Acute Dizziness in the ER: Expensive and Ineffective Practices

Can I get an “Amen?”

A recent article published by Johns Hopkins (www.hopkinsmedicine.org) nicely summarizes and adds some interesting facts to the argument (okay, soapbox) that I have been trying to make over the past year or two: the practice of ordering CT scans, and not doing a brief vestibular function screening when a patient arrives at the Emergency Room complaining of dizziness, just can’t be defended. The evidence is there, and it is overwhelming. A simple 5-minute screening would allow physicians to efficiently separate patients in to a “peripheral vestibular” or a “possible stroke” category with near perfect accuracy. Nothing’s perfect, but a simple screening protocol is more efficient and sensitive at separating these groups than a CT scan or even a cranial MRI.

A couple of years ago, I had this discussion with a local ER physician, and he agreed that I was probably right, but that he would not change his practice patterns. Why? Because, he said, doing a CT scan and an EKG on all patients complaining of dizziness, was standard protocol, and he wasn’t going to take a chance on missing a stroke or a heart attack. He felt that missing an inner ear disorder was less problematic and less likely to trigger a lawsuit than was missing a stroke or heart attack. Who can argue that logic?

But…can we continue to afford this practice? The Hopkins article points out two things I have written about in the past, and I will point out a third problem.

1. CT scans miss most brain stem strokes in the early acute stages, and MRI’s miss a significant percentage.

2. CT’s and MRI’s are potentially harmful, expensive or both.

3. The patient remains undiagnosed and ineffectively treated.

So, what’s the logical, cost effective solution? The Hopkins article alludes to two options, and I will offer a third:

1. Education for ER and Primary Care physicians. They need to know how to do the simple vestibular function screening.

2. Equipment. Basic vestibular screening equipment is not cost prohibitive (probably less than the cost of CT and MRI scanning ordered over a few weeks).

3. A Clinical Practice Guideline for initial assessment of the dizzy patient. If there is an accepted protocol , not only will it give physicians more confidence to perform the correct screening, it will give them confidence that they are not going to be successfully sued in the very rare circumstance that an emerging stroke evades the screening protocol.

This Johns Hopkins article should be mandatory reading for all primary care physicians. In addition to a great summary of existing arguments supporting vestibular screening in primary care and emergency rooms, the article offers some new demographic information I had not seen previously.

We will continue to review/explore this article and topic next week.

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.