Acute dizziness: A personal journey through a paradigm shift

Abstract

As a philosophy major in college in the 1970s, the most memorable book I read was Thomas Kuhn's The Structure of Scientific Revolutions. 1 Kuhn argued that science does not always progress in a linear fashion, from the cumulative results of sequential experiments but rather, advances often occur abruptly, due to revolutionary innovations prompted by new tools or new concepts.His most famous example is the shift from the Ptolemaic geocentric theory of planetary motion (sun revolves around the earth) to the Copernican heliocentric view (earth revolves around the sun).The Ptolemaic system had been scientific gospel since Aristotle. It successfully explained many of the ancient astronomers' observations, but increasingly failed to explain others. Galileo's modifications to the telescope produced new data that were inconsistent with the Ptolemaic theory and supported the Copernican view.Kuhn called this a "paradigm shift." He described a progression of "normal science" (sequential experiments) to scientific "crisis" sparked by new data that do not fit the prevailing paradigm. These crises sometimes culminate in "revolutions" and ultimately lead to a "resolution" as the new paradigm becomes generally accepted. Scientific revolution is not restricted to the natural sciences. New tools (Einthoven's electrocardiogram or Rontgen's x-rays) and new concepts (Semmelweis' work on puerperal sepsis) revolutionized medical practice. However, new ideas are rarely greeted with open arms, but rather with skepticism and mistrust. In 1847, Semmelweis' imple-How to cite this article: Edlow JA. Acute dizziness: A personal journey through a paradigm shift.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

“…The crucial caveat is that emergency clinicians must learn to perform the maneuvers and interpret results effectively and, currently, no validated training program exists. Creation of such a program with validated content, methods, and duration that result in proficiency should be a priority for emergency medicine 266 …”

Effectiveness and reliability of the four‐step STANDING algorithm performed by interns and senior emergency physicians for predicting central causes of vertigo

“…Third, a seemingly minor difference is critical to recognize the usefulness of the STANDING algorithm designed by Vanni et al 18 a few years later. Some cases of direction‐changing nystagmus triggered by head movement are related to otoliths adhering to the horizontal semicircular canal 7 . This mistake occurred only in one case of lateral BPPV that was correctly diagnosed by the senior EP thanks to the supine head roll test.…”

“…Several history‐based scores have already been proposed to stratify the risk of stroke by avoiding a vestibuloocular examination, 42,43 but recent works have proven that doing so in ED patients would lower the quality of care, by increasing the number of requests for neuroimaging without lowering the number of missed strokes to an acceptable rate 13,19 . The value of LRs of the algorithm (i.e., 10.33, 0.35, and 0.001 for worrisome, inconclusive, and benign outcomes, respectively) suggested that EPs should shift their paradigm in patients with no objective anomaly through the four‐step algorithm, by relying timing and triggers of symptoms 2,7 . Experience gained from the routine practice of BPPV testing would likely reduce the number of inconclusive outcomes as they were more frequent among interns than among senior EPs.…”

“…Experience gained from the routine practice of BPPV testing would likely reduce the number of inconclusive outcomes as they were more frequent among interns than among senior EPs. Indeed, as with other chief complaints in emergency medicine, appropriate identification of vestibular symptoms causes call for EPs of all experience levels to adopt evidence‐based diagnostic tools in their practice 7,24 . The training implemented in this study requires reasonable time and effort that should be feasible in many EDs.…”

“…Given the concern for stroke, EPs are challenged from a diagnostic and a management standpoint: relying on reliable clinical features, deciding adequately either to perform or to defer neuroimaging, and either referring patients to an otologist consultation or admitting them in the neurology department. Without a reliable clinical approach due to lack of learning about vestibular conditions, 7 this dilemma could lead to overuse neuroimaging in benign disorders. However, brain computed tomography (CT) is commonly available around the clock, but very insensitive at detecting posterior ischemic strokes (28.5%) 8,9 .…”