Two Chief Complaints that drive me nuts.

[GeneralVeers]

Hispanic panic is real, extraordinarily real, and an enormous burden on our health care system

After working in an all-hispanic area for 5 years I can attest to this. The key is to give them a shot. It doesn't matter what. It can be morphine, ativan, toradol or saline. If it's a shot it will fix their "aye-tach" and they will want to go home. I never do PO meds on my hispanic patients.

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[thegenius]

LOL a shot of saline. LMAO. I wonder how you order that. NS 1ml IM x2 in each arm.
OMG that is funny.

I wonder what to tell them. "It's special, magic water"....e.g....."Es agua mágica y especial"

 

[GeneralVeers]

LOL a shot of saline. LMAO. I wonder how you order that. NS 1ml IM x2 in each arm.
OMG that is funny.

I wonder what to tell them. "It's special, magic water"....e.g....."Es agua mágica y especial"

It's got electrolytes.....plants crave them!

 

[pandahunter]

I wonder if we trained at the same place.

Hispanic dizziness (and Hispanic like Mexican, central America, not Spanish) is a catch all phrase that means they just don't feel good. It doesn't mean fainting, it doesn't mean vertigo, it doesn't mean anything besides what a bowl of cooked black beans means......nothing. It took me 4 years, about 50 consecutively negative MRI's, about 10 admissions as such, Neurology consults, and lord knows how many labs and neuro exams to realize that MAREO means ****ing NOTHING. I don't care how old you are....if you say you are MAREO you get a neuro exam, EKG, labs maybe a CT Head and if all is negative AN ABSOLUTE FUUUUCCCCCKKKIINNG discharge. God I wracked up 5M in useless tests just based on that one word that isn't even English.

Hispanic panic is real, extraordinarily real, and an enormous burden on our health care system

... my brother... I am with you

 

[frosted2]

Bonus points when they call the squad for transport on those... Triple word score when it’s the nursing home that calls the squad..

My entire existence working for a private EMS service.

 

[Apollyon]

It's got electrolytes.....plants crave them!

"Water? Like, from the toilet?"

 

[RuralEDDoc]

It's awfully nice of you to even check their kidneys.

I like the fight of elevated BP, I take it to them. If it's one of our PCP's sending them in though I chicken out and don't say "They ARE WRONG!!!!"

I know you’re joking around a bit, but some people take an Al Gore, ManBearPig super-serious approach which is a little confusing. Why make a big fight out of this? I mean, push back on bull**** appropriately, but the rest of the house of medicine considers moderate to severe hypertension an emergency. Emergency physicians are an outlier, thankfully. Educate, order a test or two if it helps everyone involved, and move on! This shouldn’t be some crazy battle and if it is, change your approach.

 

[Apollyon]

The dizzy thing was the same in Hawai'i, with the Filipino patients. Dizzy in the head? Vertigo, OR headache. Dizzy in the belly? Nausea. Dizzy in the chest, chest pain. But, always, "dizzy".

 

[deleted836128]

TMC Syndrome is common in my neck of the woods. And I hate TMC syndrome.

“What’s hurting you, ma’am?”
“Todo mi cuerpo. Tooooodo mi cuerpo, ay.”

(“Todo mi cuerpo” = “all of my body” in
Espanol)

Often times these ones are the ones who are “dizzy” too...

 

[deleted836128]

After working in an all-hispanic area for 5 years I can attest to this. The key is to give them a shot. It doesn't matter what. It can be morphine, ativan, toradol or saline. If it's a shot it will fix their "aye-tach" and they will want to go home. I never do PO meds on my hispanic patients.

Yes, and they want an antibiotic for everything. Most of the time you’ll see them for something completely NOT infectious like muscular strain and you’ll ask what they’re taking for it and they whip out a pack of “ampicillina” from Mexico and wonder why you don’t give them an antibiotic at DC...

 

[deleted836128]

Me: “What are you here for, sir?”
Patient: “I don’t know... you tell me!” Or “That’s what I came in to find out!” Or “If I knew I wouldn’t be here!”

When taking a history feels like unknotting a knot from Rapunzel’s hair. They complain of something from every organ system. Then you realize after a while this or that is chronic. And you still don’t get WHAT brought them in...You have to follow up everything they complain about with “and how long has THAT been going on?” Then at the end you realize they’re pissed you didn’t address “the real reason I came in. Why did you focus on chest pain? That’s nothing and I’ve had that since the 90s. What I came in for is... I can’t see out of my right eye” but you missed it along the way of taking a nightmare history.

When you ask a patient, “Have you had this before?” They go on a tangent. “No, but have you had this before?” They day “Not like this.” Okay... what do you mean?” “Like I’ve had back pain a lot but like... not like this.” And after a bunch of “not like this” you realize the issue has really been going on for four years.

Speaking of... “I’ve come in today because my hand hurts.” “How long has it been going on?” “A LONG time.” “... how long?” “Like six to eight months.” “Why are you here today?” “I finally just got tired of it and realized I need to be checked out.”

 

[southerndoc]

I'm still in disbelief that you guys MRI/CT "dizziness" without focal neurologic findings. The only way I'm imaging a "dizziness" complaint is if they have a neurologic finding (including gait ataxia -- I actually witness them walk).

I don't think I've ever MRI'd a dizzy patient without focal findings and I work in a comprehensive stroke center who sees posterior strokes all the time.

Many of the patients who complain of dizziness actually mean lightheadedness. When you ask them if they feel like they're on a merry go round or the room is spinning, most will say no. If you ask if they feel woozy when they change positions, most will say yes: lightheadedness instead of dizziness.

 

[The Knife & Gun Club]

+1 Mareado. I’ve had people be “mareado” for decades. Came in today because “no peude comer” (I don’t want to eat).

diagnosis: end stage oldness

 

[Zebra Hunter]

Another CC that irks me a bit is the CC of “Chest painS” which has yet to yield emergent pathology in my short career. I don’t understand why. Whenever the “s” is added to the end of chest pain it essentially rules patients out for MI. I’ve considered publishing a paper on the phenomenon. It’s essentially the “Cheetos sign” of chest pain. My assumption is that these are typically the low IQ patients with poor grasp of the English language despite it being their first language who are the type to get most of their unnecessary care in the ER. The pain is almost always reproduced with palpation of the chest wall:

 

[Groove]

LOL a shot of saline. LMAO. I wonder how you order that. NS 1ml IM x2 in each arm.
OMG that is funny.

I wonder what to tell them. "It's special, magic water"....e.g....."Es agua mágica y especial"

This reminded me... we used to have to have this psych pt who would come in for all sorts of various complaints...most docs treated her like a pain seeker because she would ask for dilaudid and phenergan and this was prior to all the opiod craziness. She would be hyper manic and walking around the department, up at the nursing station, asking for hugs, and generally being a nuisance. She had trichotillomania and patches of her hair would be missing on occasion. Hyperverbal, tangential thinking, poor insight, the usual annoying psych pt qualities. She would generally have a chronic pain complaint. People would slug her with all types of meds just to get her to shut up and then discharge her. I finally figured out she was really just there for the attention and not a drug seeker at all. It was 100% psych. So we started offering "Normazaline" = "Normal Saline". She'd come in asking for dilaudid and I'd go..."Listen, all I've got is a Normazaline shot, but listen....I'm only giving you one of these since they are so potent and I want to make absolutely certain you have someone to take you home today. This shot will cure your pain, itching, anxiety, all of it! It's a wonder drug! But listen...we just don't give these out to just anybody...so hold on and let me get your nurse. We'll get this done and get you back home. You'll feel brand new!" Her eyes would get wide and she'd thank us so much for the normazaline. Pretty soon, she started coming into the ER claiming that those "normazaline" shots were from God and were the best thing she'd ever had. She'd show up every few days begging for another one. I haven't seen her in our ED in awhile, but the talk about saline shots reminded me of that. LOL

 

[Groove]

I'm still in disbelief that you guys MRI/CT "dizziness" without focal neurologic findings. The only way I'm imaging a "dizziness" complaint is if they have a neurologic finding (including gait ataxia -- I actually witness them walk).

I don't think I've ever MRI'd a dizzy patient without focal findings and I work in a comprehensive stroke center who sees posterior strokes all the time.

Many of the patients who complain of dizziness actually mean lightheadedness. When you ask them if they feel like they're on a merry go round or the room is spinning, most will say no. If you ask if they feel woozy when they change positions, most will say yes: lightheadedness instead of dizziness.

Here's two articles you might find interesting that show the problems with traditional quality based symptom approaches to dizzy patients. "What does "dizzy" feel like? Do you mean X,Y,Z?" (Which is how I was trained and has been difficult for me to overcome.)

Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting - PubMed

Descriptions of the quality of dizziness are unclear, inconsistent, and unreliable, casting doubt on the validity of the traditional approach to the patient with dizziness. Alternative approaches, emphasizing timing and triggers over type, should be investigated.

www.ncbi.nlm.nih.gov

RESULTS:
Of 1,342 patients screened, 872 (65%) were dizzy, light-headed, or off-balance in the past 7 days (n=677) or previously bothered by dizziness (n=195). Among these 872 patients with dizziness, 44% considered dizziness "the main reason" or "part of the reason" for the ED visit. Open-ended descriptions were frequently vague or circular. A total of 62% selected more than 1 dizziness type on the multiresponse question. On the same question, 54% did not pick 1 or more types endorsed previously in open description. Of 218 patients not identifying vertigo, spinning, or motion on the first 3 questions, 70% confirmed "spinning or motion" on directed questioning. Asked to choose the single best descriptor, 52% picked a different response on retest approximately 6 minutes later. By comparison, reports of dizziness duration and triggers were clear, consistent, and reliable.
CONCLUSION:
Descriptions of the quality of dizziness are unclear, inconsistent, and unreliable, casting doubt on the validity of the traditional approach to the patient with dizziness. Alternative approaches, emphasizing timing and triggers over type, should be investigated.

Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians - PubMed

Physicians report taking a quality-of-symptoms approach to the diagnosis of dizziness in patients in the emergency department. Those relying heavily on this approach may be predisposed to high-risk downstream diagnostic reasoning. Other clinical features (eg, timing, triggers, associated...

www.ncbi.nlm.nih.gov

CONCLUSION:
Physicians report taking a quality-of-symptoms approach to the diagnosis of dizziness in patients in the emergency department. Those relying heavily on this approach may be predisposed to high-risk downstream diagnostic reasoning. Other clinical features (eg, timing, triggers, associated symptoms) appear relatively undervalued. Educational initiatives merit consideration.

If you've ever got some time...and are interested. I highly recommend a couple of journal articles by a guy named Dr. Jonathan Edlow on approaching the dizzy patient. It's a two part series in Annals from 2017 and 2018. It is probably the best and most comprehensive, EBM approach to dizziness that I've ever read and I emailed the guy to thank him for his contribution, I thought so highly of it. Anyway, check it out. Even if you feel like you've got dizziness mastered and are already on the HINTS train, etc.. you'd probably still pick up a few things. Really good stuff. I recommend reading both of them twice.

https://www.annemergmed.com/article/S0196-0644(17)31795-X/fulltext

https://www.annemergmed.com/article/S0196-0644(18)30510-9/fulltext

 

[SamtheWise]

I wonder if we trained at the same place.

Hispanic dizziness (and Hispanic like Mexican, central America, not Spanish) is a catch all phrase that means they just don't feel good. It doesn't mean fainting, it doesn't mean vertigo, it doesn't mean anything besides what a bowl of cooked black beans means......nothing. It took me 4 years, about 50 consecutively negative MRI's, about 10 admissions as such, Neurology consults, and lord knows how many labs and neuro exams to realize that MAREO means ****ing NOTHING. I don't care how old you are....if you say you are MAREO you get a neuro exam, EKG, labs maybe a CT Head and if all is negative AN ABSOLUTE FUUUUCCCCCKKKIINNG discharge. God I wracked up 5M in useless tests just based on that one word that isn't even English.

Hispanic panic is real, extraordinarily real, and an enormous burden on our health care system

Here's two articles you might find interesting that show the problems with traditional quality based symptom approaches to dizzy patients. "What does "dizzy" feel like? Do you mean X,Y,Z?" (Which is how I was trained and has been difficult for me to overcome.)

Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting - PubMed

Descriptions of the quality of dizziness are unclear, inconsistent, and unreliable, casting doubt on the validity of the traditional approach to the patient with dizziness. Alternative approaches, emphasizing timing and triggers over type, should be investigated.

www.ncbi.nlm.nih.gov

RESULTS:
Of 1,342 patients screened, 872 (65%) were dizzy, light-headed, or off-balance in the past 7 days (n=677) or previously bothered by dizziness (n=195). Among these 872 patients with dizziness, 44% considered dizziness "the main reason" or "part of the reason" for the ED visit. Open-ended descriptions were frequently vague or circular. A total of 62% selected more than 1 dizziness type on the multiresponse question. On the same question, 54% did not pick 1 or more types endorsed previously in open description. Of 218 patients not identifying vertigo, spinning, or motion on the first 3 questions, 70% confirmed "spinning or motion" on directed questioning. Asked to choose the single best descriptor, 52% picked a different response on retest approximately 6 minutes later. By comparison, reports of dizziness duration and triggers were clear, consistent, and reliable.
CONCLUSION:
Descriptions of the quality of dizziness are unclear, inconsistent, and unreliable, casting doubt on the validity of the traditional approach to the patient with dizziness. Alternative approaches, emphasizing timing and triggers over type, should be investigated.

Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians - PubMed

Physicians report taking a quality-of-symptoms approach to the diagnosis of dizziness in patients in the emergency department. Those relying heavily on this approach may be predisposed to high-risk downstream diagnostic reasoning. Other clinical features (eg, timing, triggers, associated...

www.ncbi.nlm.nih.gov

CONCLUSION:
Physicians report taking a quality-of-symptoms approach to the diagnosis of dizziness in patients in the emergency department. Those relying heavily on this approach may be predisposed to high-risk downstream diagnostic reasoning. Other clinical features (eg, timing, triggers, associated symptoms) appear relatively undervalued. Educational initiatives merit consideration.

If you've ever got some time...and are interested. I highly recommend a couple of journal articles by a guy named Dr. Jonathan Edlow on approaching the dizzy patient. It's a two part series in Annals from 2017 and 2018. It is probably the best and most comprehensive, EBM approach to dizziness that I've ever read and I emailed the guy to thank him for his contribution, I thought so highly of it. Anyway, check it out. Even if you feel like you've got dizziness mastered and are already on the HINTS train, etc.. you'd probably still pick up a few things. Really good stuff. I recommend reading both of them twice.

https://www.annemergmed.com/article/S0196-0644(17)31795-X/fulltext

https://www.annemergmed.com/article/S0196-0644(18)30510-9/fulltext

Mareo, mareado, dizziness, vertigo, whatever you want to call it is a brutally challenging complaint, it's anything from frustration from a sleepless night to a STEMI to sepsis to a stroke to an otolith being 1/4 of a millimeter out of place. There's a lot of noise about it and everyone has some 'magic bullet' approach for sorting it out: HINTS exam (if the patient is currently symptomatic and you're a fellowship trained neuro-otologist), do an epley on everyone and eventually the patient decides they hate it so much they'll just say they feel better and leave, MRI everyone, or just give everyone ativan and fluids and accept that you'll miss a few posterior strokes and can live with it because you know in your heart that TPA is the wrong thing for a patient with mild isolated vertigo.

I personally feel that an extensive in patient neurologic workup (including MRI) is unnecessary if the patient has no FND and is ambulatory. They can follow up with vestibular PT and their PCP.

 

[Groove]

Mareo, mareado, dizziness, vertigo, whatever you want to call it is a brutally challenging complaint, it's anything from frustration from a sleepless night to a STEMI to sepsis to a stroke to an otolith being 1/4 of a millimeter out of place. There's a lot of noise about it and everyone has some 'magic bullet' approach for sorting it out: HINTS exam (if the patient is currently symptomatic and you're a fellowship trained neuro-otologist), do an epley on everyone and eventually the patient decides they hate it so much they'll just say they feel better and leave, MRI everyone, or just give everyone ativan and fluids and accept that you'll miss a few posterior strokes and can live with it because you know in your heart that TPA is the wrong thing for a patient with mild isolated vertigo.

I personally feel that an extensive in patient neurologic workup (including MRI) is unnecessary if the patient has no FND and is ambulatory. They can follow up with vestibular PT and their PCP.

I used to feel this way years ago as a resident but dizziness is actually one of my favorite chief complaints. I find them interesting and challenging. (I'll admit that I'm probably in a minority.) Which is why I took such an interest in Edlow's work form Annals. It's rare to find such a thorough, modernized and evidence based approach to the dizzy pt (Especially in an EM journal). Check it out if you haven't read them before (and have an Annals subscription). I'm not sure where to download them otherwise.

 

[thegenius]

In my example above about MRIing 50 people who are Hispanic dizzy, most of those were during residency. Part of the time I was dealing with my attendings but I was also learning during that time.

Just this year my part time job at Kaiser, we had two people who had posterior circulation strokes whose sole complaint was dizziness. Apparently the neuro exam was normal in the ER. One of them was sent home and the MRI done a day or two later confirmed the stroke. I believe that was the patient who also had a carotid or vertebral artery dissection without having any pain. I don't know the remaining details about that one or the other one.

A few pitfalls about dizziness in the ED

1) ER docs in general, as a group, don't do comprehensive neurologic exams. It is conceivable that a comprehensive neuro examination might turn up subtle neurologic signs that a screening neurologic physical exam does not. I have a little fetish for neuro so I tend to do more than the average ER doc in my group.

2) Patients are notoriously bad at describing their symptoms, even reliable, intelligent ones. Vertigo can feel like being on a boat. Wobbily back and forth. It doesn't always have to be "room spinning" or "things spinning in one direction that shouldn't be moving" despite me telling patients that is the case.

3) Always...always....always!!! If you consult a Neurologist and get either recommendations over the phone or they actually see the patient in the ED with acute dizziness. What is their recommendation? Get the MRI. Ding Ding Ding. I've never had a neurologist not ask for one in a >= 40 old pt with acute dizziness without another obvious cause.

I walk every patient with dizziness and do a really detailed exam. My incidence of MRIing has gone down SIGNIFICANTLY as I've become more comfortable with it. But occasionally I will if they don't have a neuro deficit.

 

[thegenius]

https://www.annemergmed.com/article/S0196-0644(17)31795-X/fulltext

https://www.annemergmed.com/article/S0196-0644(18)30510-9/fulltext

I got a copy of the first one, the second one says I need to login to get a copy. Can anyone provide a link or attach the article here?

 

[thegenius]

I know you’re joking around a bit, but some people take an Al Gore, ManBearPig super-serious approach which is a little confusing. Why make a big fight out of this? I mean, push back on bull**** appropriately, but the rest of the house of medicine considers moderate to severe hypertension an emergency. Emergency physicians are an outlier, thankfully. Educate, order a test or two if it helps everyone involved, and move on! This shouldn’t be some crazy battle and if it is, change your approach.

Look man I hear you. I don't make a big deal out of this and if a patient demands stuff, then they can sit in my ER for a few hours and I'll order a few labs. But that rarely happens, if ever, for me. But I do politely disagree with the notion that most of the house of medicine considers it an emergency. I actually think most PCP's, FM docs, etc know that asymptomatic hypertension is NOT an emergency. The problem is most of the PCP's, FM docs either 1) can't actually talk to the patient and their administrative staff who answers the phone say "we don't have an appointment for you today, please go to the ER." or 2) the FM / PCP talks or even examines the patient and they think "they are a little dizzy, or they have a little HA, they need a CT Head" or some other such nonsense and if the referring doc bothers to call me and requests it, then I usually order it...

...and most of the time I don't tell them "Well ACEP guidelines say no CT, no nothing for asymptomatic HTN" because it's just rubbing it in their face and what's the point in that. I'm not going to change the way they practice. I think I one time said "Hypertensive emergencies look like emergencies and it sounds like she doesn't have an emergency, but I'll be happy to evaluate her." and left it at that.

 

[Groove]

I got a copy of the first one, the second one says I need to login to get a copy. Can anyone provide a link or attach the article here?

Sure, I guess that would have been easier. Let me see if I can attach the PDFs.

 

[cyanide12345678]

I'm still in disbelief that you guys MRI/CT "dizziness" without focal neurologic findings. The only way I'm imaging a "dizziness" complaint is if they have a neurologic finding (including gait ataxia -- I actually witness them walk).

I don't think I've ever MRI'd a dizzy patient without focal findings and I work in a comprehensive stroke center who sees posterior strokes all the time.

Many of the patients who complain of dizziness actually mean lightheadedness. When you ask them if they feel like they're on a merry go round or the room is spinning, most will say no. If you ask if they feel woozy when they change positions, most will say yes: lightheadedness instead of dizziness.

My neuro interventionalist wants a CT head, CTA head and neck, as well as MRI on vertigo patients above 65 with risk factors for a stroke, even with normal neuro exam.

 

[thegenius]

My neuro interventionalist wants a CT head, CTA head and neck, as well as MRI on vertigo patients above 65 with risk factors for a stroke, even with normal neuro exam.

Yea.....it’s like the surgeon wanting a CT scan to see if they need surgery, or the CABG surgeon wanting a left heart cath to determine if they need a CABG.

These doctors only deal with medical conditions that rule in, and once they ruled in, they are happy to make money and do the work. They don’t think about EBM, they don’t think about pre-test probabilities, they don’t think about medical liability (well they do because they want all tests done...) they don’t care about anything except pathology they can treat.

Admittedly with my example as well, asking the neurologist or consulting the neurologist about whether a patient needs a work up for acute stroke. They always say the same thing.

 

[bravotwozero]

in patient neurology in a nutshell: eeg, mri, mra all day long.

 

[deleted836128]

Ugh... my grandma said she was feeling vaguely dizzy for a week and she didn’t seem right. No hard findings on exam. We saw her PCP and she ordered a head CT outpatient and said to stop drinking alcohol because “I am gonna assume it’s the alcohol that’s making you dizzy” even though she’s been having three cocktails a night for fifty years... I was pissed about the visit, had a weird feeling, brought her to the ER and asked the ER doctor to MRI her... no hard findings on exam whatsoever but she listened to me and ordered it. Long story short, my g-am had little infarcts EVERYWHERE... showers of little infarcts. The whole situation super freaked me out about missing things with dizzy patients. See my g-ma’s MRI.

 

[DrGasPasser]

In my example above about MRIing 50 people who are Hispanic dizzy, most of those were during residency. Part of the time I was dealing with my attendings but I was also learning during that time.

Just this year my part time job at Kaiser, we had two people who had posterior circulation strokes whose sole complaint was dizziness. Apparently the neuro exam was normal in the ER. One of them was sent home and the MRI done a day or two later confirmed the stroke. I believe that was the patient who also had a carotid or vertebral artery dissection without having any pain. I don't know the remaining details about that one or the other one.

A few pitfalls about dizziness in the ED

1) ER docs in general, as a group, don't do comprehensive neurologic exams. It is conceivable that a comprehensive neuro examination might turn up subtle neurologic signs that a screening neurologic physical exam does not. I have a little fetish for neuro so I tend to do more than the average ER doc in my group.

2) Patients are notoriously bad at describing their symptoms, even reliable, intelligent ones. Vertigo can feel like being on a boat. Wobbily back and forth. It doesn't always have to be "room spinning" or "things spinning in one direction that shouldn't be moving" despite me telling patients that is the case.

3) Always...always....always!!! If you consult a Neurologist and get either recommendations over the phone or they actually see the patient in the ED with acute dizziness. What is their recommendation? Get the MRI. Ding Ding Ding. I've never had a neurologist not ask for one in a >= 40 old pt with acute dizziness without another obvious cause.

I walk every patient with dizziness and do a really detailed exam. My incidence of MRIing has gone down SIGNIFICANTLY as I've become more comfortable with it. But occasionally I will if they don't have a neuro deficit.

Failure to perform (or document) a thorough neuro exam is a common issue in EM. It bites a number of people in the ass.

Ugh... my grandma said she was feeling vaguely dizzy for a week and she didn’t seem right. No hard findings on exam. We saw her PCP and she ordered a head CT outpatient and said to stop drinking alcohol because “I am gonna assume it’s the alcohol that’s making you dizzy” even though she’s been having three cocktails a night for fifty years... I was pissed about the visit, had a weird feeling, brought her to the ER and asked the ER doctor to MRI her... no hard findings on exam whatsoever but she listened to me and ordered it. Long story short, my g-am had little infarcts EVERYWHERE... showers of little infarcts. The whole situation super freaked me out about missing things with dizzy patients. See my g-ma’s MRI.

So yes, you can absolutely miss strokes in patients presenting to the ED with just dizziness. However, before you change your practice based on a case report (or even a case series), let’s take a run through the numbers.

Sorry, not found ... | Swiss Medical Weekly

smw.ch

Central vascular causes make up 6% of patients presenting to EDs with dizziness; about half (3%) will have a stroke. CT is less than 20% sensitive for ischemic stroke in the first 24 hours. MRI is roughly 80% sensitive for strokes in the first 6-12 hours, and performs even worse (roughly 50%) for strokes presenting as dizziness since the posterior circulation is more often involved. The sensitivity for MRI goes up considerably 2-7 days later for strokes presenting as dizziness. Most physicians do not understand these limitations and vastly over-estimate the capabilities of neuroimaging performed in the first 12-24 hours of symptom onset.

Given these numbers, a very safe, defensible, and cost-effective approach is to obtain emergent imaging on all patients with dizziness and focal deficits, ataxia, or red flag symptoms such as thunderclap HA. Also, admit those who suddenly can’t walk. Refer others for out-patient imaging after working-up other causes via exam +/- labs. And please, for the love of God, make sure your exam documents thorough neuro and CV assessments including consciousness, CN, comparative strength, comparative sensation, DTRs, coordination, and gait. Yes, you will miss a very small number of patients who had a stroke but a normal exam, but this is acceptable and expected. So, give good, time-specific follow-up and let them know that further evaluation is needed if their sx persist.

A very expensive approach, with little return on safety and accuracy, is to liberally image patients in the ED with acute dizziness. In other words, your grandma’s doctor simply ordered the wrong test in a patient who had been dizzy for a week, but that doesn’t mean that you should order the same wrong test for patients who have been dizzy for a few hours.

 

[Renaissance Man]

1) ER docs in general, as a group, don't do comprehensive neurologic exams. It is conceivable that a comprehensive neuro examination might turn up subtle neurologic signs that a screening neurologic physical exam does not. I have a little fetish for neuro so I tend to do more than the average ER doc in my group.

I am curious what the neurologic exam looks like in your chart? Could you give an example of a normal comprehensive one?

 

[Fox800]

Can't walk/cerebellar signs/neuro findings = neuroimaging with angiography. If at a facility without after-hours MRI, I get a CTA. If it's negative and they're still symptomatic I consult neurology over the phone to pad the chart. They invariably want an MRI, so I keep the patient until the morning when the MRI folks come in (or admit them to observation). Most of the time it's normal but I'm not taking chances with these folks, unless they have a slam-dunk story for BPPV with a congruent exam, or have a history of BPPV with totally identical symptoms to prior.

 

[DrGasPasser]

Can't walk/cerebellar signs/neuro findings = neuroimaging with angiography. If at a facility without after-hours MRI, I get a CTA. If it's negative and they're still symptomatic I consult neurology over the phone to pad the chart. They invariably want an MRI, so I keep the patient until the morning when the MRI folks come in (or admit them to observation). Most of the time it's normal but I'm not taking chances with these folks, unless they have a slam-dunk story for BPPV with a congruent exam, or have a history of BPPV with totally identical symptoms to prior.

The sensitivity of DWI-MRI is as low as 80% in the first 24 hours of a posterior fossa ischemic stroke. It’s even lower in the first 12 hours.

Posterior circulation ischaemic stroke | The BMJ

www.bmj.com

Even if it’s not a stroke, old people with BPPV who can’t walk are at high-risk for busting their ass if sent home unable to pass a road test.

This is where having a director with good relationships with your admitting services pays dividends.

 

[Fox800]

The sensitivity of DWI-MRI is as low as 80% in the first 24 hours of a posterior fossa ischemic stroke. It’s even lower in the first 12 hours.

Posterior circulation ischaemic stroke | The BMJ

www.bmj.com

Even if it’s not a stroke, old people with BPPV who can’t walk are at high-risk for busting their ass if sent home unable to pass a road test.

This is where having a director with good relationships with your admitting services pays dividends.

Agreed. I ain't kicking them out the door if they can't walk. Even if imaging is negative, I'll keep them on OBS for more treatment and PT/OT upstairs, with delayed imaging (MR) if we weren't able to get it overnight.

 

[southerndoc]

My neuro interventionalist wants a CT head, CTA head and neck, as well as MRI on vertigo patients above 65 with risk factors for a stroke, even with normal neuro exam.

And what is your yield on that? MRI misses up to 6% of posterior strokes in the first 24 hours. Do you also admit all 65 year olds with dizziness even with a normal neuro exam?

I think it's overkill to do this on all. I'm betting that your posterior stroke rate with this workup with people who have a normal neurologic exam (including not having vertical or rotary nystagmus) is <1%.

 

[southerndoc]

Ugh... my grandma said she was feeling vaguely dizzy for a week and she didn’t seem right. No hard findings on exam. We saw her PCP and she ordered a head CT outpatient and said to stop drinking alcohol because “I am gonna assume it’s the alcohol that’s making you dizzy” even though she’s been having three cocktails a night for fifty years... I was pissed about the visit, had a weird feeling, brought her to the ER and asked the ER doctor to MRI her... no hard findings on exam whatsoever but she listened to me and ordered it. Long story short, my g-am had little infarcts EVERYWHERE... showers of little infarcts. The whole situation super freaked me out about missing things with dizzy patients. See my g-ma’s MRI.

Rare presentation. I've had one lady come in with an EARACHE (swear it was her only complaint) who was having an INFERIOR STEMI at the ripe age of 45. Only reason it was found is because a tech did the EKG in the wrong room. She thought it was ordered on the patient when it wasn't. Does that mean I obtain an EKG for every earache? Nope. It's a zebra, much like your grandmother's. The yield of doing an MRI on every dizzy patient is very low. In your mother's case, there was no emergent intervention available.

 

[southerndoc]

I am curious what the neurologic exam looks like in your chart? Could you give an example of a normal comprehensive one?

Speech appears normal and is not slurred. CN II-XII intact. 5/5 strength in all extremities both proximally and distally and equal with contralateral extremity. Equal grip strength. Light touch sensation intact in all extremities (equal between contralateral extremities). Finger-to-nose and heel-to-shin intact bilaterally. No dysmetria or dysdiadochokinesia. I witnessed the patient ambulate >10 feet and they were able to do so without evidence of ataxia or other difficulty. There is no vertical or rotary nystagmus noted. Test of skew is normal in both eyes.

That is my Dragon autotext. And yes, before you ask, I test everything (including dysmetria and dysdiadochokinesia) on a dizzy patient. I hate dealing with them because they are time consuming to do a detailed neuro exam.

 

[Birdstrike]

Chief complaint from patient, "My lawyer sent me in."

"Why, what medical problem do have?"

"Nothing, but he told me that I need to be seen if I want to get any money from the accident. So I need you to check my neck."

"Does it hurt?"

"Not really. Well, yes, actually. My lawyer said I could have whiplash."

"Uh....Okay. When was the accident?"

"Last Monday. I don't know. No, 2 weeks ago. I think."


I find this chief complain particularly irritating. Not only are you providing no actual medical service, you mainly just acting as a tool for the personal injury lawyer, so he can get a commission. In the meantime, your E&M fee will be tied up with their third party car insurance for umpteen years until they settle the case, and you'll be lucky if you get pain even then.

 

[DrGasPasser]

Rare presentation. I've had one lady come in with an EARACHE (swear it was her only complaint) who was having an INFERIOR STEMI at the ripe age of 45. Only reason it was found is because a tech did the EKG in the wrong room. She thought it was ordered on the patient when it wasn't. Does that mean I obtain an EKG for every earache? Nope. It's a zebra, much like your grandmother's. The yield of doing an MRI on every dizzy patient is very low. In your mother's case, there was no emergent intervention available.

I agree to the extent that MRI is a low yield test in the ED for patients with dizziness and no focal deficits.

On the other hand, neurovascular imaging on an outpatient/inpatient basis is appropriate in patients when other, far more common, causes have been excluded.

My big problem is with the PCP’s decision to get a non-contrast head CT. That is about as worthless as an acre of fungus. CTs are an expensive version of giving Z-packs to viruses - they are done to address patient perception rather than any disease.

 

[thegenius]

The sensitivity of DWI-MRI is as low as 80% in the first 24 hours of a posterior fossa ischemic stroke. It’s even lower in the first 12 hours.

Posterior circulation ischaemic stroke | The BMJ

www.bmj.com

This implies there is a better test than DWI-MRI for posterior circulation stroke, no?

 

[thegenius]

I am curious what the neurologic exam looks like in your chart? Could you give an example of a normal comprehensive one?

I do this about 5% of the time...I might exclude a few things.
For some reason I can't copy/paste from Cerner into this.

takes about 10 minutes

 

[thegenius]

Chief complaint from patient, "My lawyer sent me in."

"Why, what medical problem do have?"

"Nothing, but he told me that I need to be seen if I want to get any money from the accident. So I need you to check my neck."

"Does it hurt?"

"Not really. Well, yes, actually. My lawyer said I could have whiplash."

"Uh....Okay. When was the accident?"

"Last Monday. I don't know. No, 2 weeks ago. I think."


I find this chief complain particularly irritating. Not only are you providing no actual medical service, you mainly just acting as a tool for the personal injury lawyer, so he can get a commission. In the meantime, your E&M fee will be tied up with their third party car insurance for umpteen years until they settle the case, and you'll be lucky if you get pain even then.

I've had this before....once there was enough pathology I could document that I did order the imaging test. Even though I knew it would be normal. The other time the patient had a completely normal exam for the neck, and I told them "medically speaking you need nothing. I'm certifying that you do not need any emergency care. If you want imaging to further back that up, you will have to find a doctor who will order the test and you will have to pay for it out of pocket, which can be hundreds or thousands of dollars. The patient understood and I discharged him."

 

[thegenius]

This conversation above reminds me of dealing with chest pain. Although there are more clearly delineated EB guidelines for dealing with chest pain, most of this comes down to physician (and patient) risk tolerance for not missing a stroke.

This seemingly comes down to what is the "standard of care", or what would most ER docs do, when someone who comes in with stroke risk factors presents with dizziness, with a normal neuro exam and walking normally.

For what it's worth...I think it's fun doing a neuro exam especially in front of the patient's family because you can demonstrate, and they can see that there are no focal neuro deficits.

 

[southerndoc]

I feel like those of us at a comprehensive stroke center would be held to a higher standard during litigation (we're the specialty hospital, we should never miss a stroke). Despite this, I still don't work up dizziness with imaging without neuro findings. May be why my CT utilization is 2 standard deviations below my colleagues. Despite this, I haven't had any misses except one appendicitis that I'm aware of. Who knows if somebody went somewhere else and I missed something.

 

[thegenius]

The other thing too is often you get these old people who have problems completing a detailed neurologic exam simply because they are old. Not because they have deficits. People who use wheelchairs at baseline and occasionally use a walker, and now they are dizzy. It's actually very difficult to get them to stand up and move around. And then you have to assess whether their movement represents an acute neurologic deficit or just worsening oldness. It can be difficult to do.

They may not even do things like ocular movements properly. How many times have you asked an old person to "follow my hand" and they can't do it? Like you move your hand to the left, and their eyes don't move. You try and try and try......and you eventually see them move their eyes to the left but it takes some time. Their ocular movements are intact...just takes time to elicit them.

I don't think many of us would get imaging for the person whose sole complaint is dizziness and they move around with alacrity without a neuro deficit. I don't. But those people are on the far side of the spectrum of being able to get a reliable neuro exam.

 

[DrGasPasser]

This implies there is a better test than DWI-MRI for posterior circulation stroke, no?

Not really. MRI is still a gold standard - it’s just of questionable utility early in the disease process.

Physicians need to realize the limitations of the imaging tests that they order, and take them in the context of the pretest probability and clinical context.

For example, nobody needs an MRI to act on a patient with 2 hours of acute vertigo and ataxia with a PICA cutoff on a CTP. A negative MRI would be deemed to likely be a false negative while a positive would add little to the time-sensitive acute management.

On the other hand, a MRI would be a very reasonable test for that same patient who had stable symptoms for 4-5 days. It just doesn’t need to be performed in the ED since the patient will be inevitably admitted for their work-up and inability to ambulate. In fact, I’d argue that the non-contrasted head CT to rule-out cerebellar hemorrhage that admitting services demand from the ED is also of questionable value in a patient with 4-5 days of stable symptoms who is going to get a MRI within 24 hours.

Bottom line, physicians need to stop reflexively ordering head CTs unless it’s to drive emergent therapies in patients with hyperacute symptoms or some other special circumstances such as anticoagulant use, remote trauma in elderly, etc.

 

[DrGasPasser]

The other thing too is often you get these old people who have problems completing a detailed neurologic exam simply because they are old. Not because they have deficits. People who use wheelchairs at baseline and occasionally use a walker, and now they are dizzy. It's actually very difficult to get them to stand up and move around. And then you have to assess whether their movement represents an acute neurologic deficit or just worsening oldness. It can be difficult to do.

They may not even do things like ocular movements properly. How many times have you asked an old person to "follow my hand" and they can't do it? Like you move your hand to the left, and their eyes don't move. You try and try and try......and you eventually see them move their eyes to the left but it takes some time. Their ocular movements are intact...just takes time to elicit them.

I don't think many of us would get imaging for the person whose sole complaint is dizziness and they move around with alacrity without a neuro deficit. I don't. But those people are on the far side of the spectrum of being able to get a reliable neuro exam.

There is a point where elderly, debilitated, and dizzy becomes altered and unexaminable. When that boundary is crossed can be very nuanced.

While I’m not opposed to CTing that patient, neuroimaging is pretty low on my hierarchy of needs. In fact, we should probably stop ordering it in the ED on patients that will be admitted unless they are obtunded, anticoagulated, a victim of trauma, or someone who needs a LP (a underutilized test in elderly undifferentiated AMS). The vast majority will be walking in the morning once you hold a couple doses of their Xanax and Ultram. Let the floor team watch them after d/c’ing all sedating meds and ruling-out metabolic and infectious causes of delirium.

If you decide to CT them, understand that you are ruling out only 2 potential causes of their AMS - ICH and large masses. It should in no way make you feel better about ischemic stroke.

 

[RuralEDDoc]

Chief complaint from patient, "My lawyer sent me in."

"Why, what medical problem do have?"

"Nothing, but he told me that I need to be seen if I want to get any money from the accident. So I need you to check my neck."

I’ve had these a few times. It’s one of the rare times that I try and directly quote the patient for most of the H&P. So it makes sense to everyone else when little to nothing is ordered.
In a similar vein, I’ve found that many patients presenting 2-5 days after MVC with various minor pains that everyone and the family dog knows is not serious, when you really dig into it, are there because a family member told them they need the ER visit for a lawsuit. It’s too early to have made a plan with a lawyer, but also enough time for everyone to know that nothing serious has happened. People know their necks are not broken when they show up four days after an MVA. I discuss NEXUS, radiation risk and CANCER, and treatment options before ordering the CT they came in for.
Sigh... I miss working with the truly rural poor, where this wasn’t an issue, ever (at least where I worked).

 

[thegenius]

Bottom line, physicians need to stop reflexively ordering head CTs unless it’s to drive emergent therapies in patients with hyperacute symptoms or some other special circumstances such as anticoagulant use, remote trauma in elderly, etc.

Well...most people who come in dizzy are elderly people on anticoagulation and have possibly fallen in the recent past.

 

[deleted109597]

And what is your yield on that? MRI misses up to 6% of posterior strokes in the first 24 hours. Do you also admit all 65 year olds with dizziness even with a normal neuro exam?

This is where malpractice and other things have screwed us.
If they don't have a neuro finding (other than dizziness), then sure, they can go home. The data for crescendo strokes is nowhere near as robust as crescendo TIAs.
If they have hard neuro findings/cant't walk (and could prior to today), then they get admitted.

 

[Rendar5]

I’ve had these a few times. It’s one of the rare times that I try and directly quote the patient for most of the H&P. So it makes sense to everyone else when little to nothing is ordered.
In a similar vein, I’ve found that many patients presenting 2-5 days after MVC with various minor pains that everyone and the family dog knows is not serious, when you really dig into it, are there because a family member told them they need the ER visit for a lawsuit. It’s too early to have made a plan with a lawyer, but also enough time for everyone to know that nothing serious has happened. People know their necks are not broken when they show up four days after an MVA. I discuss NEXUS, radiation risk and CANCER, and treatment options before ordering the CT they came in for.
Sigh... I miss working with the truly rural poor, where this wasn’t an issue, ever (at least where I worked).

I never image these folks. Just giving a diagnosis of cervical strain/sprain should be plenty. I’ve never had someone complain but if they did I’d ask if they’d rather have a diagnosis showing damages or a CT showing no damages.

 

[thegenius]

This conversation about dizziness with no neuro symptoms is akin to unstable angina - discharging a 65 yo person with acute chest pain and negative EKG's and Troponins, yet they continue to have chest pain in the ED (that isn't a PE, dissection, PNX, etc.). I doubt many of these are going home.

 

[RuralEDDoc]

I never image these folks. Just giving a diagnosis of cervical strain/sprain should be plenty. I’ve never had someone complain but if they did I’d ask if they’d rather have a diagnosis showing damages or a CT showing no damages.

Right. To clarify, they don’t get imaging unless the history and exam support it.