Should Senator Mitch McConnell have gone to the ER after his alarming on-air 'blank out'?

Yesterday, Senate Minority Leader Mitch McConnell had a sudden change in his mental status while delivering remarks on Capitol Hill. McConnell was hospitalized with a concussion and rib fractures in March of this year, and per reports, has suffered both some physical challenges and an apparent slow-down in some of his work.

In this “event,” his remarks began normally enough, before he suddenly faded out, seemingly. He then proceeded to stare off into space for an alarmingly long period of time before anyone (he or anyone else) said anything.

I clocked it. There’s around 27 seconds of silence from the 81-year-old Senator—and it is a long 27 seconds. It’s not easy to watch. But he did respond to his colleague, and made some verbalization at the end of the 27-second stretch. A short time later, as the video below shows, he was apparently back to his normal.

Reactions, questions, and answers:

Here’s my reaction to the video (on Instagram):

This is clearly an acute change in mental status. Possible causes are extensive, but certainly include small strokes or transient ischemic attacks [TIAs]. He would absolutely require medical attention. If this sort of thing has been happening often, it may not necessarily need an ER or hospital visit, but that would be certainly worrisome overall for different reasons. But generally, if I saw this in a patient and it was a "new event," I'd be doing a pretty big barrage of tests.

Inside Medicine fan Katie Couric asked me a follow up question:

My mom had a couple of TIAs and her speech was garbled and nonsensical. Isn't that the way TIAs normally present? Could this be associated with his previous head injury? Upsetting...

Here was my response to Katie:

Yes, garbled/nonsensical speech would be a very common presentation of a TIA. But sorta trailing off like this is another one we see. Partial seizures can also look like this. And certainly his prior head injury could have been caused by an event like this (he briefly loses attention focus/ orientation and then falls) or could be the result of the fall (intermittent symptoms of chronic concussion). It's very broad, but some tests can quickly narrow it down.

How bad was this? Did the Senator need the ER?

McConnell maintained consciousness and his posture. In a more major event, he may have passed out and collapsed.

McConnell’s colleagues didn’t seem to fazed by this. It’s almost as though they’d seen this before and knew how to handle it. (They did a nice job.) Partial seizures (which don’t always have shaking) are always a risk after concussions like the one the Senator suffered earlier this year.

Based on the video alone, my impression is that any patient who experienced such an acute change in mental status would have required an immediate transfer to an emergency room for tests and observation. There’s a caveat, though. If these events have happened to McConnell many times in recent months, it might have been determined by the Senator’s doctors that he and his staff need not activate 911 every time it happens—unless the events have changed in some way, either in duration, frequency, character, or in severity. Knowing what to do in such events can be tough calls when they happen frequently.

So it’s possible that McConnell did not “need” to go to an ER, because the event was in line with what his doctors and he determined was “okay” to ride out, under supervision of aides. Of course, if these events have become commonplace for the Senator, it raises other questions about his overall cognitive abilities and risk.

I’ve worried aloud about our aging politicians on both sides of the aisle. It’s not an age thing. It’s not even about being able to function at a high level with some medical problems. But watching the McConnell video—and as well as other recent examples of politicians looking a little frail—made me wonder just how well some of our aging leaders are able to handle complex and nuanced information. Can they be relied on to react quickly and clearly in a key moment? Our leaders don’t literally need to be able to dodge a shoe—although to this day, I remain impressed with then-President George W. Bush’s nimble reaction to being ambushed by flying footwear. There’s just something to be said for that level of situational awareness.