Sps. Ramos v. CA G.R. No. 124354 29 December 1999

Facts:

Erlinda Ramos, an otherwise healthy woman, experienced occasional pain due to a gallstone, and was advised to undergo an operation for its removal (cholecystectomy).  She was referred to a surgeon, Dr. Orlino Hosaka, who agreed to perform the operation and promised them to find a capable anesthesiologist.

The day before the scheduled date, Erlinda was admitted to De Los Santos Medical Center for her early morning operation. At 7:30 AM, she was prepped by hospital staff and the anesthesiologist, Dr. Perfecta Gutierrez, and was accompanied by her sister-in-law, Herminda Cruz (Dean of College of Nursing at Capitol Medical Center), for moral support. Preparatory injections and procedures were administered. As of 9:30 AM, Dr. Gutierrez advised Herminda that Dr. Hosaka was running late and that the operation might be delayed. Erlinda and the OR staff wanted to find a replacement surgeon but no one was found until Dr. Hosaka finally arrived at 12:15 PM, whereupon the staff proceeded to perform their duties.

Dr. Gutierrez intubated Erlinda, who remarked on the difficulty of the procedure and that her belly was distending; Herminda noticed that Erlinda’s fingernails were turning blue, and Dr. Hosaka issued an order to call another anesthesiologist, Dr. Calderon, who proceeded to intubate Erlinda but raised her feet to increase bloodflow to her head. There was a commotion and several other doctors and a respiratory machine were rushed into the room. At 3:00 PM Erlinda was comatose and rushed to the ICU.

Two days after the operation,  Dr. Hosaka explained to husband Rogelio that there was a complication during intubation, which Rogelio said wouldn’t have happened had Dr. Hosaka found a good anesthesiologist as per their agreement. Dr. Gutierrez explained to DLSMC that Erlinda experienced a bronchoplasm.

Erlinda stayed in the ICU for a month, and was released from DLSMC after four months without improvement and an exorbitant bill. She is completely comatose and reliant on mechanical respiration and feeding to survive, and was diagnosed with diffuse cerebral parenchymal damage due to 5 minutes without oxygen while the doctors were having trouble intubating her.

Rogelio filed a civil case for damages against Drs. Hosaka and Gutierrez and DLSMC, on behalf of Erlinda and their children. The plaintiffs presented Herminda and another doctor as witnesses that Erlinda suffered injury as a direct result of the intubation, but the defendants relied on expert testimony of a pulmonologist to prove that the brain damage was a result of an allergic reaction to the anesthetic agent.

RTC sided with Rogelio, finding the defendants guilty of negligence in the performance of their duty: Dr. Gutierrez is liable not properly intubating Erlinda and not readministering the preparatory drugs since the operation was delayed for 3 hours; Dr. Hosaka is subsidiarily liable for selecting Dr. Gutierrez as anesthesiologist and for inexcusably arriving 3 hours late; and DLSMC for the doctors’ practice within their operating room and for not cancelling the operation due to delay. RTC notes that the doctors were negligent because the coma was a direct result of the improper intubation,there shouldn’t have been a need to call another anesthesiologist if everything was alright, and the procedure should have been cancelled due to the delay since it was only an elective procedure.

On appeal, CA reversed the decision but failed to properly notify Rogelio’s counsel on record, hence Rogelio was only able to seek legal assistance4days before expiry of the reglementary period. Motions on the extension of the period to file for reconsideration were denied, hence this present petition for certiorari.

Issues:

  • Are the expert witnesses needed?
  • Are the doctors and hospital negligent?

Held:

  • NO, expert testimony is not necessary
  • YES, the defendants are negligent and liable

Ratio:

  • Res ipsa loquitur applies in this case
    • “The reason is that the general rule on the necessity of expert testimony applies only to such matters clearly within the domain of medical science, and not to matters that are within the common knowledge of mankind which may be testified to by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to whether a patient has been treated or operated upon with a reasonable degree of skill and care. However, testimony as to the statements and acts of physicians and surgeons, external appearances, and manifest conditions which are observable by anyone may be given by non-expert witnesses. Hence, in cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper proof of injury to the patient, without the aid of expert testimony, where the court from its fund of common knowledge can determine the proper standard of care.”
  • Res ipsa loquitur does not automatically apply to all cases of medical negligence
    • “Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied, depending upon the circumstances of each case. It is generally restricted to situations where a layman is able to say, as a matter of common knowledge and observation, that the consequences of professional care were not as such would have ordinarily have followed if due care had been exercised.”
    • “A distinction must be made between the failure to secure results, and the occurrence of of something more unusual and not ordinarily found if the service or treatment rendered followed the usual procedure of those skilled in that particular practice. … Thus, res ipsa loquitur is not available in a malpractice suit if the only showing is that the desired result of an operation or treatment was not accomplished.”
  • Defendants were unable to overturn presumption of negligence
    • Appellate court erred in holding that Herminda’s testimony as a nurse is incompetent compared to the expert testimony of an anesthesiologist, on the ground that nurses are not taught to intubate and that she did not personally check on Erlinda’s condition, because Herminda is perfectly capable of observing Dr. Gutierrez’s statement of difficulty and discoloration of Erlinda’s fingernails, hence expert testimony is unnecessary.
    • Anesthesia procedures are now so common that ordinary persons can tell if it was administered properly, even without a medical degree. Herminda, as a clinical nurse in several noteworthy hospitals and now Dean of a College of Nursing, is more than competent to testify on what she saw.
  • Gutierrez did not deliver the standard of care expected
    • She only met Erlinda on the morning of the operation itself and was not able to conduct a thorough pre-operational assessment of her airway, and so was unable to anticipate difficulty in finding Erlinda’s trachea “because it was positioned more anteriorly (slightly deviated from the normal anatomy of a person) making it hard to locate and, since Erlinda is obese and has a short neck and protruding teeth, it made intubation even more difficult.”
    • Gutierrez attempts to evade by saying that she doesn’t conduct pre-operational evaluations except in emergencies or abnormal cases, but the exact opposite is actually true—emergency cases mean there is no time to evaluate the patient, while elective cases give the doctor all the time in the world to assess the patient before the procedure.
  • Defendant’s expert testimony is inadmissible
    • The expert witness they provided was a leading pulmonologist, but not an anesthesiologist, hence is not competent to enlighten the Court on the effects of the drug administered.
    • There is no supporting evidence that the coma was induced by an allergic reaction—no rash, wheezing, or other symptoms.
  • The improper intubation was the proximate cause of the coma
    • The first intubation led the tube through the esophagus into the stomach, not through the trachea into the lungs, as shown by the distention of her belly.
    • The time from the first and second attempt was significant, leaving Erlinda without oxygen which resulted in brain damage.
  • Hosaka is liable as the “captain of the ship
    • It was his duty to ensure that the anesthesiologist complied with proper protocols
    • He was late because he had scheduled another operation at the same time in a different hospital, and should have rescheduled Erlinda’s operation.
  • DLSMC is liable despite not having a strict employer-employee relationship
    • Private hospitals exercise significant control in hiring and firing consultants, even if they’re technically not “employees.”
    • DLSMC failed to adduce evidence that it exercised the diligence of a good father of a family in hiring and supervising the doctors in this case.

Credit:

Nathan De Leon

One thought on “Sps. Ramos v. CA G.R. No. 124354 29 December 1999

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