LAUSR

This commentary accompanies the third Guidelines for Reasonable and Appropriate Care in Emergency medicine (GRACE) focusing on dizziness in the emergency department (ED) setting.1 My primary goal of this short commentary is to put the guidelines in perspective. From a historical perspective, when first I proposed GRACE to the Society for Academic Emergency Medicine Board of Directors in 2018, the number one topic on my list was dizziness. The significance of the complaint is obvious. First, the complaint of dizziness occurs as the chief complaint of about 3% of all patients seeking emergency care.2 Second, dizziness raises a diverse and long list of potential causes, ranging from selflimiting conditions to disabling or fatal stroke. In current ED practice, dizziness often leads to a descriptive diagnosis, rather than (patho)physiological diagnosis.2 Third, no previous guideline for the overall management of dizziness from emergency care (or any other) literature exists. Fourth, in contrast to many other complaints such as chest pain, dyspnea or syncope, dizziness is less often a focus of teaching forums such as grand rounds or book chapters. More recently, dizziness was recognized as a potential source of diagnostic error in emergency care.3 Thus, dizziness was the perfect topic for GRACE. From the clinical perspective in the ED, at the bedside, readers should immediately contextualize the fact that GRACE 3 only addresses the patient who does not have medical causes of dizziness such as inadequate cerebral perfusion (which itself has many causes), multiple sensory deficits, or side effects of a medications. Only half of the 3% of patients with acute dizziness have diagnoses attributable to the central nervous system or inner ear and this is the group that GRACE 3 addresses.2 Moreover, GRACE 3 does not provide any guidance on how to distinguish medical causes from neuroor otogenic causes of dizziness, causes that typically are identified by history, vital signs, and physical examination. However, for the patient with dizziness that a reasonable and prudent physician believes is not medically caused, GRACE3 suggests transformative thinking and call to action in terms of training and education. This call for change is reminiscent of the introduction of ultrasound to emergency care in the 1990s.4– 8 Analogous to the case with ultrasound then, I expect now to hear some grumbling about having to learn new skills to distinguish peripheral from central causes of nonmedical dizziness. Based on multiple studies, discovered and processed using the rigorous GRADE methodology, the expert panel sets forth the evidencebased rational to compel us to learn the head impulse test and the Dix– Hallpike test, and Epley and supine roll maneuvers.2,9 (Note, whether you use the HINTS or STANDING methodology, both require the head impulse test.) Taking the easier skill first, the Dix– Hallpike, Epley maneuver, and supine roll test can be done on any given day by anyone with access to YouTube. However, when it comes the head impulse test, from firsthand experience, I have found this skill is the opposite of intuitive and requires hours of training to achieve adequate competence. This learning challenge applies to the leadership in emergency care training and education and to those in current practice. In 28 years of academic emergency care practice, I had never learned or heard of the head impulse test until about 5 years ago. I found the head impulse test so challenging to learn that I spent my own money to buy a commercially available, FDAcleared, computerized video eye tracking device to help teach myself and others how to do the maneuver (Natus vHIT).10 I also recruited a fantastic education fellow at my institution (Dr. Jacob Lenning) to devise an educational research project (approved by the Wayne State University Institutional Review Board [IRB]) that employs this device as a criterion standard quality test of the ability of learners to do the head impulse test. Although likely a function of recall bias, for me, at this stage in my career, I have found the head impulse test skill more difficult to acquire than I recall was the case to learn intubation, inserting a central line, or suturing. The head impulse test requires at least three simultaneous skills: (1) the