Decipher Dizziness aka “Giddiness”

From the Desk of Sagar Galwankar, MD

Today I want to discuss about another common complaint in Adult patients Emergency Departments often quoted as “Dizziness” aka “Giddiness” which is NON TRAUMATIC.

This is a very crucial complaint which requires a detailed history and clinical examination.

Vital Signs are very important and when I say Vital Signs I mean Temperature Pulse Blood Pressure and Respiration. Pulse Ox is also important.

I regularly ask for a Bedside Blood Sugar and Patient to be put on a Monitor and a IV Line be placed.

I will discuss some cases which brig out important aspects about this Major Masquerader.

Case One

55-Year-Old Healthy Male comes with Dizziness. Vital Signs Are Stable. Dizziness was sudden onset and patient felt diaphoretic. The patient is having Vertigo too and says everything is spinning.

There is Diabetes Hypertension History of CAD/MI or a CVA.

Pt looks distressed and feels everything is Spinning.

Vitals ordered and IV Oxygen Monitor placed.

EKG CBC LFT RFT Troponin and CXR and CT Head is ordered. 

Orthostatic BP is ordered and Pt is Orthostatic.

EKG Shows ST Elevation MI and Patient is sent to Cath lab.

Case Two

25-Year-old female comes with Dizziness. 

Patient is on her menses and feels very weak. 

She is restless and is saying that she can’t even stand. 

Bleeding started today. She is orthostatic positive.

Vitals , Vitals ordered and IV Oxygen Monitor placed.

EKG CBC LFT RFT Troponin Bedside UA and HCG Ordered.

HCG came back positive and Ultrasound was done. 

Patient had an ectopic and was sent to Sx.

Case Three

Patient comes with Fever Dizziness and inability to maintain balance. 55 Years old Male. Diabetes Hypertension + No H.O MI/CAD

Detailed Neuro exam reveals Ataxia. Dizziness started one hour ago.

Vitals ordered and IV Oxygen Monitor placed.

EKG CBC LFT RFT Troponin and CXR and CT Head is ordered which is negative.

Pt continues to feel dizzy.

MRI/MRA Brain is ordered and an Evolving CVA is diagnosed.

Pt  gets Thrombolysis.

Case Four

66 Year Old Female comes with Dizziness.

Says she has uneasiness in the chest and has bouts of dizziness.

When she feels dizzy she has Palpitations in the heart and she feels short of breath.

Pt is obese and has Diabetes Hypertension and is a Chronic Smoker with COPD.

Vitals ordered and IV Oxygen Monitor placed.

EKG CBC LFT RFT Troponin and CXR and CT Head is ordered which is negative.

Everything is negative and Pt again has Tachycardia upto 140 and feels dizzy in the ED.

A CTA Chest is ordered and she has Saddle Emboli in the Lung.

Case Five

15 Year old Downs syndrome Child comes with Mom complaining that “Room is spinning”

Clinical Exam is done. Neuro Exam is Normal.

ENT Exam reveals Fluid in Middle ear.

CT Head is done and patient has early Mastoiditis.

Treated with abx post admission.

Case Six

55 Year Old Female comes with Dizziness and vertigo. This has increased in last one week.

No history of weakness or chest pain or TIA or Anginal Symptoms

No Risk Factors

Vitals Orthostatic negative

Two sets of EKG Enzymes CT Head CBC LFT RFT Negative.

Clinical Exam normal

Epley Maneuver is done and patient feels better and is discharged after 4 hour observation.

Case Seven

35 Year Old male comes with extreme dizziness. Everything including clinical exam and Labs and CT Head is negative.

Cardiac Markers negative.

Detailed Deep History reveals that patient was at a rave party and a UDS reveals Amphetamines and Cocaine +

MRI/MRA Brain Reveals a Thalamic CVA

Case Eight

50 Year old Male comes with new onset dizziness. IV Oxygen Monitor and Labs EKG Ordered . No Risk Factors, But is Obese.

Inverted T waves seen in anterior leads.

Pt says that he has been having chest and abdominal discomfort.

Abdomen is tender all over.

Rectal Exam Positive for Fresh Blood.

Patient gets a Lactate Ordered which is high and so is the white count.

CTA Abdomen done which reveals SMA Ischemia.

Patient goes to Sx.

Summary

Dizziness is a great masquerader. Looks simple but can be a presentation of a life threatening Medical Conditions.

The Recipe to decipher Dizziness Evolves around a detail history keeping age and gender in mind.

Diabetes and Hypertension are risk factors for any Neuro Vascular or Cardiac Acute Syndrome. 

DKA and HTN Emergency are major causes of Dizziness and a IC Bleed needs to be ruled out.

Vital Signs Orthostatic and taking a detail history to R/O TIA / ACS is key

CBC LFT RFT Trop EKG CT Head and UA with Pregnancy Test (In Females in Pregnancy Age group w/o Hysterectomy) are basic labs.

When you do a clinical Exam do ask about H/O PE , Thyroid Issues, Pacemaker Status and H.O CA or MI

 Fever with dizziness could be early sign of meningitis / encephalitis/ brain abscess so do an LP and a CT Head

GI Bleed, Ectopic Pregnancy are also presentations which cannot be missed.

Arrhythmia could indicate cardiac ischemia or a conduction defect which may also be related to drug abuse or endocrinal disorders like thyroid storm.

A Drug abuse history is important and Pulmonary Embolism has many unconventional presentations.

Stress Anxiety are also diagnosis which can be present when all major causes are ruled out.

Abuse also should be considered.

Examining the ears and eyes and considering Ear Pathologies and Glaucoma can be a cause.

I will admit a patient if I suspect a TIA or ACS even though everything is negative. Ataxia is a Major factor which decides admission for me.

Admitting other conditions like GI Bleed Ectopic SMA Syndrome is a no brainer.

Dizziness can be an allied presentation of something very different, so remember that.

Ask for history of Trauma Syncope Fall Head Injury: The patient may not tell you that initially unless you ask.

When you have many patients in the ED with Different Presentations and one of them is Dizziness- Remember there is more to just being DIZZY !

Happy New Year to all !

(Image Courtesy: Bing Images themissespots.wordpress.com)

Sorting out Gabrahat ~ The Common Complaint in the ED

From The Desk Of Sagar Galwankar, MD

Gabrahat is often a common complaint with many implications.

 While working in Emergency Departments in India I have been surprised with what the ultimate diagnosis was when I investigated Gabrahat.

For me Gabrahat is as vague as the Horizon and I take this complaint very seriously. It is very easy for any Nurse or Emergency Physician to get framed and just label Gabrahat as Anxiety or Hysteria.

This can be the Epic Blunder of Large Proportions.

Many times relatives who accompany the patient will Frame the Emergency Physician by saying words like “There is Tension”.

What they mean to imply is Gabarahat is Stress Related.

I often relate Gabrahat to a “SENSE OF IMPENDING DOOM”

When you grade GABRAHAT in that perspective, it guides the Emergency Physician to be very Proactive and diligent.

Let me share a few blasts from the past which I have modified for the sake of Education.

Case One:

Middle Age Female comes to the ED saying that she is feeling SOB. She is hyperventilating and Diaphoretic. She says that she has been having pain all over the body and fells GABRAHAT as if something is going to happen to her.

Her vitals are stable but she continues to breathe hard and breath fast.

The relatives were doing a Fine job of Framing her as hysteria.

Rapid Fire Questionnaire Labs EKG Trop and a X-ray Beta HCG UA and a BNP are ordered.

On examining the patient the only Finding is the breathing.

Lorazepam given IV and Oxygen started and ABG Ordered which is showing alkalosis.

Aspirin given and a bedside Glucose is Normal.

She settles down but continues to breathe hard. A CTA Chest is ordered.

There are massive shower Pulmonary Emboli.

Pt gets thrombolyzed and goes to ICU.

 

Case Two:

A 55-year-old women comes with GABRAHAT. She says that she is afraid something is going to happen.

She has no other symptom. She has no Past Psyc Issues.

Labs EKG Trop and an X-ray UA ordered. She has had a prior hysterectomy.

She had an ST Elevation MI. Went to the Cath Lab.

No Symptoms at all. No Past History at all.

 

Case Three:

30-Year-old man came saying He had Gabrahat and felt that there was Irritation in the Chest. NO PAIN BUT ONLY IRRITATION.

Exam Past History negative.

Cardiac labs CBC RFT LFT was negative so was his EKG and Xray.

Against the will of the Internal Medicine Colleagues Pt admitted.

4 hour repeat EKG and Trop was placed from the ED

His EKG was normal but his Trop had become positive.

Cardiology who scheduled the patient for a cath after admitting him to CCU found a Tight Lcx Lesion which needed a Stent.

 

Case Four:

48 Female with Gabrahat.

Second visit after discharge from the hospital.

Come back saying she is afraid.

No Pain, No Focus of Infection.

CBC RFT LFT Cardiac Labs X-ray Beta HCG and UA Negative.

Says her Mind tell her Something is wrong. She has GABRAHAT.

Was admitted in a nursing home. CBC Electrolytes creatinine and SGPT was done and after overnight IV Fluids patients sent home.

A CT Head done and the patient had SAH. No Neck stiffness no Eye signs. Admitted to Neurosciences ICU

The only thing that prompted a CT Head was “My Mind is telling Me.

This was perceived as Hallucinations hence CT Head Ordered.

Case Five:

18 Year Old Male comes with Gabrahat with Hallucinations.

He was at friends party and says “ I have gabrahat as I see a ghost”.

Tox Work up was done and it was positive for multiple substances.

Routine CBC RFT LFT EKG Trop UA and Xray with a CT Head and Tox Screen were done.

Case Six:

40 year old male comes saying that he has Gabrahat and he feels like a huge Log of wood just fell on his head and nailed his whole body vertically into the ground.

Clinical Exam and Vitals were normal.

CBC LFT RFT Trop EKG Xray negative

No Neck stiffness Neuro exam normal.

He kept saying I am afraid I am sinking into the ground.

CTA Aortagram ordered: He had a dissection from Thorax to iliac bifurcation.

Admitted to CVTS Sx.

 

Summary:

• Basic Approach should be T/P/R/BP/Pulse Ox
• I always order a CBC LFT RFT EKG Trop CXR. Looking for Rhythm abnormalities is also important. Fever can also cause Gabrahat.
• In Females in the Pregnancy Age group a HCG-UA is ordered
• If Patient has SOB I will R/O Thoracic Causes like Dissection/Pneumothorax and PE.
• If Patient has a presentation of Altered Mental Status I always order a CT Head.
• If Toxicology screen is available, I will order one.
• Co-Symptoms should guide further investigations.
• Discussing with the Relatives in key to educate them- that this is not Hysteria / Tension / Stress. Those are the diagnosis to be considered once Major Life threatening causes are ruled out.
• I have often Seen Marital Discord / Intimate Partner Abuse to be causes of GABRAHAT. So Going deeper into the history. Sitting with the patient with Privacy is the key.
• Anxiety / Panic attack also can be on the differential once Major causes are ruled out.
• Being a Compassionate Emergency Physician is the key. Communication is the answer and Competency to Care is crucial.
• GABRAHAT CAN KILL !

 

I want to Share a Web Review of what Non EM Experts say about GABRAHAT.

I feel a Well Trained Emergency Physician leaves no stone unturned to do the best for his/her patient

 

Web Review:

http://bhj.org.in/journal/special_issue_tb/DPII_11.HTM

http://hrelate.com/natural-remedies-for-anxiety/

http://www.njhonline.com/1993/july_aug_93_vol_11_no_4/spider/ghabrahat.shtml

 

Image Courtesy: Anxiety Cartoons on Bing Images

Guarding the Specialty of EM in India ~ A call to Action by Qualified Real Emergency Physicians !

By Vimal Krishnan Pillai, MD, FACEE                                                                                Principal Secretary, The Emergency Medicine Association 

India is at Cross roads of conflict when it comes to Emergency HealthCare.

The Health Care Industry in India is booming with Corporate for Profit hospitals mushrooming across India …thanks to Investments in India’s HealthCare.

The culture in India is that every MBBS Physician in India aspires to be a specialist. There are around 65,000 MBBS seats in India and only around 20,000 PG seats

 Due to the staggering difference was a constant struggle to achieve some sort of an accredited qualification after MBBS.

This also gave birth to a corrupt pathway where non-accredited courses were designed and marketed for monetary gains. These could be anything from paid Fellowships to any type of non-accredited courses.

Even though there are clear guidelines on what should be quoted as a qualification, there are numerous non- accredited courses thriving here due to regional heterogeneity in medical education and the challenge to govern, regulate and track healthcare providers enforcing the rule was tough.

With the rise of International Investments in HealthCare, like the west the expectations from these investment driven hospitals to prove Quality Emergency Care 24/7 grew.

The campaign to get EM Recognized by the regulatory bodies like Medical Council of India (MCI) and the National Board of Examinations (NBE) as a specialty was only was realized after 2009.

Running a Competent for profit Emergency Department needed committed and qualified Emergency Physicians.

That was the elbow gap when vested forces started manufacturing non-accredited Training Courses which are illegal in India.

If unconfirmed estimates have to be believed there are over 1000+ Medical students who have been lured into such courses.

The unregulated manner in which these malignant and corrupt courses have mushroomed has left the academic community in India stunned.

There has been massive anxiety as regards the factors under which such Unrecognized Training Programs are conducted at hospitals without permissions.

Physicians not recognized or qualified to be Teachers are impersonating the role of being trainers and are conducting training programs using the most vulnerable patients presenting to the Emergency Departments as training subjects without governmental permissions.

Physicians/ Institutions/ Associations not permitted to train are handing out qualifications.

These factors raise a lot of ethical and patient safety concerns.

There are all sorts of Certifications in India without prior permission of the Government of India. These Certifications are also causing a lot of confusion and disharmony for the regulatory agencies.

In this era where Government is moving towards One Nation-One Admission-Uniform Training- One Examination- Standardized Model there will be a dire need to immediately regulate and discipline these irregularities.

It is sad that Emergency Medicine has emerged as a front runner in this misconduct as this is a new specialty and the violators are misusing the brand value of Emergency Medicine to fulfill their selfish motives.

The violators try to justify their actions saying that they are doing “Capacity Building”. They forget that when it comes to be being certified as a SPECIALIST …there has been a system in place for India since independence. The Medical Council of India and The National Board of Examinations have that role well mandated.

CAPACITY BUILDING to improve Emergency Care by training physicians to better care is one thing but to assume and impersonate training programs and award non- accredited masters or degree is grossly illegal.

It is a known fact that India needs Specialist not only in EM but in every field. The worst fear is that If EM Violators continue to foster then other specialties will try to do the same and India will be flooded with Surgeons, Physicians, Pulmonologists, and Intensivists with all sorts of certificates.

It’s a Pandora’s Box which will spring open if this misconduct is not stopped.

At One hand Indian Hospitals are boasting of being a Medical Tourism Destination and one the other hand they are involved in irregularities.

I am a firm supporter of Governmental control of HealthCare and Medical Education.

Violations like these grossly undermine the authority of the Medical Council of India and the National Board of Examinations.

The Government is working hard to improve HealthCare at large and standardize the Medical Education system…..

The Emergency Medicine Irregularities have emerged to be its biggest hurdle.

Violators are fooling the medical fraternity and community while the government accredited degree holders MD/DNB face the uncertainty of being in a job market where non-accredited training and certifications are being doctored as the standards for qualification and quality care.

The future of hardworking post graduate qualified MD/DNB Emergency Physicians are in danger if steps are not taken to one and for all discipline the violators.

No Country would allow this indiscipline or forgive the violators.  India is no different!

I call upon my Fellow MD/NBE PG Students and Qualified Emergency Physicians to unite in this struggle against this fraud where the Authority of our Accreditors (MCI/NBE) is undermined and a mockery of Academic Emergency Medicine is being made.

The Time is now before it’s too late !

 Jai Hind !

 

Mergers, Acquisitions, and Physicians

From The Desk Of ~ Sagar Galwankar, MD

As I read the media there is never a time that I don't get aware that some group is buying some group or merging with some group.

Merging and Acquiring hold the same meaning : It means Reorganization of Resources and Finances for Better Performance and Stronger Position in the Competitive Landscape.

Each of the above words narrows down to only one thing - SROI - Strategic Returns on Integration- Which is a nicer acronym for Financial Growth.

Financial Growth for the harvesters and the investors who steer these initiatives.

The real question is : Where does it leave US (the emergency physicians) and what is our future in US (the United States)

In this aggressively reorganizing industry called EMERGENCY HEALTHCARE , I see ourselves being repositioned to be skilled laborers. We the laborers have a highly competitive growing segment  called the  Mid Level Workforce.

EM is going through a phenomenon called LEAP FROG.

The IT industry evolved from large computers to a stage of internet in phones. It evolved and expanded.

We in EM are now straight away a part of this technology driven Industrialization without going through phases of evolution. We have become a small part of the the capitalistic revolution.

We have leaped the cycle of Evolution in this capitalistic revolution, I just hope like the cycle of life evolution , we don't face extinction.

 Care and Cost Balancing is driving the industry productivity. 

Customer- client satisfaction is a metric for stability.

We as a speciality have to evolve with this leap and be aggressive to change, we should think and act to stabilize our present and sustain our future.

The specialty we love needs to live on and live in itself.

The time is now and Optimism is the first phase of evolution.

Fear to not sustain is the key to effectively sustenance.

Creating and Encouraging Thinkers and Innovators to come up with solutions coupled with implementation of strategies nationally are steps which can change things for a better future.

Rethinking Leadership and transforming Education And Innovation for a progressive tomorrow which is in sync with  the changing landscape is the need of the hour.

Change is inevitable & we are all able, let's work to make it stable !

Just thought , hence shared !