We all know that it's called the "practice of medicine" and everyone has heard that a doctor is always learning. In fact, I bet that you have heard at least once in your life that your doctor learned from you. Usually we think of this in a different way, for example, a unique disease teaches us, or maybe a patient responds in a special way to a treatment and we learn and log that experience in our memories. But, today I have a very different story to tell.
First, I want to tell you how I helped my patient. A gentleman in his sixties presented with a month of significant dizziness. He would have severe rotational vertigo when rolling over in bed lasting several seconds and leaving him with a feeling of imbalance. He could pinpoint the exact time andplace when his symptoms developed and ever since he had been uncomfortable and actually fearful of motion.
On physical exam he was completely normal except for one abnormality. When I did a Dix-Hallpike maneuver he became rapidly vertiginous on his right side. The Dix-Hallpike maneuver is done by rotating someones face to either their left or right side while sitting up and rapidly laying them down flat. When one experiences intense vertigo that starts after a brief delay and lasts for about twenty seconds they are diagnosed with a disorder called benign paroxysmal positional vertigo, or BPPV.
BPPV occurs when very tiny crystals in the inner ear in the balance portion fall off and become lodged in one of the three semicircular canals. Those semicircular canals are oriented in the X, Y, and Z axis. When crystals become lodged in there when ever you move your head the crystals slide around and cause vertigo. The disorder is very common yet very strange. Whenever I show a patient a diagram of the inner ear and explain how this occurs everyone is amazed how the problem occurs.
Before 30 years ago people suffered until the brain learned to ignore the problem. They would be given exercises to practise. If they didn't improve surgery would be done to plug or destroy the balance portion of the ear to stop the problem. But then a ENT doctor in Washington ,Dr. John Epley, was doing doing surgery on someone with the problem and he could see the little crystals floating around in the semicircular canal. He took a model of the inner ear and figured out that if you placed someone in just the right position and rotated them 360 degrees you might be able to cure the problem.
His idea was slow to catch on because everyone thought it was kind of hokey. I attended one of his lectures and I was impressed by the idea. I was in residency then and my professors thought the idea was silly and wouldn't let me try it. But when I was in practice a few years later I did the maneuver on a nurse who had been dizzy for over a year and cured her.
So, with this gentleman I identified the likely offending ear and took him through my modification of the "Epley maneuver". As I was taking him through it I discussed with the patient that he might be skeptical but that I had a 90% chance of helping him. He promised me that the next time I saw him he would teach me something as well.
Two weeks later, a few days ago, he showed up and said his dizziness was cured. He hadn't had a problem again since he saw me that day. So now he was ready to teach me his trick. When he was young he was frequently afflicted with hiccoughs. Nothing would help. One day he saw an elderly woman that he described as gypsy like. She put her finger on each side of his face just in front of his ears and held them there for a few moments. And, his hiccoughs were instantly cured. Amazed, he asked her exactly how to do this and she taught him. Ever since then he would cure people who were afflicted. He said it was a great barroom trick and earned him more than one free beer. He explained to me exactly how to do the trick.
Just my luck an opportunity presented itself a couple of days later. My three year old daughter Ellie, developed hiccoughs. I did the maneuver and Voila! She was immediately cured. Granted this was just one time and it may have been coincidence so time will tell if it really works. But, either way, this is a patient who really did teach me something new and unique.
Thanks for the great post, Dan. I don't know if you remember, but I woke up one morning about a year ago with rotational vertigo; when I rolled over in bed the whole room spun. I could barely stand. Naturally, my first thought was to call my dear ENT friend Dr. Daniel Spilman. Little did I know that my call would find you relaxing on a beach in Mexico. You patiently described the Hallpike and Epley maneuvers to me over the phone, and my uncomfortable symptoms were quickly relieved.
ReplyDeleteWhen my brother Doug woke up months later with severe dizziness and vertigo, my brother Andrew drove him to the emergency room, and I met them there. Doug had been given a sedative and an anti-nausea medication and was laying in the ER. I asked to speak with his doctor, and asked the gentleman if he had attempted the Hallpike and Epley maneuvers on Doug. (By this time, I had watched several videos of the procedures and considered myself quite an expert.) To my surprise, the ER doctor had never heard of them! I was surprised since dizziness is a very common reason for ER visits.
When Doug returned home later that day I described the maneuvers to him and sent him video links that offer a more detailed description. So you see, you have had an important impact on the health of your patients and friends, even from a sunny Mexico beach.
Malcolm,
DeleteThanks, I totally forgot about that. It's great to hear from you that such an annoying problem brings such great relief with such simple treatment