No doubt about it, Hillary Clinton’s fainting episode in NYC today is big, big news. It was not that hot in the city today. The Washington Post‘s Chris Cillizza, who last week dismissed talk that her Labor Day coughing fit meant anything, nails why:

Coughing, I wrote, is simply not evidence enough of any sort of major illness that Clinton is assumed to be hiding. Neither, of course, is feeling “overheated.” But those two things happening within six days of each other to a candidate who is 68 years old makes talk of Clinton’s health no longer just the stuff of conspiracy theorists.

Whereas Clinton and her campaign could laugh off questions about her health before today, the “overheating” episode makes it almost impossible for them to do so. Not only has it come at a time when there was growing chatter — with very little evidence — that her health was a problem but it also happened at a 9/11 memorial event — an incredibly high-profile moment with lots and lots of cameras and reporters around.

Her campaign may well try to dismiss this story as nothing more than an isolated incident, meaning nothing. (Democrats were already pushing the story of George W. Bush fainting in 2002 after choking on a pretzel, via Twitter.)

But the issue is that Clinton kept reporters totally in the dark for 90 minutes after her abrupt departure from the 9/11 memorial service for a health-related matter. No reporter was allowed to follow her. (Clinton has resisted a protective pool for coverage because Donald Trump refuses to participate in one.) This is, yet again, the Clinton campaign asking everyone to just trust it. She got overheated! But she’s fine now!

Trust a Clinton? That’s a big ask under normal circumstances, and these are not normal circumstances. Look, I feel sorry for both candidates. They’re old people, and the campaign schedule they follow is grueling. It would be hard on anybody. But the presidency is also grueling, and now there is reason to wonder if Clinton is up to it.

Donald Trump got a lot out of referring to Jeb Bush as “low energy.” Just you wait now.

See it happen here:

UPDATE: Noah172 posts this fascinating close-up video showing a small metal object falling out of Mrs. Clinton’s pants leg as she staggers getting into the van. Doctors, is this a thing?:

UPDATE.2: Scott Adams:

If humans were rational creatures, the time and place of Clinton’s “overheating” wouldn’t matter at all. But when it comes to American psychology, there is no more powerful symbol of terrorism and fear than 9-11 . When a would-be Commander-in-Chief withers – literally – in front of our most emotional reminder of an attack on the homeland, we feel unsafe. And safety is our first priority.

Hillary Clinton just became unelectable.

The mainstream media might not interpret today’s events as a big deal. After all, it was only a little episode of overheating. And they will continue covering the play-by-play action until election day. But unless Trump actually does shoot someone on 5th Avenue, he’s running unopposed.

UPDATE.3: From a physician:

I am in internist in a large metro area.

It is my job to make diagnoses often with just my eyes and nose and ears alone – this is especially true in the geriatric community.

It is with great consternation that I have seen and read physician evaluations of Mrs. Clinton in the news media. You should never make diagnoses like that without having the patient right in front of you.

Furthermore – some of the videos that have been put forward to support these claims have just been looney-tunes.

All that being said – I am deeply concerned about this video.

Mrs. Clinton clearly suffered a syncopal episode while getting into that van today. The “overheating” excuse is just ridiculous – a normal healthy individual would never do that type of thing in 80 degree weather unless they had just completed a marathon or something profoundly strenuous. That just does not occur. That immediately puts the lie to the “overheated” excuse that her campaign came up with.

Well you say – could it have been a fainting spell? Possible – but in my 30 years experience as a physician, “fainting spells” or vasovagal episodes do not usually require 4 or 5 people to throw someone in a van. Furthermore – in that type of event the person almost always slinks straight down or backwards – NOT FORWARDS. Mrs. Clinton very clearly is going forward.

I see the metal object in that video – I haven’t a clue what that could be – nothing in my experience as a physician looks quite like that – could it have been an inkpen? Regardless – the far far more telling issue that you can clearly see in that video around the time the metal is dropped is Mrs. Clinton’s right foot. It was clearly being dragged along the street with the anterior portion down on the concrete. I am certain this is how the shoe came off. The comportment of this foot could only mean one thing – her brain or her spinal cord was offline – if ever so fleeting – during that moment. Her right foot was acutely flaccid. There are but a few things that can cause this type of issue:

BRAIN or Spinal Cord TRAUMA – no way this happened

An overdose of powerful sedatives or general anesthesia – again – this seems to not be the case

A seizure – not likely – this type of thing usually occurs in the post-ictal phase after a tonic-clonic seizure – and people who are having this type of thing – DO NOT WALK TO A VAN.

A Stroke or TIA – It is possible but not likely – given her interview on the street just an hour later. It would have had to have been a very very fast TIA or transient ischemic attack to recover this quickly – the recovery on this is usually hours or days.

The most likely diagnosis – in my mind – an acute cardiac arrhythmia – either ventricular tachycardia – or more likely atrial fibrillation with a rapid ventricular response. A FIB with RVR is very very commonly associated with people feeling flushed or overheated – for quite extended periods of time – dizziness and nausea are also possible. When they exert themselves – it is not unusual at all for them to have complete syncope like she appeared to do today. If not afib with RVR – it is possible there could have been some other supraventricular tachycardia – there are several different types.

(A side note – this is NOT without precedent in modern American presidential history – If you will recall the incident where George H W Bush stood up and vomited all over the Prime Minister of Japan at a state dinner. That incident was precipitated by exactly this – AFIB with RVR.)

Why am I gravely concerned about this diagnosis?

In my experience as a physician – this can happen at any time – however – it typically and often happens at times of great stress. Cardiac arrhthymias can be very easy to control – or very difficult to control. However – this has often meant “retirement” for my business executive patients down the years – the syncopal events can simply happen at very inopportune times and cause all kinds of havoc for the person and his/her company. This is NOT the type of thing that I would want my President to have during a very stressful time.

My fear is that it is fully known what is wrong with her – and this is being hidden from the American public.

By the way – the diagnosis of “pneumonia” being put forth by her physician – Dr. Bardack – is just simply imbecile. A patient who would have this kind of event with pneumonia – would NOT be up and walking around an hour later. If this type of thing happens during pneumonia or any other infection, the patient is almost always suffering from sepsis – and not up and walking. Again – this is imbecile. Third year medical students know better than this.

By the way – as an internist – I have been very very concerned about the reporting of the physicians covering Trump and Clinton. There is something clearly mentally wrong with Trump’s personal physician. I am not sure what is wrong with that guy – but something clearly ails him. The scrutiny there was deserved and as of yet has not been answered even remotely by the Trump campaign. For the life of me – I do not know why there has not been equal attention on Dr. Bardack – Mrs. Clinton’s physician. It has been known for a few weeks to internists in America connected to social media THAT Dr. BARDACK IS NOT BOARD-CERTIFIED by the American Board of Internal Medicine. If you look at the website for the American Board of Internal Medicine – and look her up – abim.org – you will find that SHE IS NOT BOARD-CERTIFIED. Why would Mrs. Clinton release a medical statement from a non-Board Certified physician? I have been puzzled by the fact that the national press has made such a deal about the failings of Trump’s physician (rightly so) – but chirping crickets about the obvious board issues with Dr. Bardack. Any ideas about that?

UPDATE.4:

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UPDATE.5: Another update from the internist:

A few clarifying points to my earlier post –

First of all – let us talk about walking pneumonia.

I have no doubt that Mrs. Clinton may have been diagnosed with pneumonia on Friday. That is entirely possible. 70 year olds have pneumonia all the time. My point is that pneumonia in and of itself – WOULD NEVER make someone do what happened today. I am fully aware of walking pneumonia – and indeed – by definition – it is “walking”. It is a type of pneumonia caused by very specific organism(s) that are much different than those types that will put you in the hospital. The point being – walking pneumonia will produce ill symptoms – often a cough and overall malaise – but will never ever cause a syncope like episode. Pneumonia or reaction to antibiotics simply do not produce what happened today in the absence of many other grave symptoms – and believe me people would not be walking through a parking lot with these symptoms.

I want to clarify the cardiac arrhythmia issue as well. AFIB with RVR is but one of many types of rhythm problems that could be going on – it is by far the most common therefore the most likely. This is what happens when people have afib: the atria – the top chambers of the heart – are beating in total chaos. Normally – your AV node protects the bottom part – ventricles – or pumping chambers from being exposed to the chaos. You can go for long times months even years without any problems at all. However, ever so often the AV node fails in its protection – the chaos from above is transported to the ventricles below and suddenly the bottom of the heart is beating 150, 160 whatever. Just think how you feel after 15 minutes on a treadmill. Running hard. Heart rate of 150 – light-headed and short of breath. Now imagine that you get off the treadmill – and your heart just keeps right on going at 150. In about 10 minutes you will begin to feel very bad. This is manifested in different ways by different people. Shortness of breath is very common. The feeling of being flushed or hot is very common. Nausea and vomiting are very very common. But your heart will not slow down. After several minutes of this – even the most simple exertion like walking – can lead to such low blood pressure that you will have syncope (pass out). That is why AFIB with RVR is so high on the differential diagnosis of the tape I saw today.

Something else of concern that has been running through my mind since I saw that tape is yet another diagnosis that I neglected to put in the initial discussion. This is EXACTLY how people will react if they have an implantable defibrillator and it fires. This would be the same as having the big paddles put on you in the ER – and shocked. Over the past 20 years or so – we have been putting “paddles” directly into patients chest that fire and shock them whenever the computer that is attached to them perceives there is a problem. These patients would already have a diagnosis of a cardiac rhythm problem. One of two things in my experience happens. 1) The rhythm problem comes out of nowhere – and the patient is shocked. They would seem to drop to the ground instantly 2) Often, the rhythm problem is lurking for several minutes before the shock occurs. It all depends on the diagnosis and the settings of the device. But the patient will often feel very very weak and tired, dizzy, hot and light-headed in the seconds/minutes before the device fires. When it does fire however – most of the time – the patient goes down temporarily – just like Mrs. Clinton did today.

Will someone ask her please if she has a defibrillator in her chest? This may or may not be so – but do you want someone who can be shocked like that in charge of the country in a crisis?

I want to for personal reasons address concerns about my ethics in some of the above comments.

I agree – no diagnosis should ever be made without the patient being right in front of you. And many of the tapes and videos used in the past month about Mrs. Clinton’s health have been “out there”. I am not making a diagnosis on her – I am offering up medical facts about what could have caused something like this to occur. Common things occur commonly. This video today is clearly not from the lunatic fringe like some of the others I have seen this past few weeks. I am gravely concerned about this after what I saw today – and I wholeheartedly believe the voters need to know the whole story – whatever that may be – and what the campaign is telling and putting forth makes little sense medically speaking. As is so often in politics – it is the lies and confusion put forward to cover things up – that gets people in trouble.

I like most of America am absolutely dismayed with the choices we have this year for President. This video today did not help decrease my concern about this election.

Another question I have – and about this I need to be perfectly clear. Had I seen that video on any of my patients – and believe me – having things caught on video is actually very common in medicine today – my very very first reaction would be GET THAT PATIENT TO THE ER – I AM MEETING YOU THERE. Why on earth was Mrs. Clinton not rushed to the hospital???? — That issue alone brings up all sorts of concerning thoughts in my mind..

And about her personal physician – Dr. Raback. In my haste – to get the previous comment done – and typing quickly – I did not fully convey her status with the Board of Internal Medicine. (This is really in the deep woods) If you care to do some research about this issue – Board Certification and its maintenance is HIGHLY CONTROVERSIAL among internists now. (Please see drwes.blogspot.com for full details). She is listed as CERTIFIED – but NOT PARTICIPATING in MAINTENANCE. That means that she has made the decision not to maintain her certification. She passed her initial exams and was certified at some point in the past – but is not participating in maintaining this going forward. At some point – this will put her at great risk of being dropped from insurance panels, etc. This is a huge thorn in the side of the internal medicine community at this point. The whole thing is a total mess. It is an example of government regulation gone horribly awry. But the fact of the matter is that she is not participating in her continued certification – There are those in internal medicine who would think that to be not a good thing.

Just a few clarifying points.

I am not a journalist. I am a physician.

I am most certainly not trying to make a diagnosis – I am certainly not going on TV and making an expert opinion on this. That is foolishness. Just trying to present how a trained internist would think through and process this video today. I am just trying to do my duty to make sure people are aware that this looks far far worse than what is being put out for public consumption.