Bush not a fall guy for fainting

SUN JOURNAL

Swoon: While comedians are likely to have a field day with the president's tumble, doctors say such spells are common - with or without pretzels.

January 15, 2002|By Frank D. Roylance | Frank D. Roylance,SUN STAFF

In Victorian times, they built furniture for people prone to the unexpected swoon. It was called a fainting couch - usually an upholstered chaise with one arm that allowed the suddenly lightheaded to sit down quickly and put their feet up.

Unfortunately, when President George W. Bush swooned Sunday evening, reportedly while coughing up a wayward pretzel, he had no fainting couch to catch him.

"I hit the deck," Bush told reporters yesterday. "Woke up, and there was Barney and Spot [his dogs] showing a lot of concern."

The fainting episode occurred while Bush was munching alone in a room at the White House, watching the Ravens-Dolphins football game. It cost him a fat lip and a nasty scrape on his left cheekbone. But by all accounts the presidential tumble - while personally embarrassing and certain to be fodder for cartoonists and Saturday Night Live comedians - appears to have been medically benign.

Doctors call it "vasovagal syncope," a quick squall of competing nerve signals between the brain and the cardiovascular system. It ends in a plummeting heart rate and falling blood pressure and, quite frequently, a brief loss of consciousness.

"It is the most common cause of fainting," says Dr. Eric J. Rashba, a cardiac electrophysiologist at the University of Maryland Medical System. "It can happen in people who have no heart disease, no medical conditions at all."

Fainting problems, it turns out, are common enough to warrant their own clinics - called syncope clinics. There are swallowing clinics, too, although they deal more with stroke and tumor victims than with presidents who forget their mother's advice.

"My mother always said, `When you're eating pretzels, chew before you swallow,'" Bush says.

If Bush's airway was ever obstructed by his pretzel, he - or his fall - apparently opened it again. After a prompt exam at the White House, Bush's doctor pronounced him fit.

Vasovagal syncope means a faint (syncope) caused by an interaction of the blood vessels, or vascular system (vaso) and the nervous system - specifically, the vagus nerve, which connects the brain stem with the organs of the chest and abdomen.

It can be triggered by a variety of seemingly innocuous events. Hard coughing, which seems to have been the trigger in Bush's case, is one. Others include pain; fear; intestinal cramps; the sight of blood, or prolonged standing.

The pain of intestinal cramping can trigger the response, says Dr. Fetnat Fouad-Tarazi, head of the Syncope Clinic, at the Cleveland Clinic Foundation in Ohio.

So can straining during urination - sometimes a problem for men with prostate problems. The discomfort of a very full bladder, coupled with the sudden relief of emptying it, especially while standing up can also cause a faint.

Vomiting, too, can touch it off. That was the official cause of the elder President Bush's fainting spell in 1992, after he vomited at a dinner in Japan. The nausea was blamed on a gastrointestinal virus.

But while the triggers vary, the mechanism they loose in the body is always pretty much the same, says Fouad-Tarazi.

Stimulated by the trigger, the brain fires up the sympathetic nervous system, which instructs the heart to pump faster and harder. But then, she says, "the brain recognizes that the heart is overworked. By trying to tone it down, it activates the vagal nerve. The vagal nerve overdoes it, slowing the heart rate and dropping the blood pressure."

The flow of blood to the brain slows to a crawl, and the victim fades into unconsciousness.

Dr. Richard Tubb, the president's physician, examined his patient and concluded that Bush's coughing to dislodge the pretzel in his throat was likely his trigger.

Fouad-Tarazi says that's quite possible, but there may well have been a confluence of factors at work. Bush's physical fitness, ironically, may have predisposed him to vasovagal syncope by increasing the capacity of his veins, she says.

Sitting in front of the television for an extended period may have allowed his blood to pool in the veins of his legs and lower body - the same trigger that can cause soldiers to faint on a parade ground, or passengers to swoon on long airplane flights.

Choking on a pretzel would have added pain and apprehension to the mix, Fouad-Tarazi says, stimulating the president's brain to kick-start his heart and raise his blood pressure through the sympathetic nervous system.

"Coughing increases pressure in the thorax, becoming sort of a barrier," impeding the blood returning from the lower body to the heart, lungs and brain, she says.

Sensing the heavy load on the heart, the brain, through the vagus nerve, hits the brakes.

The heart rate and blood pressure drop, and the brain is starved for oxygen. So the president conks out.

Once a fainting victim is horizontal, of course, the problem is self-correcting, says Dr. William J. Ravich, clinical director of the Swallowing Center at the Johns Hopkins Hospital.

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