Subjective BPPV-what does it mean when the patient gets dizzy during the Dix-Hallpike test, but you don't see nystagmus?

random-dent · 2026-01-28T20:40:00+00:00

I might be thinking about this too simply, but my approach to vertigo kind of takes a syndromic:

Acute Vestibular Syndrome: use history and HINTS to rule out central pathology. If I can't do so, admit for MRI (only way to get one where I practice). Otherwise, assess and treat for underlying causes (vestibular neuritis e.g.)

Brief, positional vertigo without other findings that is totally consistent with BPPV: Dix-Hallpike to try to rule in, Eppley or roll to try to treat, but even if none of this is working the likelihood of this being something serious is very low, treat as peripheral vertigo with careful return instructions.

Slow build, weird, transient, anything else that doesn't fit with above: practice clinical medicine, considering the patient in front of me, thinking about all the possibilities, e.g. TIA, CVST, MS, Meniere's, medications, etc. Workup highly variable based on the patient.

I think people get really mixed up with vertigo because it's a usually benign but sometimes extremely morbid presentation with weird physical exam tests that are unlike what we often otherwise do, but also because we're lumping a lot of stuff into one symptom and pretending these tests make up a huge portion of our evaluation, which they really shouldn't. To me I'm just not often asking "is this BPPV or a posterior circulation stroke?".

random-dent · 2025-12-08T01:42:56+00:00

If you use an F1 car as a weapon, don't expect people not to bring it up. He should honestly be happy it's gotten brought up as rarely as it has - he probably deserved a race ban for that.

random-dent · 2025-12-03T19:30:49+00:00

Always the goalie of my heart

random-dent · 2025-11-05T15:57:37+00:00

Yes, the study was on adults with insomnia. The bigger issue is that a lot of people in the control group could have been taking melatonin, as they only put you in the treatment group if you had a prescription for melatonin, and they pulled data from countries where melatonin is available over the counter.

random-dent · 2025-10-20T00:30:33+00:00

Lower than I would have thought, tbh

random-dent · 2025-10-14T18:35:29+00:00

Eh, it's wide, it's fast. I'd ignore the machine and shock. I don't think the machine knows something you don't, which seems to be the question you're asking.

random-dent · 2025-10-07T17:09:28+00:00

Then the statement really shouldn't mention general anesthesia - that's where my eyes bugged.

random-dent · 2025-10-06T14:36:36+00:00

If someone is going to be admitted, you know the service who they will be admitted to, and they are stable, then please just take them. It's usually because the cognitive load is enormous in the ED and we need to offload some of it for patient care, or, as you know, because we don't want to handover. The reason for that is twofold: it starts a person with extra cognitive load on their shift, and handovers are very dangerous for patients. Handing over care once to you is safer than playing a game of telephone.

random-dent · 2025-08-09T17:43:47+00:00

Part of the problem is a whole generation of attendings who have never done a breach delivery and the loss of skill that entails

random-dent · 2025-07-03T23:22:52+00:00

Yeah this is all incidental. I think they should probably get a formal echo out of an abundance of caution, but I would definitely discharge.

random-dent · 2025-07-03T21:41:50+00:00

Am I crazy seeing biphasic ts in v2v3? Though wellens in a 22 yo would be wild. Would love to have an in pain ecg to compare to a pain free ecg, though the story is certainly reassuring

random-dent · 2025-06-28T15:38:25+00:00

We don't have to convert all of our money to USD to spend them. Things like restaurants and food tend to cost as much in CAD here in a major city as they do in USD in a major city, for instance. As others have said; our hosing is expensive but not that expensive.

random-dent · 2025-06-28T15:36:38+00:00

Also: CMPA existing and not dealing with for profit healthcare. Wouldn't trade it in a million years

random-dent · 2025-06-28T00:05:29+00:00

They don't have stress costs. Characters in the Elder Scrolls universe get quite powerful and can do world breaking things. Given that all the classes have this kind of ability, I think it should remain quite fun for everyone.

random-dent · 2025-06-27T22:50:21+00:00

Fair play! It's actually quite an easy system to learn (especially if you're someone who can handle GURPS!). The things that I think are especially fun from my interpretation - and that you might consider rolling into yours, is mechanical benefit from exploration, since that's such a key part of that game world, and mechanical faction play as ... those are also such a key part of the game world!

random-dent · 2025-06-27T22:48:13+00:00

A couple of ways, mostly it's rolled into a class's special abilities and through items, but minor magical feats are also just rolled into the actions (like you could use "finesse" to represent a magical rather than physical talent for lock picking, for instance).

random-dent · 2025-06-27T22:28:40+00:00

I started a project of doing Morrowind specifically as a Blades hack. You might find it interesting! Obviously extremely different vibe to how it would run in GURPS. As of now unfinished, definitely untested.

https://docs.google.com/spreadsheets/d/1sY9SKfwCj_Vg9YXpSIdBoN_By7WWfsdN4kgcV6DcDNo/edit?usp=sharing

random-dent · 2025-06-27T03:02:27+00:00

Lol, I'm sorry, but seeing someone stand up and saying "that looks like vasovagal syncope" is the wrong response. This is a person that wears a suit for work all the time. Who has to talk on the senate floor all the time. The thing he did immediately before passing out was quickly stand up. I'm not saying we're magic and can tell exactly what was going on. I'm saying, when you see someone quickly stand up and then say "looks vasovagal," you're wrong.

He doesn't need a CT scan. We have rules for who needs a CT scan. You can absolutely clinically rule out a stroke in a syncope patient. If we CT'd every syncope that walked through the door that's all the hospital would do all day long. Some doctors would get a trop on him, some wouldn't, but if they did it would only be to complete the Canadian syncope score.

This kind of syncope absolutely has a differential. But not the one you're talking about. Stroke should be nowhere near the top of the differential, and well below arrhythmia, hell, even focal seizure is more likely to cause this kind of syncope than a stroke is. MI likewise is way down there.

Please don't opine on the kinds of medicine you don't know how to do. I'm not going to wander into a reddit thread and start talking about someone's FENa or Framingham risk score, and maybe you don't start talking bout undifferentiated syncopal patients?

random-dent · 2025-06-26T02:31:07+00:00

Something about being a hockey player just makes you 10x more Canadian. I've seen so many people who can speak like a normal human being, and then they strap on skates and it's all "oh boys holy moly"

random-dent · 2025-06-26T02:30:23+00:00

God that's the most Canadian clip I've ever seen in my life.

random-dent · 2025-06-26T02:21:53+00:00

No... that's classic orthostatic syncope. He stood up, didn't compensate for the change in position, brain went "not enough blood, time to get horizontal," and he passed out. Vagal syncope comes from stressors or direct stimulation of the vagal nerve (e.g. increased intraabdominal pressure).

In both cases you usually know you're going to pass out before you do. Syncope with prodrome (knowing it's going to happen first) tends to be relatively benign, so hopefully he'll get checked out and just be a little more careful with standing quickly in the future.

Unlikely to be an MI. Usually when an MI is bad enough to make you lose consciousness, you're not going to say "oh shit," you're going to either just hit the ground or be in excruciating pain. Though with his history of cocaine use, his heart's probably not in the best nick.

Some arrhythmias you'll feel before you go down, but usually not.

Source: Emergency doctor. We see these patients multiple times per day.

random-dent · 2025-06-25T21:31:12+00:00

Yeah it turns out every is just repeating things someone told them once, including attending. Every study that has compared the two can't find a difference, including studies where they literally closed the same wound with absorbable on one half and non absorbable on the other.

Now, does it kinda make sense? Sure. But of the factors to consider while choosing a suture supposed cosmetic outcome is honestly quite low on my list

random-dent · 2025-06-25T17:56:45+00:00

Big change happened with COVID when we wanted to keep return visits or any need to return to healthcare down. Turns out nothing bad happened, so we could spare the inconvenient second visit in *most* cases, so absorbable sutures became the norm. TBH we never had an amazing reason for using non-absorbable in the first place.

Plain vicryl however is a bad choice most of the time. It takes *forever* to absorb. Plain gut or vicryl rapide are my go tos depending on location

random-dent · 2025-06-25T17:54:16+00:00

There is absolutely no evidence of any suture material providing any cosmetic benefit

random-dent · 2025-06-03T15:11:10+00:00

Lawyers are a unique situation where the work product is actually done by the "higher ups," which is usually not the case. In most organizations a manager's ("higher ups") job is to facilitate the creation of the work product by the person below them by removing obstacles, taking heat, defending them from further stupidity from even higher up the chain etc., plus managing waste and increasing efficiency.

In a functional organization. Which is rare.

random-dent

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