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...
Source:
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
