The eyes can’t see what the mind doesn’t yet know – an axiom to remind us not just of the value of lifelong learning, but that the answers are often in the exam room with us.
Though bright and committed clinical people we may be, we’re dragged by the tendrils of a lumbering behemoth. American health care is designed to produce revenue and built to punish highly visible mistakes over more common (but less easily discerned) errors of reasoning. A natural compensation in this system is to overemphasize diagnostic testing. And as the ubiquitous understaffing of hospital departments leads to patient volumes swollen well beyond reasonable standards, the time for careful physical examination can be squeezed away from us. This pushes us, daily, further away from the high-value, high-quality care we set out to provide.
In cases of acute dizziness, the harm of an inaccurate, or delayed, or incomplete diagnosis is not easily overstated. What sounds like neuritis might well be dissection of a vertebral artery, and so-called red flag symptoms may not be apparent until a disabling stroke has occurred. Is delay of emergent CTA the culprit? Lack of a neurologist on site?
No, the problem is that the most effective approach for examining patients with acute dizziness isn’t universally taught or used. Lingering misperceptions – like the one that subjective report of room-spinning dizziness bears some association with a vestibular source – are still taught to new clinicians as though they have not been disproven. Searching this very website for the term “vertigo” reveals examples which may give the reader pause.
The good news is that the approach is not complicated. While trained experts performing the physical techniques of evaluation of acutely dizzy patients may become more sensitive than an MRI, even the provider with an introductory knowledge of the approach can help prevent a catastrophic delay in diagnosis and care.
Are the patient’s symptoms continuous, or do they come and go in episodes? Is there a movement trigger or a position that provokes the symptoms, or do they arise spontaneously? Does the patient have nystagmus, if not in primary gaze, then at least evoked by gaze position? If so, the cluster of physical tests for which the acronym is HINTS – Head Impulse, check for Nystagmus changing directions, and Test of Skew – can tell the examiner with a high degree of certainty whether the symptom’s source is a peripheral vestibular problem or the result of central nervous system insult.
Dizziness is an ideal stepping stone toward the aim of better diagnostic capability through physical exam: it’s widely recognized as a trouble area, and simple, effective techniques exist. But the same can be said for screening of early movement disorders, or myelopathies, and many other problems. The challenge is forcing the system to allow the clinical commitment. It takes time – not much, but a little more than might be available in a busy ED – to perform a careful examination. Yet the cost savings can be enormous: diagnostic accuracy is the ultimate Quality Improvement focus. And the benefits to patients could not be greater. When the techniques are known, best practices become care standards, and progress becomes a positive feedback loop. Any of us can be the one to start that cycle in our institution.
John Corsino is a physical therapist who blogs at his self-titled site, Health Philosophy.
