Jonathan Edlow

@raghu_venugopal @NightShiftMD @PeterJohns84 @TheSGEM Big difference between "CAN" EPs use HINTS correctly versus "DO" EPs currently use HINTS correctly. Data are clear that we don't, but data are equally clear that, with training, we CAN. The majority is correct that we don't, but wrong that we can't learn!

When called upon if we can do thoracotomy, cricothyroidotomy, pericardiocentesis, perimortum c-section - then we can learn HINTS and improve. An EPIC smartphrase about the neuro exam is not enough either. @PeterJohns84 @TheSGEM

@LWestafer @TheSGEM Two comments. First, OK, there is nothing quite like watching the tube go through the cords, or the rush of air from a chest tube for a Ptx, but the Epley is INCREDIBLY FUN!! The nursemaid's elbow of neurology. And as for "good faith", it's really good Dx and good technique.

I think this is one of the major wins of #GRACE3... Too often it’s meclizine & dc rather than good faith effort at canalith repositioning & troubleshooting if epley fails (bc time & maybe because less “fun” than other “procedures”?). Evidence for meclizine isn’t great

@Hamishmcmack @TheSGEM @PeterJohns84 @ZoiNetou @SAEMonline @NeurologyToday @aleksmineyko @syaddana_neuro @neuroccm @robertohle @marymclean85 HINTS & BPPV Dx/Rx techniques are NOT 'shortcuts' anymore than testing limb ataxia/Babinski are shortcuts. The 'difficulties' are partly b/c people are hesitant to use them. Dix-Hallpike/Epley are not new. HINTS is not magic. Sure, be humble, but be smart too.

@TheSGEM @PeterJohns84 @ZoiNetou @SAEMonline @NeurologyToday @aleksmineyko @syaddana_neuro @neuroccm @robertohle @marymclean85 A bit of a straw man argument here. Of course they don't all need MRI and admission. But they do need a humble approach and acceptance of the difficulties of diagnosing vertigo, without over-reliance on shortcuts. The anecdotes here are heavily biased and not truly evidence imo.

#GRACE3: Acute Dizziness and Vertigo in the ED New guidelines from @SAEMonline saem.org/publications/g… Looking for feedback from Neurologists. @NeurologyToday @Hamishmcmack @aleksmineyko @syaddana_neuro @neuroccm @ZoiNetou Watch for #SGEMHOP episode this weekend.

Custom Image imgflip.com/i/7luadg via @imgflip OK, last Star Wars meme on HINTS and dizziness. Believing that you can intubate, place a chest tube, do a FAST exam, use up to date bedside exams for dizziness, you won't ever learn.

imgflip.com/i/7lu6jf via @imgflip Don't use the old "what do you mean dizzy"? (symptom quality) approach. Ask about timing and triggers of dizziness, just like you would a chest pain patient

Don't use dizziness symptom quality but rather its timing & triggers Custom Image imgflip.com/i/7lu6jf via @imgflip

Custom Image imgflip.com/i/7lu6jf via @imgflip

Yoda training Luke imgflip.com/i/7lu4dr via @imgflip

Custom Image imgflip.com/i/7lu3nv via @imgflip Must be open minded to learn new techniques; think POCUS.

@emlitofnote @DrJessePines @SAEMEBM @embasic @lucasojesilva12 @SAEMonline @mfbellolio @SameerSharifMD @SuneelUpadhye @DanyaKhoujah @dromron @MDaware @EMSwami @broomedocs @EMManchester @EMEducation This guideline is NOT a medico-legal danger. We write in black and white right in the abstract that, "it is not standard of care". How much more clear could one be that HINTS is NOT standard of care. Not buried on page 10, but IN THE ABSTRACT!!

@DrJessePines @EdlowJonathan @SAEMEBM @embasic @lucasojesilva12 @SAEMonline @mfbellolio @SameerSharifMD @SuneelUpadhye @DanyaKhoujah @dromron @MDaware @EMSwami @broomedocs @EMManchester @EMEducation There's also particular medicolegal danger for regular docs in proposing these as "reasonable and appropriate", with the implication those without expert HINTS training or rapid access to MRI are inadequate. We ought not promote "zero miss" as the only appropriate care.

GRACE-3 is out 🔥 🔥 🔥 First evidence-based clinical practice guideline on the diagnosis and management of acute dizziness and vertigo in the emergency department onlinelibrary.wiley.com/doi/epdf/10.11…

@emlitofnote @SAEMEBM @DrJessePines @embasic @lucasojesilva12 @SAEMonline @mfbellolio @SameerSharifMD @SuneelUpadhye @DanyaKhoujah @dromron @MDaware @EMSwami @broomedocs @EMManchester @EMEducation @MayoClinic @klinelab Re: it being aspirational, it is. But and it differs from a CG that you can start tomorrow & that's why we focus on TRAINING (previous post - it works). Should we not have the target at delivering BETTER patient care than we currently give?

@SAEMEBM @DrJessePines @EdlowJonathan @embasic @lucasojesilva12 @SAEMonline @mfbellolio @SameerSharifMD @SuneelUpadhye @DanyaKhoujah @dromron @MDaware @EMSwami @broomedocs @EMManchester @EMEducation @MayoClinic To propose widespread adoption of examination practices where even @klinelab has gone out and bought a specialized trainer – somewhat absurd absent proof this training will result in practice changes improving outcomes for patients. It *probably* will, but that's beyond GRACE.

@emlitofnote @SAEMEBM @DrJessePines @embasic @lucasojesilva12 @SAEMonline @mfbellolio @SameerSharifMD @SuneelUpadhye @DanyaKhoujah @dromron @MDaware @EMSwami @broomedocs @EMManchester @EMEducation @MayoClinic @klinelab Apart from anecdote (mine, Peter Johns, others), there are 3 articles showing that training works and works well (Gerlier, 2021 and 2023 AEM and Vanni 2017). NOT speculation but data from large numbers of patients!

@emlitofnote @SameerSharifMD @SAEMEBM @DrJessePines @embasic @lucasojesilva12 @SAEMonline @mfbellolio @SuneelUpadhye @DanyaKhoujah @dromron @MDaware @EMSwami @broomedocs @EMManchester @EMEducation @GRADE_McMaster @GRADE_WG 'Zero miss' for ANY diagnosis is not c/w biology or normal practice. GRACE-3 does NOT argue that is should be for PC stoke!! But we do advocate for fewer misses than current care - I don't see that as a bad thing, nor a malpractice risk

@SameerSharifMD @SAEMEBM @DrJessePines @EdlowJonathan @embasic @lucasojesilva12 @SAEMonline @mfbellolio @SuneelUpadhye @DanyaKhoujah @dromron @MDaware @EMSwami @broomedocs @EMManchester @EMEducation @GRADE_McMaster @GRADE_WG For example, passages such as these – widespread intensive training in this specific skill – is a rather big leap from our nearly-no-miss practice state to an even lower-miss/perfect state, without clearly having a generalizable and/or sustainable pathway for said training.

@emlitofnote @SameerSharifMD @SAEMEBM @DrJessePines @embasic @lucasojesilva12 @SAEMonline @mfbellolio @SuneelUpadhye @DanyaKhoujah @dromron @MDaware @EMSwami @broomedocs @EMManchester @EMEducation @GRADE_McMaster @GRADE_WG @DNewmanToker First, re: time HINTS takes ~ 1min ,<3min including BPPV maneuvers (Vanni 2023 AEM). New data since our search. This can save HOURS of ED LOS on the back end. Have been using these tests for ~ 10 years - it is NOT a burden, any more than POCUS is.

@SameerSharifMD @SAEMEBM @DrJessePines @EdlowJonathan @embasic @lucasojesilva12 @SAEMonline @mfbellolio @SuneelUpadhye @DanyaKhoujah @dromron @MDaware @EMSwami @broomedocs @EMManchester @EMEducation @GRADE_McMaster @GRADE_WG @DNewmanToker I agree the estimate of the time spent doing HINTS should be compared to the time spent in a non-structured examination addressing the complaint of dizziness – by a practiced expert, it is likely every bit as efficient.

@TheSGEM @PeterJohns84 @Hamishmcmack @SAEMEBM @drjeffgoodloe @mfbellolio @AcademicEmerMed @SAEMonline @klinelab But that doesn't necessitate a MR in pts with vestibular migraine, or an atypical BPPV (or dizzy sepsis or drug intox pts) w/o nystagmus. So maybe our Rec could have been better crafted/word-smithed, but we are CLEAR that we are re: not doing HIT in AVS pts w/o nystagmus.

Do you want to hear what vertigo expert @PeterJohns84 has to say about the #GRACE3 document on dizzy patients? Click on this link. thesgem.com/wp-content/upl… #SGEMHOP #EBM #FOAMed

@TheSGEM @PeterJohns84 @Hamishmcmack @SAEMEBM @drjeffgoodloe @mfbellolio @AcademicEmerMed @SAEMonline @klinelab OK, his issues with Rec: 6. Maybe not the most artful wording, b/c we were trying to limit the # of recs, but the only safe way to avoid MR in an AVS patient is if your exam = peripheral. We are clear that HIT is only validated in AVS + nystagmus. (TBC)

@TheSGEM @PeterJohns84 @Hamishmcmack @SAEMEBM @drjeffgoodloe @mfbellolio @AcademicEmerMed @SAEMonline @klinelab One more point about hc-BPPV: @KevinKerber12 and I wrote a companion BPPV article. We get into the weeds of the horizontal canal. It's important. We hope as people's comfort with pc-BPPV increases, they will begin to notice the horizontal nystagmus of hc-BPPV.

@TheSGEM @PeterJohns84 @Hamishmcmack @SAEMEBM @drjeffgoodloe @mfbellolio @AcademicEmerMed @SAEMonline @klinelab Re: hc-BPPV, we debated ad nauseam including it and even VOTED on it. I wanted to include hc-BPPV, but was outvoted. Those voting against were not saying it's unimportant, but that TMI would get in the way of recommendation uptake, "perfect being the enemy of the good".

@TheSGEM @PeterJohns84 @Hamishmcmack @SAEMEBM @drjeffgoodloe @mfbellolio @AcademicEmerMed @SAEMonline @klinelab Re: "jumping right to HINTS", our intro defines "isolated" dizziness calling out focal findings (diplopia, dysarthria, weakness, limb ataxia, Horners) so although Peter is unhappy with how or where we said it, the history & exam are obviously quite important

@TheSGEM @PeterJohns84 @Hamishmcmack @SAEMEBM @drjeffgoodloe @mfbellolio @AcademicEmerMed @SAEMonline @klinelab Regarding Peter's "quibble" about our description of the expected "upbeat torsional" (our words) "vertical torsional" (Peter's words), we are saying the same thing. We actually did use "vertical torsional" (p444) based on Peter's review of the draft document.