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Torn tendon results in $1.2 million settlement
News: A man sustained lacerations to his right index finger and middle finger and was immediately taken to the emergency department (ED) of a local hospital, where a physician's assistant sutured the wound. The man returned to the hospital on three occasions, where hospital officials noted decreased extension in the man's long finger of his right hand. The hospital referred him to a hand specialist, who determined that the man's injury included a complete tear of the extensor tendon of the man's long finger and soon thereafter repaired the tendon. Within months, the man began experiencing a dropping of his uninjured ring finger and eventually began suffering the effects of carpal tunnel syndrome and related ailments. The man sued the hospital, claiming that the actions of the ED staff in not recognizing the torn tendon were outside the normal standard of care. Despite the fact that the man could use his hand for normal activities, a jury awarded the plaintiff damages in the amount of $1,278,000.
Background: A 56-year-old man, who was employed as a supermarket executive chef, sustained lacerations to the back of his right, dominant hand. Lacerations were suffered on his right index finger and the back of the large knuckle of his long finger. Immediately following the injury, one of the man's co-workers took him to the ED of a local hospital. The injuries were sutured by a physician's assistant, who was being supervised by an ED physician. At the time of discharge, the diagnosis read, "laceration to finger without tendon injury, laceration to hand without tendon injury."
Unfortunately, the man's injury did not heal properly. He visited the hospital on three additional occasions during the two weeks following the date of the injury. During those visits, the hospital noted decreased extension in the middle finger of his right, and more dominant, hand. During his last visit, the hospital advised him to consult a hand specialist and provided him with a referral slip stating "rule out ligament injury."
About 20 days following the date of the injury, the man visited a plastic surgeon with no special training in hand reconstruction. The physician splinted the man's hand and scheduled him for an MRI one month later. The MRI scan showed that the man's injury actually was a complete tear of the extensor tendon of the middle finger of the right hand. The physician performed surgery to reconnect the tendon via primary repair at another local hospital.
A few months following the surgery, the man began experiencing a dropping of the uninjured ring finger of the right hand, also known as "mallet finger," probably caused as a result of the slackening in the ring finger's tendon when the long finger's tendon was tightened by the plastic surgeon during the reconnection surgery. The majority of mallet finger injuries can be treated without surgery. Physicians recommend that ice should be applied immediately, and the hand should be elevated above the level of the heart. A doctor may apply a splint to hold the fingertip straight (in extension) until it heals. Most of the time, a splint will be worn full time for eight weeks. Over the next three to four weeks, most patients gradually begin to wear the splint less frequently. Although the finger usually regains an acceptable function and appearance with this treatment plan, many patients may not regain full fingertip extension.
Nevertheless, as a result of an extensive period of swelling, immobilization, pain, nonuse, and altered use of the hand/wrist, the man developed severe carpal tunnel syndrome and thereafter, reflex sympathetic dystrophy, also known as complex regional pain syndrome, in the right hand and lower arm. The man underwent surgery for carpal tunnel release about two years after the initial injury. Carpal tunnel release can improve strength and decrease pain in most patients, if they are good candidates for the surgery. The procedure improves pain, nerve tingling, and numbness better than it improves muscle weakness. The longer the patient has had symptoms, the longer the recovery time and the less fully he or she may recover.
The man filed suit against the treating hospital, alleging that the hospital's ED staff failed to diagnose the torn extensor tendon in his right middle finger and that the failure constituted a gross deviation from the accepted standard of care. Likewise, the man's plastic surgeon testified on his behalf stating that the ED physicians' failure to recognize the possibility of a torn tendon was a deviation in the standard of care. As a result of the alleged negligence, the man suffered the permanent effects of carpal tunnel syndrome and reflex sympathetic dystrophy, including tremors, burning pain, a hyperextended long finger, a dropped ring finger, decreased strength, and diminution of his fine motor skills. In light of these effects, the man claimed that he was unable to return to work as a chef, earning $50,000 per year.
The man also argued that the hospital's records failed to provide any evidence that ED staff had performed "standard" tests necessary to rule out a torn tendon. Those tests include the "strength against resistance" test that is protocol for potential injuries to the tendon; because if the tendon tear is close to the juncturae tendinum, then the patient still would be able to display motion on other, nonresistance-bearing, physical exams. Finally, the man argued that while the ED staff may have ruled out a tendon tear as to the injury to his middle finger, they did not do so as to the index finger.
The hospital's expert witness countered by stating that the failure to diagnose a torn tendon can occur in the absence of negligence, and the fact that torn tendons do not always lie directly beneath the location of the wound make them more difficult to diagnose. Under cross-examination, the hospital expert did concede that a patient may be able to pass a physical examination of the injured finger despite the existence of a torn tendon, thereby highlighting the importance of testing similar to the strength against resistance test.
In response to the man's claim that he could not return to work because of the long-term injury, defense counsel introduced evidence that the man was able to rake leaves, drive his car, open his trunk, and carry large bags of grocery from his car to his home.
Ultimately, a New York jury felt that the hospital's ED staff had not met the requisite standard of care and awarded the man $1,278,000 in damages.
What this means to you: This case illustrates an issue that does not receive sufficient attention: Return visits to the ED.
The patient was a chef. Since the law mandates that you "take the patient as you find him" this fact becomes significant in assessing damages. Given the patient's occupation, the injury he suffered was not only foreseeable, but could also negatively affect his ability to engage in his profession. It appears from the limited facts that this injury occurred during the course of the patient's employment, and thus would be perceived as an injury covered by workers' compensation. Since the facts do not touch on this issue, it is unknown how this issue was managed and whether any award was secondary to insurance coverage.
The patient was taken promptly to the ED by a co-worker; however, it appears that even on this first visit, it could be argued that sufficient care was not provided in that there is no evidence that the physician's assistant conducted appropriate tests to determine if there was additional injury to the patient's fingers and hand. This points out an issue with supervision of physicians' assistants and the importance of protocols that require appropriate training and oversight.
Also important is the fact that the patient returned to the ED three additional times during the two weeks following his initial visit to the ED. Even if the failure to diagnose a torn tendon can happen in the absence of negligence, there can be no excuse for the failures to appropriately treat this patient on three additional visits.
It appears likely that the jury took this fact into consideration, as well as the fact that the negligence directly affected the patient's ability to perform his profession in awarding the patient more than $1 million in damages.
The issue of return visits to the ED has traditionally received attention only retrospectively during routine quality assurance reviews. However, a more proactive approach would not only improve patient care, but also it would decrease the likelihood of claims. To that end, it is recommended that ED staff develop policies and procedures to address return visits that include the following criteria: 1) level of review; 2) need for consult; 3) additional lab or X-ray studies; 4) a call-back system; and 5) detailed documentation. When a patient returns within a relatively short period of time with the same symptoms, it is incumbent upon the health care providers to heighten the level of inquiry and a specific course of action related to the patient's injury. Clearly, when a patient returns three additional times within two weeks, bells should have gone off, alerting staff to the need for greater diligence in treating this patient.
New York County (NY), First Judicial Circuit, Case No. 108872/03.