bell’s palsy and the unasked question

Monday, April 2, 2012

Bell’s Palsy is one of those diagnoses that defines the disconnect between physicians and patients. Imagine the thoughts that raced through Kim Mulkey’s mind when she looked in the mirror and saw that half her face was paralyzed. The Baylor womens’ basketball coach was diagnosed with the nerve irritation just before she left to coach her team at the national championship. Unless, they have had experience with Bell’s, most people don’t calmly survey their face, but instead move right into panic mode worrying about stroke or other brain disasters.

Bell’s palsy describes irritation of the 7th cranial nerve, the nerve that controls the face muscles and allows a smile, frown, a tight squeeze of the eye and other facial expressions. If the nerve stops working, the muscles it controls stop working as well. Bell’s is a peripheral neuropathy just like hitting your funny bone (actually the ulnar nerve) at the elbow and having your hand hurt and go numb. The body anatomy is described like a computer. Central problems involve the brain and spinal cord. Everything else is peripheral and affects the nerves after they have exited the central system and made their way to the far reaches of the body.

In the ER, Bell’s is an easy diagnosis and usually takes a minute or two at most to make. Often the nurses make the diagnosis as they place the patient in the room and the doctor has to work hard to keep an open mind. The facial droop is easily seen but because the way the face is wired, the key to the diagnosis is looking at the whole face. If the patient cannot wrinkle their forehead, then the diagnosis is Bell’s. If they can wrinkle it, the big concern is something bad happening centrally in the brain like stroke, bleeding or tumor. Common things are common and most often the diagnosis is Bell’s. The doctor makes the pronouncement, suggests treatment and leaves the room happy that all is well.

But all isn’t well with the patient, because they looked in the mirror and thought stroke. Without hearing the actual magic words like stroke, brain bleeding or tumor, the patient might leave the doctors still fearful that some disaster is percolating. The same disconnect happens with other complaints and unless the doctor can anticipate the patient’s unasked question, their needs won’t be met. The diagnosis may be fine but there is something missing with the visit. Some unasked questions are easy. Abdominal pain equals appendicitis. Chest pain equals heart attack but never mind that other killer diagnoses can also present with chest pain. Leg swelling equals blood clot. In most unplanned visits to the doctor, the patient fears some disaster diagnosis whose name needs to be spoken before the visit can be called a success.

Sometimes the unasked question is so specific to the patient’s situation that the permission must be given to actually ask the question. The worry might stem from a relative who had a catastrophic illness that began with a benign complaint. There may be a previous experience where the diagnosis was delayed or missed and may cause longstanding fear and distrust. Regardless of the situation, both patient and doctor need to be on the same page.

While the playbook needs o be the same, the patient does not get the automatic right to demand tests or treatments that would not necessarily be beneficial. Not all headaches need CT scans or MRIs and not all chest pain needs a heart catheterization. Sometimes, though, the battles aren’t worth fighting from the doctor’s perspective and it may be easier to give in to technology instead of standing firm with a diagnosis made on clinical grounds. That should be the exception. Patients need to be involved in decision making and deserve to understand what the doctor is thinking and how the diagnosis came to be made… with or without technology.

Back to Ms. Mulkey and her paralyzed face. When she left her doctor’s office, she knew that her face didn’t move because of a peripheral neuropathy. Hopefully she was also told what wasn’t going on and perhaps she asked the questions that are often left unasked.

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