In Parts 1 and 2 of this series, we covered the science behind vasovagal syncope and how to recognize and prevent it. But let's be honest – even with the best prevention strategies, sometimes patients are going to faint. When that happens, your response in the first few seconds can mean the difference between a minor incident and a serious injury.

I learned this lesson early in my career when I had a student who panicked during a fainting episode. Instead of securing the needle first, they automatically pulled it out of the patient and then tried to hold the slumping patient while still holding the needle – accidentally stabbing them in the shoulder with the same needle. That incident really helped cement how important it was to ensure that all the students and myself were familiar with, and practiced the syncope protocol before beginning live sticks.

We had talked about it, watched a video, and I had done a demo of what to do, but the student still forgot everything we had talked about and the patient got a needle in the shoulder. Luckily, the injury was really minor. The patient was a good sport about it, and joked that at least we could have given them their flu shot if they were going to get stabbed in that part of their arm. They didn’t even realize it had happened until I told them about it (being unconscious when it occurred). It could have led to an exposure, or a more serious injury.

Having a clear, practiced protocol isn't just helpful – it's essential for everyone's safety. After that incident we changed what we were doing, and in addition to the things I mentioned before, we now had all the students practice the syncope protocol a few times. That is still how things are being done at that school, and I know it is immensely helpful for when someone inevitably faints. Muscle memory kicks in, and they are able to automatically react a bit better since they have prepared for this moment.

So, what is this syncope protocol? Here is what I recommend and have implemented in trainings I have provided.

Priority #1: Secure the Needle Immediately

When a patient starts to faint during a blood draw, your first instinct might be to catch them or help them. Don't, not yet at least. Your absolute first priority is dealing with that needle. This isn't negotiable, and here's why: an accidental needle stick injury is potentially far more serious than a bruise from an incomplete blood draw.

In the story above, the patient is lucky that the needle got them in the shoulder instead of the neck or face. And the student is lucky that they didn’t stab themselves or another classmate/instructor (or me) coming over to help. I had to grab the student’s needle hand and hold it in the air. I repeated several times that they needed to safety the needle. The student was in a panic and not thinking straight. The patient was in a phlebotomy chair, and wasn’t going to be injured by falling. We could help them in a moment when it was safe to do so.

The moment you realize your patient is going down:

Stop the draw immediately. Don't try to finish filling that last tube. The blood draw is over.

Activate the needle safety feature or immediately dispose of it in the sharps container. Do this before you do anything else. I don't care if the patient is sliding out of the chair – that needle has to be secured first.

Accept that other things will happen. Yes, the patient might get a hematoma. Yes, blood might get on their clothes or the floor. Yes, the puncture site will need pressure later. All of that is secondary to needle safety.

I've seen too many phlebotomists get caught up in trying to salvage the blood draw or prevent a bruise while there's still an unprotected needle in play. That needle represents a contamination risk and potential injury to everyone involved – you, the patient, and anyone else who might try to help.

Once that needle is secured, then you can focus on the patient. But not a second before.

Getting the Patient Safe and Horizontal

With the needle secured, your next priority is getting the patient into a position where they can recover safely.

If they're in a reclining phlebotomy chair: Put that chair all the way back immediately. This is the ideal scenario because you can get them horizontal quickly without having to move them. I talked about this last week, but I will repeat it again - I think a reclining phlebotomy chair should be available to every phlebotomist, and should replace standard phlebotomy chairs. It makes handling or preventing these situations so much easier.

If they're in a regular chair: You need to make a quick decision about whether you can safely move them. If the patient is conscious but feeling faint, you might be able to help them to a nearby gurney or get them to lie down on the floor. But if they're unconscious or you're not confident you can move them safely without injuring yourself or them, leave them in the chair and work with what you have.

To move a patient who cannot move themselves. If they are small, you may be able to lift them yourself, but typically the safest way to do this is to get at least three people to help lift them. Two people - one on either side of the patient get ahold of an arm, and support their back and head. The third lifts the legs. On the count of three, the patient is lifted gently from the chair to the floor, and the legs are elevated. Again, if the patient is not able to be safely lifted then do not attempt. I know sometimes we may not have coworkers nearby, or available to come running when called, remember, while being horizontal is best, the patient will be okay and still recover even if they stay seated in the chair.

Critical safety point: Do NOT let a patient exhibiting signs of fainting walk anywhere. This is absolutely crucial. If a patient tells you they feel hot, dizzy, nauseous, or "weird," they do not get to walk to the bathroom, walk to get a drink, or walk to a gurney/bed. The moment they stand up, gravity will make it exponentially harder for blood to stay in their brain, and they're much more likely to pass out – potentially hitting their head on the way down. There are many instances of this happening that have led to severe injuries and lawsuits. They need to stay in the chair, or lay down where they are at.

If you can't safely move them to the floor yourself and they're already in a chair, leave them in that chair. If they need to be on a gurney, have someone bring the gurney to them. DON’T LEAVE THEIR SIDE. I've heard too many stories where patients insist "I just need to walk to the bathroom" or "I'll feel better if I can just get some water" only to collapse in the hallway. Don't let politeness or a patient's insistence override your clinical judgment. You can call for help and get some coworkers to help you move them if you think it is feasible to do so, but do not try to lift or move someone who is beyond your capabilities. A back injury to you is much worse than a syncope episode for a patient, or dropping a patient who you find out is too heavy for you.

If you can't get them horizontal immediately: Don't panic. Recovery will take longer – instead of 30-60 seconds, they might be out for a few minutes. The longer someone remains unconscious, the higher the risk they'll lose control of their bladder or bowels, which is obviously something we want to avoid. But sometimes you have to work with the situation you have rather than the situation you want. Elevate their legs, fan them, call their name. As soon as they start to regain consciousness and can follow instructions you can then have them lay down on a gurney/stretcher or the floor.

If they're falling: Sometimes a patient will try to get up even when you insist they stay seated. Sometimes they were totally fine during the draw and seemingly afterwards, but now 10 minutes later they are suddenly woozy. Whatever the situation, don't try to catch a falling patient unless you're confident you can do so without injuring yourself. A trained phlebotomist with a back injury can't help anyone. Sometimes the safest thing is to let them fall, or try to at least prevent them from hitting their head. You may try to slow their fall a little, or clear obstacles from their path and then help them once they're down. Minimize their possibility of injury while still protecting yourself.

Active Prevention During Early Warning Signs

If you catch the warning signs early enough – when the patient is feeling hot, dizzy, or "off" but hasn't lost consciousness yet – there are several techniques that can help prevent progression to full syncope. We call this pre-syncope, or a near-syncope event when it successfully prevents someone from fully fainting.

Muscle tension techniques: Have the patient flex and relax their thigh muscles repeatedly. This helps pump blood back toward the heart and can counteract the blood pooling that's happening in their lower extremities. They can also make circles with their feet or flex their calf muscles – any movement that activates the muscle pump in their legs. This can work really well and keeps blood moving.

Upper body techniques: Ask them to cross their arms and grip their hands tightly while pulling outward, or have them clench their fists repeatedly. These isometric exercises help maintain blood pressure and heart rate during the vasovagal response.

Breathing techniques: Encourage slow, deep breathing rather than shallow, rapid breaths. Some patients instinctively hold their breath when they feel faint, which doesn’t help the situation. Deep breathing helps maintain oxygen levels and can have a calming effect on the nervous system. Don’t let them overdo it though. Some patients do this too hard and end up hyperventilating and making themselves feel dizzy and tingly instead of feeling better.

Coughing: If the patient feels like they're about to faint, having them cough several times can help raise blood pressure temporarily through increased intrathoracic pressure.

Position modifications: If they're already seated, have them lean forward and put their head between their knees if possible - be sure to stand in front of them so that they don’t fall forward. If available, lean them back in a reclining chair immediately. Don't let them stand up or walk anywhere.

What will work best is getting them horizontal. If your facility allows it, and you can safely do it (and no gurney is available), instruct the patient to move from the chair to the floor. They shouldn’t stand up, it’s more of a scoot-out-of-the-chair-and-lay-down motion. Have them lay on their back, and put their feet up in the chair they were sitting in, or another chair in the room. All the muscles they use to maneuver to the floor will help keep blood moving, and once they get horizontal and put their feet up they will immediately begin to feel better.

“Okay, but the floor is gross and no one is going to want to lay down on it.” I already knew you were going to say that. I totally understand, but, as long as your patient isn’t licking the floor they should be okay. Staying upright can be worse than temporary floor contact. Floors are gross, but hopefully they get cleaned regularly. If you have ever passed out before you know that it can feel like you are dying. The symptoms start to come on, and it feels terrible. Most people who are starting to faint will not care about laying on the floor. Laying down on their back will really quickly reverse what is happening and make them feel better. It will be 5-10 minutes on the floor where they feel better fast, vs 30 minutes to an hour of miserable recovery and feeling “off” the rest of the day if they stay in the chair.

I once saw a woman crawl into a public hospital bathroom and lay down on the tile. I went over to her and tried to help her up, but she didn’t want to lift her face off of the cool tile of the damp public restroom floor. She had been stuck by another phlebotomist, and was feeling nauseous, and the other phlebotomist had let her get up to go to the bathroom. It was only about 15 feet away from her station. The patient made it 10 or so feet, and then crawled the last 5. She’s lucky she didn’t pass out and smash her face on that tile. My point is, sometimes people don’t care about the germs when the symptoms of fainting can be so strong.

You know what is the best solution to prevent someone from laying down on the floor though? A reclining chair. It solves most of these problems. Plus, if the patient is not capable of laying down on the floor due to age, or disability, or serious illness, this is a much better and safer alternative anyway. The floor works great if it’s your best option and safe to use. But really, I wish everyone would just get the reclining chairs.

These techniques work best in the early stages of a vasovagal response. Once someone has progressed to the point where they're losing consciousness, focus shifts to getting them horizontal and letting their body recover naturally. But catching it early and using these active interventions can sometimes prevent the fainting episode altogether.

The key is recognizing those warning signs we discussed in Part 2 and acting quickly. Don't wait to see if they'll "snap out of it" on their own – intervene as soon as you notice the first signs of trouble. In my experience, once the symptoms start, they are not going to go away until the patient lays down, or quite a bit of time passes. When people have refused to lay down, either they change their mind when things start to get worse, or they pass out and then we move them (if we can). If they manage to stay conscious, it is a really slow recovery. Like I said above, it’s typically 30 minutes to 1 hour (and sometimes more) of them feeling sweaty, nauseous, dizzy, weak, shaky, and overall just terrible until their body starts to recover.

The Recovery Position and Protocol

Once you have the patient in the best position possible:

Elevate their legs above their heart. This is called the Trendelenburg position, and it's your best friend in this situation. If they're on a reclining chair, raise the foot of the chair. If they're on the floor, prop their legs up on a chair or have someone hold them up. Gravity helps get blood flowing back to the brain, which is exactly what we need. If they can’t move out of the phlebotomy chair then at least prop their legs up on another chair (though that won’t help a whole lot with their head elevated above their heart).

Don't try to wake them up. Aggressively that is. You can gently pat their arm or shoulder, and call their name. No shaking them, no loud voices, no smelling salts. Their body is doing exactly what it needs to do. Most people will regain consciousness within a few seconds, though sometimes it may take a minute or two depending on the situation. Yelling or aggressive shaking will terrify them as they start to come-to. Wake them up nicely, and don’t scare them.

Muscle contractions. Convulsive syncope is normal. This is not a seizure, and is actually very common when someone faints. Don't try to stop or restrain these movements unless the patient is in danger of hurting themselves by hitting something. A patient who has actually had a seizure will have a postictal stage afterwards where they are confused, profusely sweat, are lethargic, etc. Convulsive syncope will not have any of those symptoms (except some sweating). Once they wake up they will know where they are and will not be confused. Educate family or friends who may have witnessed the event so that they know that they didn’t witness a seizure.

These jerky muscle movements can look really scary to people, but are not a big deal at all. Most of the fainting episodes I have seen over the years have included convulsions. These muscle contractions are due to the brain reacting to the lack of oxygen. The muscle movement can actually help increase blood circulation, which is a good thing. When this happens, just make sure the patient isn’t hitting anything that will hurt them. The movements are not usually extreme, but sometimes an arm or leg will jerk more dramatically than expected.

Keep them lying down for 5-10 minutes minimum. I know they're going to want to sit up right away because they're embarrassed, but this is not negotiable. They need time for their blood pressure to stabilize. Their body just went through a significant physiological event, and it needs time to recover. Don’t rush it.

The Gradual Recovery Process

After the patient has been horizontal for a minimum of 5-10 minutes and seems alert:

Help them sit up slowly. I usually have them just sit on the floor where they are at, but they can move back to the chair too if that is more comfortable. Don't let them pop up quickly. Sudden position changes can trigger another episode.

Watch their face like a hawk. If they start losing color again or say they feel dizzy, get them back down immediately. This is a critical moment – many patients will have a second episode during this transition if we rush it. The patient will say they feel better after just a couple of minutes when the blood has returned to their brain, but the physical cascade that has begun takes more time to stop and reverse itself.

The food and drink test. Once they've been sitting up for a few minutes (another 5-10), and they don’t have any nausea, and their color looks good, offer them something to eat and drink. Something with a little sugar and salt is ideal – juice and crackers work well. But never give food or fluids while they're still lying down. Choking and aspiration are real risks when someone's consciousness isn't 100% stable, and it’s hard to eat or drink when laying flat.

The walking test. Before you let them leave, have them walk around a bit. Start with just standing for a minute, then a few steps, then more. If they're going to faint again, better it happens while you're there to help than when they're driving home.

The whole process should take at least 30 minutes. Don't let anyone rush this. I've seen people who seemed fine after 10 minutes suddenly get pale and wobbly again when they tried to leave too quickly. Many places have a policy in place that a patient must remain at the facility for at least a half hour to be monitored after a near-syncope, or full syncope event. They should feel completely fine and back to normal before being allowed to leave.

If you were not able to move them to a horizontal position then plan on their recovery taking much longer than 30 minutes. It may take at least 30 minutes before their symptoms begin to go away, whereas when they lay down they will begin to feel better almost immediately. They may throw up, and they may come in and out of consciousness along with all the other symptoms that go along with fainting. It’s a lot harder on the body to stay upright when dealing with a syncopal episode. They will likely need much longer to recover, and will feel much worse throughout the process. At the very least, if no gurney or stretcher is available, and they cannot lay down, get a wheelchair and wheel them to an exam table to lay on. Be vigilant for them to lose consciousness at any point or multiple times while being moved, especially if they try to stand to get on the table. This process can be riskier than the alternatives we have talked about.

At home recovery. Once they get home, they need to eat a well balanced meal (carbs and protein), and be sure to drink lots of fluids to help refuel their body. A lot of energy and stores get used up when someone goes through this process.

When to Call for Help

Most vasovagal episodes resolve quickly and completely with proper positioning. But there are times when you need backup:

If the person doesn't regain consciousness within 2-3 minutes of being horizontal, call for additional help. This might not be simple vasovagal syncope. Typically people wake up in less than a minute once horizontal.

If they seem confused or disoriented for more than a few moments after waking up, this could indicate a postictal state, which suggests they may have had a seizure rather than simple fainting.

If they have another episode after recovering from the first one, especially if you're following proper protocol. Something may not be right, and they might need further evaluation (blood pressure issues, heart problems, etc.)

If they have any injuries from falling – head injuries in particular need immediate attention. Even if the patient insists they are fine, you should call someone to evaluate them and ensure they are okay. The incident and injuries need to be documented.

If you're not sure whether what you witnessed was fainting or something more serious. When in doubt, get help. It's always better to call for assistance and not need it than to need help and not call for it.

Trust your instincts. If something doesn't feel right about the situation, don't hesitate to call for backup.

Understanding Institutional Protocols

Some healthcare facilities have protocols that require calling rapid response teams or codes for any loss of consciousness, including vasovagal syncope during blood draws. While these policies are often well-intentioned and designed to ensure patient safety, it's worth understanding that simple vasovagal syncope is typically a benign, self-resolving condition that responds well to basic positioning and supportive care.

If your facility has such protocols, follow them – but also use your clinical judgment to provide appropriate information when calling for help. Be clear about what you witnessed: "Patient experienced vasovagal syncope during blood draw, now conscious and responsive in recumbent position" gives a much different clinical picture than simply "patient lost consciousness."

Understanding the difference between vasovagal syncope and other causes of loss of consciousness helps you communicate effectively with response teams and ensures patients receive appropriate care without unnecessary interventions. Document thoroughly so that patterns can be identified and policies can be refined based on actual clinical outcomes.

The goal is always optimal patient care – sometimes that means calling for additional help, and sometimes that means providing appropriate basic care and monitoring until the patient recovers naturally.

Common Myths About Recovery

Let me clear up some misconceptions that can actually make things worse:

Myth: You should try to wake them up quickly. Wrong. Let their body recover naturally. Shaking them or shouting at them doesn't help and might actually stress their system more.

Myth: Smelling salts are helpful. They're not, and they can actually be dangerous. Smelling salts can trigger asthma attacks in susceptible patients, and since patients don't typically breathe deeply when they're unconscious, the salts often don't work as intended anyway. Additionally, smelling salts can cause a sudden head movement or startle response when the patient does regain consciousness, potentially causing injury. They can create a bigger problem than the simple fainting episode you're trying to treat. They should not be used.

Myth: They'll be fine as soon as they wake up. Not true. The recovery process takes time, and rushing it often leads to second episodes.

Myth: If they say they feel fine, they can leave. Patients often feel embarrassed and want to minimize what happened. Taking recovery in steps ending with the walking test is non-negotiable.

Myth: Only weak or anxious people faint. As we discussed in earlier parts, vasovagal syncope is pure physiology and can happen to anyone.

Documenting and Follow-Up

After any fainting episode:

Document everything. Record what happened, how long they were unconscious, their recovery process, and any interventions you performed. This protects both you and the patient.

Inform your supervisor. They need to know about any incidents, especially if the patient was injured or if you had to call for additional help.

Encourage the patient to inform their healthcare provider. While vasovagal syncope during blood draws is usually harmless, their doctor should know it happened, especially if it's a new occurrence.

Use it as a learning experience. What warning signs did you miss? What would you do differently next time? Each episode teaches us something about recognition and prevention.

The Emotional Side

Don't underestimate the emotional impact of fainting episodes – both on patients and on you.

For patients: They're often embarrassed, scared, or frustrated. Reassure them that this is common and that they handled it well. Don't make jokes about it or minimize their experience. A little compassion goes a long way.

For you: Especially when you're new, dealing with a fainting patient can be stressful. That's normal. Talk to experienced colleagues about what happened and what you learned. These experiences build your confidence and competence over time.

The Bigger Picture

Remember, every experienced phlebotomist has stories about patients fainting – it's just part of the job. What separates good phlebotomists from great ones is how calmly and professionally they handle these situations.

Your response to a vasovagal episode says a lot about your professionalism and competence. Patients and colleagues notice how you handle emergencies, and handling them well builds trust and respect.

Most importantly, remember that while vasovagal syncope looks dramatic, it's usually harmless when managed properly. With the right knowledge and a clear protocol, what could be a medical emergency becomes just another aspect of professional patient care.

I once witnessed a man pass out with convulsions during syncope. The student drawing his blood didn't panic, and she, another student, and I quickly moved this volunteer to the floor while he was unconscious. It happened so fast - he was out before we could react. I was standing there watching her draw when she had only collected about one tube of blood before his eyes rolled back and he began convulsing. She immediately stopped the draw, and we moved him to the floor. Once down, the muscle spasms stopped, but he remained unconscious for several more seconds.

During those moments, his wife—who had been talking to someone else in the classroom—turned around to see his pale face and open, staring eyes. He wasn't moving or speaking, just lying on the floor with us gathered around him. She somehow drew the immediate conclusion that he had died.

She screamed (very loudly), and yelled, "He's dead!" Running over to him, she screamed again that "My husband is dead!" I frantically tried to tell her he was fine and had just fainted, but she couldn't hear me. She pushed me aside, completely inconsolable, dropped to her knees beside him, still shrieking, put her hands on his chest, and started sobbing.

That's when he woke up, looked at her, and said… "What the damn hell is wrong with you, woman?" He had only been unconscious for about 20 seconds, but it felt much longer to all of us. I couldn’t help but laugh as he acted like she was the most dramatic person (I got a sense that that may have been the case). She sputtered, in relief, trying to explain why she was crying.

He was the grandfather of the student practicing on him. A farmer in denim with a big belt buckle, cowboy hat, sun-weathered skin, and a Southern accent. He had been married to his wife for about 40 years. When we told him he had fainted during the blood draw, he casually said, "Oh, I always pass out when I get my blood drawn." His granddaughter was gob smacked. His wife - who knew about his fainting history but had forgotten - was traumatized and embarrassed. Meanwhile, I was trying to calm a classroom of terrified students and their patients, and other random people who had been in the hallway who had come running when they heard the screaming.

The student then informed me that she had specifically asked if he was okay with the blood draw and if he'd ever had issues. He told us he thought it would be "good practice" for her to deal with him fainting - as a fun surprise.

The first part was very typical; the student handled it professionally. If his wife hadn't lost her mind, it would have been a textbook syncope response. I laughed about it all later that night, but managing the immediate chaos was absolutely wild. His wife apologized, explaining she knew he sometimes fainted but had forgotten and panicked because, well, she thought he looked dead.

Even with the chaos, the first part where we ended the draw and moved him to the floor went very smoothly. We practiced this with our students by putting them in groups and having them take turns moving someone to the floor in groups of three (someone easy to lift). It really helped cement that knowledge in their brain, a lot more than just watching me demo it, or watching a video on it. I have seen several times where a student has taken initiative and grabbed classmates to move someone to the floor before I can even get to them. It makes the whole classroom safer. When I do lectures or trainings for medical facilities we practice this too.

Your Action Plan

Here's your quick reference protocol for the next time it happens:

1. Secure the needle first – activate safety or dispose immediately
2. Get patient horizontal if possible – reclining chair, gurney, or floor
3. Elevate legs above heart level
4. Wait patiently – don't try to aggressively wake them (should wake within a minute or two)
5. Keep them laying down 5-10 minutes after they're conscious
6. Sit up slowly and watch for color changes, another 5-10 minutes
7. Food and drink once sitting is stable and no nausea is present
8. Walking test before discharge, wait another 10 minutes (about 30 minutes total) before letting them leave. They must feel totally recovered
9. Document everything
10. Call for help when in doubt

The key to handling vasovagal syncope isn't about being fearless – it's about being prepared. When you know what to expect and have a clear plan, you can respond confidently and keep everyone safe.

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What has been your experience with managing fainting episodes? Have you found any particular techniques especially helpful for patient recovery or your own confidence in these situations?

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