89. At 1:25 a.m., Wey was discharged from the hospital.
90. Wey's medical condition was stabilized at the time of the transfer.
91. Neither Mr. nor Mrs. Wey was ever presented with a form known as an Emergency Room Consent to Transfer to sign. As they were not presented with it, they neither refused nor consented to sign it.
92. The fact that the consent form on the authorization to transfer was left blank was unintentional, and represented a simple lack of communication between Dr. Spector and the nurse, Lydia Neitz, R.N.
93. Wey did not refuse to sign anything--specifically, he did not refuse to sign the Authorization to Transfer. Wey was not provided with any documentation at the hospital that he refused to sign, including but not limited to the Authorization to Transfer. Likewise, Mrs. Wey was shown no document or asked to sign no document which she refused to sign.
94. Wey was given a discharge instruction sheet which advised him to go directly to the VAMC and to keep his leg elevated; Wey signed this instruction sheet.
95. Wey was given his x-rays and an ice pack to take with him.
96. Wey was taken from the emergency room to his car, a 1980 Honda prelude, in a wheelchair by Lydia Neitz, R.N.. The car was brought to the door of the emergency room. The nurse assisted in tilting the car seat and placing the ice on Wey's ankle.
97. Wey was then driven to the VAMC by Mrs. Wey.
98. Neither Mr. nor Mrs. Wey told Dr. Spector that Wey wanted to go to the VAMC by ambulance.
99. Wey did not protest to Dr. Spector or to anyone else the fact that he was leaving the hospital.
100. Wey did not complain, did not show any signs of resentment or hostility, and did not react negatively when leaving the hospital and at the time of the transfer. Mrs. Wey did not complain when leaving the hospital and at the time of transfer.
101. Mrs. Wey did not verbalize to Dr. Spector that, if given a choice, she preferred to have her husband stay at the hospital or that she did not wish him transferred to the VAMC unless an ambulance was available.
102. Mrs. Wey did not have any discussion with anyone other than Dr. Spector relating to the decision to go to the VAMC or the method of transportation to be used.
103. Wey himself said nothing to Dr. Spector on the subject of whether and how to pay for an ambulance were one to be used. Wey testified that he was not involved in any discussion relative to an ambulance versus a private automobile.
104. Given his confusion and mental state at the time of the incident, Wey is not now able to reconstruct what Dr. Spector said relative to the transfer to the VAMC.
105. Dr. Spector was aware that Wey would be transported by Mrs. Wey by private car. Mrs. Wey expressed misgivings about transport by private car, but did not directly protest the mode of transport used.
106. Wey could not keep his leg elevated in the Honda Prelude, as directed by Dr. Spector, because of his height.
107. Mr. and Mrs. Wey arrived at the VAMC at approximately 3:05 a.m. on July 20, 1991.
108. About two hours after the second Demoral injection (which was given immediately prior to departure from the hospital), the Demoral began to wear off and Wey felt additional pain. This took place for about the last twenty minutes of the trip.
109. After arriving at the VAMC, Wey told Dr. Bali that he was HIV positive, had ITP, and had been on AZT and Dapsone under Dr. Plotkin's care. He was admitted to the VAMC as an inpatient.
110. Upon admission to the VAMC, Wey was given IVIG to stabilize his low blood platelet count, and was also given antibiotics.
111. On August 1, 1991, an open reduction and internal fixation of Wey's fracture was performed at the VAMC.
112. On August 5, 1991, Wey was discharged from the VAMC.
113. During the period from July 20, 1991 through his discharge, Wey received treatment at the VAMC for his ITP (low platelet count).
114. Surgery was not immediately performed at the VAMC; the surgery was delayed because, in Wey's word's "they wanted to make sure I had plenty of antibiotics and intravenous gammaglobulin to prevent any type of bleeding."
115. Before surgery at the VAMC, the physician wanted to stabilize Wey's HIV positive status and low platelet count.
116. The type of surgery performed on Wey is not typically performed on an expedient and immediate basis. In Wey's case, immediate surgery was unnecessary and medically unsound. The proper course was to consider and stabilize the underlying medical conditions.
117. During his treatment at the hospital, Wey received appropriate quality medical care and the emergency room physician, Dr. Spector, exercised appropriate medical judgment in the treatment that he gave Wey.
118. No material deterioration of Wey's medical condition occurred during or as a result of the transfer to the VAMC. Wey did not sustain any permanent injury or loss of function as a result of his transfer from the hospital or the mode of transportation, nor was the eventual surgery delayed as a result of the transfer to the VAMC.
119. Since his discharge from the VAMC in August 1991 and through the present, Wey has continued to receive treatment at the VAMC. He has also received treatment at Geisinger Medical Center.
120. Wey was readmitted to the VAMC in October 1991 because his platelets were at a questionable level and needed to be raised. During that admission, Wey again received IVIG treatment as well as physical therapy for his ankle.
121. Wey has also been seen on several occasions at the VAMC on an outpatient basis for treatment of his ankle, HIV/ITP problems, and drug and alcohol counselling.
122. Wey has also received IVIG therapy at Geisinger Medical Center in October of 1992.
123. The defendant hospital has the following policies and procedures:
(a) "Evangelical Community Hospital prohibits discrimination on the basis of race, color, creed, sex, national origin, age, veteran's status, 'marital status, or disability. This policy applies to practices, accommodations, and the opportunity for those associated with the Hospital to participate in programs or services."
Evangelical Community Hospital Patient's Guide.
(b) The Patient's Bill of Rights provides that