March 22, 2013

ER Doc Found Negligent in Bell's Palsy Case

This case is not quite what you might think...

Here's the background... The Wisconsin State Supreme Court  found an ER physician negligent for failing to offer a carotid ultrasound for a patient who presented with an isolated facial paralysis (patient did not exhibit paralysis anywhere else in the body) and upheld a $2 million jury award to the patient in 2008. Not only that, the Wisconsin Medical Board reprimanded the ER physician and fined her $300. [link]

Hmmmm... After all, it is not considered routine nor standard of care to obtain a carotid ultrasound for an isolated facial paralysis known as Bell's palsy. I should also mention that the ER physician was NOT found negligent in the diagnosis of Bell's palsy.

Well, here's the other part of the story... The patient did have a CT scan of the brain in the ER which was normal. A diagnosis of Bell's palsy was appropriately made by the ER physician and the patient sent home. Eleven days later, the patient suffered a stroke with irreversible damage. A stroke workup at that time revealed a carotid artery with 95% obstruction.

For those uninitiated, paralysis due to a blocked carotid artery would cause lack of blood flow to one entire half of the brain resulting in not only facial paralysis, but also paralysis of half the body too. Furthermore, a stroke causing facial paralysis would have forehead sparing (more on this).

The court's feeling was that the patient should have been offered a carotid ultrasound at the time of the initial ER visit for Bell's palsy... in essence, the court was stating a stroke workup should have been offered/done for a Bell's Palsy. I should also mention that most ER's do not have carotid ultrasound capabilities outside of business hours.

To reiterate, a carotid ultrasound is NOT a test that a physician would or should normally order for a Bell's Palsy workup. By the court stating a carotid ultrasound should have been performed, it has turned a medical condition of Bell's palsy which is not a stroke concern into a diagnosis of possible stroke.

Does that now mean that whenever a patient presents with a Bell's palsy, a stroke protocol should also be pursued which would include:

1) Stroke rapid response by the ER
2) Hospital admission
3) Stroke workup which would include:
  • Carotid ultrasound
  • MRI Head
  • Cardiac workup for arrhythmias (atrial fibrillation which can cause embolic stroke)
  • Pulmonary and vascular workup for deep venous thrombosis (can also cause embolic stroke)
etc, etc, etc

Medically speaking, Bell's palsy is NOT a stroke nor a concern for possible stroke nor increased risk of stroke. Bell's palsy is an isolated inflammation of the facial nerve that has nothing to do with the brain.

ER physicians have a hard enough job as it is now, but to be responsible for pursuing workups for totally unrelated diagnosis separate from the main presenting concern should be cause for concern.

Perhaps there is more to this case that was absent from what has been reported in the media...

State board reprimands doctor who was found negligent by high court. Wisconsin State Journal 3/21/13

Health Sense: How much should doctor tell you? Wisconsin State Journal 7/9/12
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.


Anonymous said...

Your recitation of the facts blatantly misstates them. I'm sure you have interesting thoughts on this case and many other legal topics, but step 1 is to know the underlying facts. Going off half-cocked after (mis)reading a media report is not advisable, as it results in utterly ridiculous pearl-clutching garbage.

"The relevant facts are not in dispute for purposes of our review. On June 13, 2003, the coffee Jandre was drinking began coming out of his nose, and he began drooling and slurring his speech. The left side of his face drooped. He experienced about 20 minutes of dizziness and weakness in his legs." (p. 17)

Anonymous said...

Before commenting anonymous, you need to understand medical facts before uttering your own "utterly ridiculous pearl-clutching garbage."

Drooling and slurring of speech can occur due to facial paralysis itself due to oral incompetence (people can not pucker the lip).

Both leg weakness actually argues AGAINST stroke. Stroke would cause only ONE-sided weakness.

Dizziness can be due to a whole list of issues... rarely a stroke (medication side effects, anxiety, BPPV, cervicogenic, etc).

Get your own medical facts straight.

Anonymous said...

Why don't you state your name and profession instead of hiding behind anonymity so you can show the world how brilliant (or not) you are!

Fauquier ENT said...

Thank you for providing a link to the full Wisconsin Supreme Court decision anonymous.

Your point about having all the underlying facts is well-taken.

However, you must also understand that when physicians read such court decisions, it is not a matter of my being "half-cocked... utterly ridiculous pearl-clutching garbage".

We make a decision on what tests to order based on how a patient presents at that moment. Once a diagnosis was reached of Bell's palsy which was found NOT negligent by the court which affirms the ER doc DID reach a correct diagnosis, the problem is being found liable for possible OTHER diagnosis (ie stroke in this case)... and being responsible to pursue testing for all the other possible diagnosis and I mean not just stroke.

A diagnosis of Bell's palsy precludes a diagnosis of stroke as I mentioned in the blog. That's a medical fact which is what makes this case outcome so "frustrating". This court case would have made MUCH more sense it the ER doc was also found negligent for INCORRECTLY diagnosing a Bell's palsy.

Physicians do not want to get sued...

We try to do the right thing... while also taking steps to avoid getting sued.

As such, we try to "learn" from such lawsuits that do come about to modify our future behavior to avoid getting sued like this ER doc.

For physicians who read outcomes of a case like this, we will be persuaded to not only order appropriate tests for what we think is going on, but we are now persuaded to order a whole slew of other testing to evaluate for all the other possible diagnosis that may be present in order to avoid getting sued.

Let's take a common ER presenting complaint of low-grade fever and cough. Normally, a chest x-ray might be obtained to ensure absence of pneumonia. Patient might be given some antibiotics and than sent home. However, this court case now mandates we now offer:

• CT Chest to evaluate for pulmonary embolus that may cause cough and fever
• Bronchoscopy to evaluate for rare fungal pneumonitis that may cause cough and fever
• CT Sinus to evaluate for sinusitis that may cause post-nasal drainage leading to cough and fever
• Barium swallow to evaluate for esophageal pathology that may cause reflux into throat with aspiration leading to fever and cough.
• Esophagoscopy and Laryngoscopy to evaluate for tracheo-esophageal fistula that can lead to cough and fever
• Cardiac echocardiogram to evaluate for congestive heart failure that can lead to fluid in lungs that would cause cough and fever
• 24 hour holter EKG to evaluate for cardiac arrhythmias that may cause transient congestive heart failure that can lead to fluid in the lungs that would cause cough and fever
etc, etc, etc

Where does it stop???

Unknown said...

I didn't read the article, but was wondering if the "patient" scheduled a follow up appointment with their primary care doctor or recommended specialist? I know every time I've been to the ER, they have told me to follow up with the appropriate doctor for said problem. When does it become negligent on the patient's part?

Unknown said...

I also don't wish a stroke on anyone. I forgot to mention that in my previous post.

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