The Panel did not find any literature advocating that patients be admitted because of bad weather

A 59-year-old male patient slipped on ice while getting off of a bus and fell onto his left knee, suffering what would later be diagnosed as a left quadriceps tendon tear. He was evaluated in an emergency department by the emergency physician, who noted that the patient was unable to extend his knee and was unable to bear weight.

An orthopedist was consulted and evaluated the patient in the emergency department. The orthopedist performed an arthrocentesis, put the patient in a knee immobilizer, and gave the patient instructions for outpatient follow-up.

Crutch training was performed by the emergency nurse and the emergency physician. During training at one point, the patient had some difficulty in ambulating, almost fell backward, but maintained his balance using his injured leg. After 20 minutes of crutch training, the physician noted that “I think the patient will do well with crutch practice.”

The patient later stated that he informed the hospital staff about concerns he had with his ambulation and with the bathroom in his home being on the second floor. He was advised that he would have to go up and down stairs in his home “on his butt.”

The emergency physician discussed crutch use versus walker use versus wheelchair use with the patient, and the patient decided to leave with crutches. The emergency physician gave the patient a prescription for a wheelchair if the patient became uncomfortable using crutches. The patient’s pain rating on discharge was 3 of 10.

While getting out of his car after discharge, the patient slipped on the ice, fell backward, and fractured his right ankle.

The patient filed a lawsuit against the hospital and the physician for failing to admit the patient to the hospital to repair his quadriceps injury on his first visit, alleging that the patient’s “unsafe” discharge was a direct cause of the patient’s ankle fracture.

Standard of Care Panel Review

The medical literature recommends early surgical repair of complete quadriceps tendon ruptures. There is no standard on when that surgery must be performed. Some sources recommend immediate repair, while other sources state that surgery may be delayed up to 1 week.

Immobilization and close outpatient orthopedic follow-up is appropriate even in patients who have suffered a complete quadriceps tendon rupture.

In this case, the patient was evaluated, diagnosed with a patellar tendon rupture, immobilized, and given crutch training.

In addition, an orthopedist evaluated the patient in the emergency department, performed an arthrocentesis, and deemed the patient stable for discharge, instructing the patient to follow up at his office as an outpatient.

While the expert witness stated that the standard of care required admission of the patient for immediate surgery and pain control, delayed surgical care after brief outpatient management is common in community hospitals, and the chart clearly showed that immediate repair of the quadriceps tendon rupture was not planned.

Furthermore, the emergency department records showed that the patient’s pain rating at the time of discharge was a 3 on a scale of 1 to 10, refuting the expert’s assertion that admission for “pain control” was warranted.

The expert witness made statements to the effect that “bad weather” and a “snowy day” created an undue risk of injury to such a patient, and the standard of care therefore necessitated the patient’s admission.

However, the Panel was unable to find any literature advocating that patients be admitted because of bad weather.

the standard of care does not require that all pa­tients with acute quadriceps tendon ruptures be admitted.

Requiring admission until weather was “acceptable” or until snow has melted from the ground could conceivably result in the requirement that all patients be admitted to hospitals for several months in some regions during winter to avoid a purported undue risk of injury.

The expert witness stated that the patient should have been admitted to the hospital because he would have to ascend stairs in his home to use his bathroom.

Again, the Panel was unable to find any literature suggesting that all patients with crutches should be admitted to the hospital if they might have to ascend stairs on discharge. Taking this requirement to its logical conclusion would also require prolonged admissions of any patients on crutches who live in multilevel housing.

In several instances during the proceedings, the expert witness referred to what the expert personally would have done in that situation. However, courts universally have rejected a standard based on expert witnesses’ personal preferences.

Rather, the standard of care should be based on what a reasonable physician would do under the same or similar circumstances—based on the information known at the time the decision was made.

Details about incidents that occurred at a later time, after a decision was made, should never come into play when determining whether a provider’s decisions were appropriate for the circumstances.

Conclusions

The Panel concluded that the standard of care does not require that all patients with acute quadriceps tendon ruptures be admitted to the hospital.

While some may consider admission to a hospital a means to “protect” patients, admission to a hospital is not without both physical and financial risks.

Patients can have bad outcomes related to inappropriate admissions. Patients may suffer complications from false-positive testing. Sleep/wake cycles and dietary routines may be disturbed. Patients are often exposed to virulent organisms in a hospital setting and are at risk for developing infections resistant to ordinary antibiotics. Costs of admission may not be paid by insurers if medical necessity is not demonstrated, leaving patients with large medical bills.

Although bad weather and a patient’s living conditions may be considerations in a patient’s ultimate disposition, neither factor should always be case-determinative.

The Panel unanimously concluded that the provider in this case met or exceeded the standard of care in managing this patient.

This entire case review and several others can be found on www.ACEP.org under Practice Resources in the category “Standard of Care Review.”

Any ACEP member aware of questionable testimony regarding the standard of care for emergency physicians, be it by experts for the defense or plaintiff, can consider sending the testimony to the Standard of Care Review Panel. Visit the ACEP Web site for more information about the process and how to submit questionable testimony.