Dizziness Series-Part I "What is dizziness or vertigo?"

Dizziness forms about 15 - 20 % of my practice.Dizzy patients are given symptomatic treatment by general practitioners & usually they are referred to specialists like Physicians,ENT's,Neurologists,Neurosurgeons,Cardiologists and to Psychiatrists.

I thought of dividing the topic into 3 parts

1. Introduction & brief anatomy

2. Clinical Approach:Good history & targeted neurotological examination

3. Management 

"What is dizziness or vertigo?"

The term Dizziness or vertigo is synonymously used.

The term dizziness tends to be used by patients to include a wide spectrum of sensation from dizziness or disequilibrium through spatial disorientation to simple faintness,blackouts  or light headedness.Some of the patients simply refer their symptoms to Meneire's or Positional vertigo.

Literally the word vertigo has come from Latin word "Vertere" which means whirling ie to turn.Other effective definitions are "a subjective sense of imbalance "which may or may not include sense of rotation"(Kerr) & "illusionary sense of unidirectional environment and/or bodily rotational movement "(Daroff).

Balance is maintained by visual apparatus (eyes & it's neural connections ),vestibular system (includes inner ear structures -3 semicircular canals & 2 otoliths) & the proprioceptive organs (proprioceptors sensory receptors in muscles, joint capsules and surrounding tissues, that signal information to the central nervous system about position and movement of body parts).

Above chart courtesy vestibular disorder association who have a very informative website vestibular.org

Though we have three organs as mentioned above to maintain balance,two are sufficient to maintain balance.Brain decodes the signal send by these organs through respective nerves.

Disclaimer :Kindly note the above information is over simplified for a lay man to understand & in no way depicts exact neuro anatomy which is not the intention of this blog)

Patients evaluating Doctors - Just dial is enough or mouthshut.com will do?

"To observe without evaluation is the highest form of human intelligence."

- J. Krishnamurti


But we are all not non violent communicators.We are all very busy people & are very good at evaluation,labeling & commenting.We mix evaluations with observations & if someone does not come up to our expectations - we are upset.

Some examples of patient feed backs -'The doctor seemed uninterested in my illness"
'The doctor is rude" "The doctors is not fit to practice"
If you go through the above survey sites even the most respectable doctors with whom I have worked & personally know that will do no harm-get such remarks!

My immediate impulsive reply to the person who brought above feedback can be -'The patients illness probably was really not interesting.What I mean is the patient may have some common cold or viral fever."

I have all empathy for any one who is sick however when I am seeing opd in an tertiary care hospital-there are so many serious things happening around.

There should be an issue if a doctor has not treated the patient properly or poor bedside manners.

In the era of "Patient is always right" -doctors opinion or feedback are never taken.
In order to please patients doctors may be overacting or reacting i.e. to satisfy patient they may over test or over-prescribe. 

Customer satisfaction has been applied to anything & everything nowadays,but can it be applied to the practice of medicine just like in supermarkets?

In Medical practice-there are various factors to be taken into consideration.

Following applies to most of the doctors who are seeing outpatients

1.May be having a sick patient in ward/ ICU
2.May have operated early morning & the patients relatives are wanting to see. (In spite of meeting a close relative post surgery).
3.Ward patients may be in a hurry to go home & the nurse is constantly ringing to give orders
4.Phone calls either about appointment or drug or a new symptom.
5.Emergency department calls to attend a patient
6.Reports to be followed up or collected
.....so on & so forth.....Not to forget ....doctor also needs a coffee break or food.

The patients should know that the doctor needs them as well.The doctors concentrate on keeping them healthy & not "satisfied" as most of the feedback ask.

Eventually the system i.e. feedback form is designed to keep them satisfied first & healthy next.

What makes a patient most “satisfied”.. isn’t what is best for their health.

The reasons for a patient being dissatisfied with a particular healthcare encounter can be very complex.  It’s not so simple as to just include a line in a survey such as, “Were you satisfied with your doctor?

I see children & some mothers are excessively worried..sometimes I do tell them to find other ways of occupying themselves than just their child.Its for their childs wellbeing-It cannot be rude.
Some Google educated patients ask irrelevant questions-I can answer only so much in 10 minutes & sometimes stop entertaining their queries.

Not to mention just like I have many things to handle even the patient may have work stress ,an ill relative or various physical/ mental causes for being anxious or "a bad experience at a previous hospital"
There is so much going on in media that everyone comes influenced & charged.
The feedback form should be designed to take above patient factor in to consideration.

For good patient care & doctor patient relationship-not just patient satisfaction but doctors satisfaction should also be considered.

But giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine.

To summarize -I personally am not against feed back.However encourage patients to describe the situation by just what they saw or heard not what they think should be.

Make your observations free from your judgments, criticism and interpretations. 

Dr. Sheelu Srinivas - The Hindu

Dr. Sheelu Srinivas - The Hindu

Being the change, they want to see - The Hindu

Being the change, they want to see - The Hindu



Support the cause I am working on - bringing deaf kids to mainstream.

Deafness Awareness:documentary in kannada

https://www.youtube.com/watch?v=YQZayyuI7jA

Finally I made a documentary for the Kannada audience as well.Please share this & help to create awareness about hearing disability & its impact on lives of kids.I also happy to inform that I have finally been able to convince National Rural Health Mission (Dept of Women & Child Health,Karnataka) & they have decided to carry out hearing screening for children all over Karnataka.We are starting a pilot at K C General Hospital & NRHM with six center's outside Bangalore.I have been pursuing this cause & must thank Bangalore Pediatric Society (IAP,Bangalore Branch) to give me a platform to present this cause.This is just the beginning & there is a long road ahead to reach the goal of improving lives of the hearing impaired.Please help to spread awareness about hearing loss & its impact.

Unilateral hearing loss in children

share click share to read.

We have diagnosed 7 cases of unilateral sensorineural hearing loss in children in the last 6 years in our center.I would like to add that clinical history,examination & radiological investigations usually help to find etiology or cause of deafness.3 cases had distinct radiological findings like abnormal inner ear development.Other 3 had history of viral illness like mumps.One case did not have any specific finding & was worked up for autoimmune etiology.
Habilitation & regular follow up is vital.

Working with special or differently abled children

On the International day of persons with disability 3rd December -would like to elaborate the role of my specialty with the differently abled.

The United Nations report of 2013 enumerates 15% of the world population to be living with some form of disability (physical,mental & sensory).In India ,approximately 10% of population suffers from disabilities related to locomotion,vision,hearing & intellect as per the NSSO 2010 report.

All you need has been given to you with your child. You’ve got love. Everything starts from there.

As an ENT surgeon,I routinely work with special children & their parents.The role of an ENT will be in assessing,diagnosing ear, nose,throat problems & helping in habilitation alongside the therapists.
Ear:
Often hearing disability or impairment goes undiagnosed as it is not as explicit or obvious as physical impairment or blindness.Ear wax & middle ear effusions should be regularly attended to as in any other child.
Reduced hearing acuity during infancy and early childhood interferes with the development of speech and language skills, because it is likely that the child will not receive adequate auditory, linguistic, and social stimulation required for speech and language learning, social and emotional development, and that family functioning will suffer accordingly (NIH, 1993).It can be argued that these effects are even larger in a population with an intellectual disability.

There are also communication disorders which can be of several types including expressive language disorder & mixed receptive-expressive language 

Nose: Commonly we come across nasal allergy,infection,muscular tone /nasopharyngeal narrowing due to structural abnormality or adenoids.
Throat:
Specific problems in differently abled children are drooling & swallowing or feeding difficulties.
It is considered abnormal for a child older than four years to exhibit persistent drooling and this problem is most commonly seen in special children.The management is tailored case basis.It can be conservative-speech therapy & oral stimulation therapy to use of Appliances –Dental.We also sometimes use anticholinergic drugs.Injection of botox in the salivary gland & Surgery is reserved for severe cases.

Inter relationships  among development of feeding & swallowing & other developmental domain.
Motor skills -> Ability to hold things -> Delay in self feed
Communication development ->Ability to express need ->Attitude towards food
Medical condition -> Delayed feeding patterns->Need to be fed with food textures

ENT Surgeon plays an important role in feeding & swallowing team.

In conclusion,there is so much to do & help our special kids.Its all about strengthening their abilities...as a team.

"It was ability that mattered, not disability, which is a word I'm not crazy about using." - Marlee Matlin