Oscillopsi-wha?

An elderly man presents with a one-week history of dizziness following a syncopal episode. He was treated with prochlorperazine (Stemetil) by his GP but is now almost unable to mobilise. Lives with spouse. Independent with ADLs. Enjoys beach walks and lawn bowls. A quick gait assessment from ambulance stretcher to the trolley reveals a left-sided list and ‘zombie gait’ – arms held straight ahead, feet picked up in exaggerated movements.  Zombie is obviously not the correct medical word, but it describes his gait perfectly. You’re picturing it now, aren’t you?
This patient presented during the very early days of my ED career. I’d never heard anyone do an assessment of patients with dizziness before, and it certainly wasn’t part of my nursing training. So I am thankful to report that this patient got a rare two-nurse workup on his arrival. I launched into the physical and neurological assessment while my colleague fired off a detailed questionnaire. I listened quietly, with growing amazement and respect, while I jotted down his vital signs (hypertensive, afebrile) and neurological obs (GCS 15, PEARL size 2mm, good bilateral limb strength).  Her line of questioning was instructive, to say the least.
Approximately 8 minutes after he rolled into our care, my fellow RN announced “sounds like oscillopsia, treatment is stemetil followed by a short course of high dose steroids if the stemetil was unsuccessful”. I try not to let my mouth hang open before I slink away to see if oscillopsia rates a mention in the department’s textbook (it didn’t). Nowadays I’d first check whether EMBasic has a podcast about dizziness (it does), because I want to ask the right questions and understand why I’m asking them. I want to know the correct terminology to describe what the patient tells me. In short, I WANT WHAT SHE’s GOT!
Three further comments:
First, this post isn’t really about oscillopsia. In fact, after listening to the EMBasic dizziness podcast (which never mentions the term) I’d have to call oscillopsia a symptom, rather than a diagnosis. The important thing is that I learned something new that translated into improved care for my future patients with and without dizziness. While writing this reflection, the excellent EMBasic podcast led me to a thought-provoking EMCrit podcast about posterior strokes. Thanks to Steve Carroll and Scott Weingart for consistently producing such high quality, free medical education!
Second, I am not in the doctor-business and am happy to keep it that way. Having said that, one of the many things I love about emergency nursing is anticipating what patients will need in their workup, and making that happen. What bloods shall I draw? Will they need IV fluids? What paperwork can I get ready for the doctor (medication chart, medical imaging form, fluid chart). Can I nurse-initiate any analgesia or do they need something stronger? etc etc. The more knowledge I have about pathophysiology and potential diagnoses, the more useful my nursing care becomes.
Third, this small episode shows the value of working side-by-side with our fellow nurses if/when it can be achieved. What I gained from listening to my colleague that day was a sense of the variety of questions that should be asked of patients with dizziness. Sadly most graduates in this district are only given 2 or 3 days of buddy time before they’re thrown in on their own.  Such a loss. Our department has recently introduced team nursing, which has somewhat increased the chances of working side-by-side during a patient work-up. The jury is still out on the success of this initiative.
FYI, after a head CT, the patient was diagnosed with a cerebellar infarct.
Never under-estimate the badness that can underlie the familiar patient complaint of dizziness.
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About tamarahills

ED nurse working on the beautiful Sunshine Coast, Australia.
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3 Responses to Oscillopsi-wha?

  1. EM Basic says:

    Thanks for the shoutout! Your blog post appeared on my WordPress dashboard so I figured I would check it out- great stuff!

    I’m glad that you find the podcast useful and if it helps you think through your patients in a more informed manner then I have done my job.

    Keep up the good work

    Steve

  2. angie says:

    hi Tamara,
    i had a similar experience – a very ataxic man presented to ED, about 50ish yr old, otherwise well.
    no symptoms other than ataxia and nausea.
    he was seen and treated very promptly.
    i remembered a doctor previously had said to me “if they walk like a drunk (or zombie in your case) , think cerebellar”. the ataxia of alcohol is due to it’s effects on the cerebellum.
    ct indicated early cerebellar infarct, sent to referral hospital with neuro specialty. good outcome for pt. 🙂
    i love those small pearls of knowledge related to a case study that demonstrates it – after that i never forget and i always include it as a possibility in assessments

    nice blog 🙂

    • tamarahills says:

      Hi Angie, thanks for your comment and for dropping by the blog. The blog’s on hiatus due to a ten-week overseas trip at the moment, but future posts are quietly simmering in the background. You’re absolutely right that certain pearls stick with you and guide future assessments. Glad there was a good outcome for your patient!

      Cheers,
      Tamara

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