When he got up quickly, he sometimes fainted. what was that?

The attending physician, a physician for 45 years, had never seen the obscure problem causing these symptoms.

The 69-year-old rose from his desk at the guardhouse in the lobby of the Veterans Administration Medical Center in Birmingham, Ala. He usually patrolled the entrance to the busy clinic once or twice an hour. This time he took no more than a dozen steps in the humid spring heat before feeling the familiar symptoms he dreaded. His vision blurred. And he was dizzy, but at the same time he could feel his legs shaking like he weighed a lot more than usual. He leaned against the cool brick wall but knew from experience that he wouldn't be standing for long. He pulled out the radio from his belt and called for help.

Within moments he was in a wheelchair, heading for the emergency department. The man was embarrassed by his temporary impotence, even though it had happened many times before. He was supposed to help those who came to the V.A. for their care. Instead, he was the one who needed help.

In the emergency department, the nurse confirmed what he already knew: he was in pain. what is called orthostatic hypotension (OH). When his blood pressure was measured while lying down, it was normal. But he dove when he sat down. And when the nurse helped him up, he fell so low he almost passed out. It had been a problem for several years, on and off, but recently it had gotten much worse. He ended up in the emergency room. half a dozen times in recent months. His doctors advised him to drink more water. He did. And he tried to wear the compression stockings that he was prescribed. It was hard because they were hot, and when he wore shorts he felt ridiculous. He tried to remember to get up slowly. That's the only thing that really helped.

Orthostatic hypotension occurs when insufficient blood gets to the brain due to a change in position. Normally, sitting or standing will signal blood vessels in the legs and lower body to constrict, sending blood to the heart and ultimately to the brain. This change also tells the heart to beat faster to help blood reach the brain faster. Dehydration is a common cause of positional low blood pressure. The blood vessels cannot constrict enough to send blood where it is needed because there is simply not enough fluid in the circulation. Nerve problems can also cause O.H. These are the nerves that tell the heart to beat faster and the vessels to constrict a little more.

When this patient came to the emergency room, he was often given intravenous fluids to try to fill a suspected empty reservoir. It never seemed to help. This made his doctors think that in his case the cause was neurogenic – his nerves were not delivering their essential messages. And for this patient, that seemed like a reasonable explanation, because it was clear that at least some of his nerves weren't working well. He suffered from severe peripheral neuropathy that left his feet almost numb, although they sometimes burned and tingled as if they were sleeping.

ImageCredit...Photo illustration by Ina Jang

Checking your heart rate

It was early morning when Dr Matt Slief , a resident at the end of his first year of training, saw his new patient. The merry silver-haired man described the strange spells he had when he got up that more than once caused him to land on the floor in a faint. "It doesn't last long," he told the young doctor, "but it sure is embarrassing." Slief quickly examined the patient and promised to return later that morning with the rest of the team. After he finished seeing his patients, he rushed to the team room where he was to meet Dr. Robert Centor, the attending physician. Centor was a few years older than the patient, but still worked hard, despite describing himself as semi-retired.