton is a “fainter” then so is George H.W. Bush. 

George H.W. Bush vomited and fainted at a State dinner in 1992. He felt warm (experienced near-syncope like Clinton did). He thought he would be okay, but he fainted. It happens.

The risk of fainting increases with age for both men and women, but lots of young poeple faint in the heat (for example models at the Yeezy 4 fashion show).  Over 20% of people older than 75 will experience syncope and the annual incidence is about 2% for people who are 80 years or older. If Presidents are going to be over the age of 75 then some of them might faint. If Presidents are going to get the stomach flu then some will faint. Hey, if presidents are going to be people some will faint.

Could Mrs. Clinton wear short sleeves to events that are hot? That’s what I do. I would be worried about fainting in a suit outside on a warm day, but I apprecaite if Mrs. Clinton might be hesitant to do this given how Michelle Obama has been critisized repeatedly for wearing sleevesless dresses.

The biggest medical concerns with fainting are the following:

1) Is there some concerning underlying medical cause. In this situation for Mrs. Clinton the answer is no.

2) Was there a need for medical resuccitation? No, she recovered very quickly with supportive care.

3) Was there an injury? No.

Mrs. Clinton felt faint. It was dealt with appropriately. It looked dramatic, but it’s ok.

And so is she.

 

 

***

Update: 1:36 pm 9/11/16

Post updated to correct the typo in President Bush’s name.

Comments with insults won’t be approved.

 

***

 

Update 9/12/16

 

A lot of people are having trouble with the no insults requirement so comments are now closed.

 

 

 

 

 

41 replies on “Hillary Clinton almost fainted. I’m a doctor. It’s really o.k.”

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  4. I respectfully disagree with your opinion. You fail to mention that HRC is on Coumadin, has a history of blood clots, head injury, and multiple falls and syncope episodes. The report by her physician is a fairy tale- it is quite obvious to see she is not an overtly healthy woman. To me it appeared as if she had a neurological incident, perhaps a TIA. It was a comfortable 78 degrees, and she was not diaphoretic. This sudden pneumonia diagnosis does not fit the narrative, and at what point did she seek medical care and have labs and X-rays when her schedule was full on Friday? If this were an isolated incident it would be possible to brush it off, but the big picture indicates something worrisome.

    1. She is on anticoagulants and so a TIA would be very unlikely.
      Several of her staff was ill with a respiratory illness.
      She may have been diagnosed clinically based on the people she was exposed to. She has a good doctor so I am confident the two of them will manage her health just fine.

  5. Pneumonia still a coverup. According to her own traveling press pool, Clinton did not go to any facility for a chest X-ray. An X-ray is the only way to definitively diagnose pneumonia. I am a Registered Nurse with 20 years experience. Clinton needs to step down from ticket. She is not fit or healthy enough to serve as the leader of our country.

    1. Many people are treated for pneumonia without a chest x-ray. As a nurse you should really know that. As a nurse you should also know that neither near-syncope or pneumonia don’t disqualify you from much beyond taking it easy for a few days.

      1. A cough with crackles on auscultation +/- fever is enough to start treatment for pneumonia, but it really should be confirmed with a CXR, especially in an elderly patient. And really especially in an elderly patient running for president of the United States.

        I have no dog in this fight, so the politics mean literally nothing to me. But I unfortunately have to admit that the pneumonia and syncope diagnoses feel forced.

      2. Absolutely it should be confirmed on chest x-ray. However, since we don’t know her schedule we don’t really know what she has or hasn’t had. We do know that several of her staff members have been ill and one was hospitalized so obviously her physician has more information than we do.

        I think it may seemed forced because of the bias that much of the media uses to look at Clinton and the fact that we do not have all of her health information because we are not her doctors.

        The point of this post is that there is no evidence of anything sinister going on and by that I mean something that prevents someone from being President and that people feel faint and not everyone who feels faint needs to go to the emergency department.

        I do have a stake in this. I am tired of systemic misogyny.

  8. Pingback: ‘It looked dramatic, but it’s ok’: Doctor rips ‘misogynist’ media coverage of Clinton’s near-faint - Transnational Television

  9. Doctor, will you be doing a write-up regarding the seriousness or non-seriousness of pneumonia along with fainting and serious coughing?

    In particular I’d be curious about whether pneumonia is more serious in a 69 year old as opposed to someone in their 20’s or 30’s or 40’s.

    Also, how contagious is pneumonia? Should the patient be going to public events and shaking hands, coughing a lot on a crowded plane, or touching and breathing next to children (I saw her do this in the “I feel great” video). As I understand it, it’s more serious than the cold or flu and relatively rare.

    Please Doc give us more info!

    1. Oh, and what causes pneumonia? Is it a weakened immune system, lack of rest, and old age, plus I assume someone sick with it coughed on her or shook her hand?

      I read an earlier quote today from Rep. Crowley saying that Hillary appeared well and gave him a big hug and a kiss. Should Crowley be concerned for his health and go to a doctor? Does it transmit by kisses and hugs and breathing close together?

      I need to know more.

      1. Pneumonia is a complication from respiratory illness, it’s not a disease in and of itself. You can get it from strep or other bacteria, viruses, etc. which present as a common cold or flu. There are certain bacteria which are particularly associated with the condition but you don’t “transmit pneumonia” – this isn’t TB or something, jesus.

  10. Of course it is! It was the heat. Wait, it’s only 79 degrees. It was too much of her antihistamines. Wait! That won’t work. It was Pneumonia! Yeah…. that’s the ticket! Lies… And the liberal media, especially CNN will play along.

  11. Hillary was diagnosed with pneumonia on Friday. That’s why she’s been coughing and now fainted. The campaign tried to keep it secret and mislead people like you into thinking “nothing is wrong.” Dishonest if you ask me. Not your fault though Doctor, as they tricked you.

  12. No, as a physician you just gave a diagnosis. And by pushing this diagnosis, and proclaiming to be a physician at the same time, you’re pushing an agenda.

    It’s very clear, by most trained professionals, that she didn’t “faint” or suffer a syncopal episode. Awhile later she came out of her daughter’s apartment and seemed very off. She’s slow, unsteady, and trying very hard to remain upright.

    My guess is she has some sort of neurological deficit. And no, it’s not “O.K.”.

    1. Doctors can’t make informed opinions without it being a diagnosis? What IS this world coming to?

    2. She did not make a diagnosis and plainly stated so in her article. With that said, HRC did not seem unsteady and unhealthy leaving Chelsea’s apartment. She was walking upright, smiling and waiving. She even stopped to talk for a minute. I guess you watched entirely different video footage than I.

  13. How can you say she is probably low risk when you have none of the objective data to fill the deciaion making tool? If a 70 yold had “a spell” like this in the ER you better believe shed get admitted for obs and further workup.

  14. You know as well as I do that’s not an episode of vasovagal syncope. She didn’t stand up and collapse. She could hardly walk and is leaning against a post for minutes. She had deficits. This could possibly be a TIA.

    1. Since I don’t know you I don’t know what you know or don’t know.
      She’d on coumadin so a TIA is really unlikely.
      When people faint they lose consciousness so of course they can’t walk and when they almost faint they have trouble walking.

  15. But the thing that makes it newsworthy is simply because it WAS caught on camera. So it stokes the flame of this “non-issue.” In that, it’s a PR nightmare. But will it really make a difference? I can’t see too many people sitting on the fence at this point. And perhaps a fainting Hillary could actually HELP her standing. Pity is a powerful thing. Similarly, has any American media pointed out that FDR had a more serious health issue and was still strong enough to serve?

  17. Our former President is named George H.W. Bush. If you weren’t so obviously partisan, you would not have gotten his name wrong, twice. I also am a doctor, and while near syncope can be “nothing”, as you stated, it can also signify serious medical issues, especially when recurrent. I’m not saying that it IS something serious, since I don’t know her entire medical history or the details of today’s incident. But neither do you, so you should probably also not speculate that “it’s really ok.”

    1. Hillary is a human being, under extreme pressure whether that human being is male or female. It is perfectly human to feel faint, if there are no underlying medical conditions, as there have been shown NOT to have been. The pressure she is under is inhuman, given the inhuman opponent she is facing, over and above the normal stress of a presidential race. If doctors say it is ok, then it is ok. Please do not let the bullying opponent stir the pot on this one. He is just beyond words–I have no words for his bullying racism and his downright meanness. Support Hillary for the person she is, with whatever foibles she may have. There IS no other choice..

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