health.mil

Sharon Renee Taylor  |  Stripe Staff Writer

March 29, 2010

A special, multidisciplinary “dizzy” clinic at Walter Reed Army Medical Center celebrated its first year of treating active duty personnel who experience dizziness due to traumatic brain injury (TBI). The clinic began March 2009 to improve access to care for soldiers returning from deployment in Operation Iraqi Freedom and Operation Enduring Freedom, and ensure they are seen by specialty providers in a timely manner.

Dizziness, headaches, visual impairment and changes in hearing are common signs and symptoms of TBI, according to the Defense and Veterans Brain Injury Center headquartered at Walter Reed. Many of the “dizzy” clinic’s patients experience dizziness after sustaining injuries due to blast exposures from improvised explosive devices (IEDs), land mines, mortar rounds and rocket-propelled grenades.

“We call it the multi-d ‘dizzy’ clinic because that’s the most common word used by patients to describe several symptoms such as light-headedness, balance problems (imbalance), the room is moving [and] vertigo,” said Robin Pinto, a WRAMC audiologist.

Before the clinic was developed, patients ping-ponged between specialty providers based on who their primary care manager (PCM) in the Warrior Clinic thought they should see — with referrals to ears, nose and throat (ENT) surgeons, audiologists, neurologists, physical therapists (PT) and ophthalmologists — often based on how the patient described their symptoms to their PCM, according to Pinto.

“Ultimately, it seemed like those patients came to us (audiology), it was just a matter of when,” she said.

Timeliness and coordination of specialty care were the main issues, according to the audiologist, who explained the medical concerns for these patients were sometimes complex and easier to discuss in a team environment comprised of specialists in the areas of physical therapy, audiology, neurology, ophthalmology, along with ENT.

“The other thing we looked at was the redundancy of our evaluation between audiology, ENT and PT,” Pinto said.

Each specialty did lengthy case histories, repeated at least six of the same examinations and conducted testing such as ocular motor exams and head shake tests for a combined total of more than 150 different tests in their medical “tool box”.

Pinto said each specialty offered something unique. Audiology provided a comprehensive hearing test and vestibular system evaluation, which tests the balance organ in the ear. PT conducted a comprehensive balance assessment. Otolaryngology reviewed the medical history, medications along with radiology and laboratory results.

The specialties came together March 2009 to form the multidisciplinary “dizzy” clinic, enabling primary care managers to make a single referral for OIF/OEF patients experiencing dizziness due to traumatic brain injury and complex cases. Working as one, the specialties used the team-approach to evaluate patients and devise a treatment plan for an efficient use of both provider and patient time.

Each Wednesday morning the team conducts an initial, 45-minute evaluation for new patients: a 20-minute case history and an additional 15 to 25-minute period consisting of tests to assess balance, visual acuity and other areas. On Thursday or Friday, patients return for two to three hours of comprehensive testing. The following Wednesday, the multidisciplinary team looks at all the tests, goes over impressions, devises a treatment plan and conducts a 15-minute follow-up with patients to educate and individualize their treatment.

Twice a month an ENT specialist, Lt. Cmdr. Arnaldo Rivera from National Naval Medical Center (NNMC) in Bethesda, Md., a head and neck surgeon with a subspecialty in neurotology and lateral skull base surgery, joins the team to review findings and determine how to treat patients. The expert of the inner ear and its balance component replaced Walter Reed’s dizziness expert, neurotologist Maj. Philip Littlefield, who deployed to Iraq October 2009.

“So the goal is integration so we can better share our resources,” said Rivera, who explained that between NNMC and Walter Reed, WRAMC is the hospital with the sophisticated vestibular equipment required to do specialty testing for these patients.

The clinic improved service to patients and efficiency, according to Pinto.

“Access to care is better for [Warrior Transition Unit] patients. Better coordination between the three providers: ENT, PT and audiology, plus we discuss our roles with each other, making more efficient use of the provider’s time and the patient’s time. The patients are guaranteed to see specialists in dizziness. [There’s] more group management-style of handling their dizziness because usually they are multi-factorial, they’ve got other things going on besides dizziness,” she said.

The clinic has treated more than 100 patients, according to Pinto, from all states and across the military services during the past year. Walter Reed works closely with PT, audiology and ENT providers, like Rivera, from NNMC, to provide care for patients at the naval hospital, according to Capt. Karen Lambert, a physical therapist at Walter Reed who works with the “dizzy” clinic.

Health Care [News]  |  TBI   Walter Reed