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Todd v. Sauls
Citations: 647 So. 2d 1366; 1994 WL 707239Docket: 94-10
Court: Louisiana Court of Appeal; December 20, 1994; Louisiana; State Appellate Court
Margaret Todd and her seven adult children filed a wrongful death and survival action against Dr. F. Clark Sauls, the cardiovascular surgeon who performed a repeat coronary artery bypass surgery on James Todd. Following the surgery on October 4, 1988, James experienced significant postoperative complications, including a heart attack and subsequent infections that ultimately led to his death on November 2, 1988. The jury found no negligence on Dr. Sauls' part, leading the trial court to dismiss the case. The Todds appealed, arguing that the trial judge made errors in jury instructions, including the application of the locality rule, the burden of proof requiring testimony from Louisiana-licensed physicians, and contradictory instructions. The appellate court reversed the trial court's judgment, determining the jury was improperly instructed, and conducted a de novo review, ultimately ruling in favor of the Todds. The medical history revealed that James had undergone previous bypass surgery in 1984 and had been referred to Dr. Sauls due to failing bypasses. His condition worsened post-surgery, leading to significant weight loss and a heart function test indicating severely compromised cardiac performance. He was transferred to St. Luke's Hospital for further treatment but succumbed to cardiac arrhythmias. Following Mr. Todd's death, his family filed a medical malpractice claim against Dr. Sauls, alleging a failure to meet the standard of care. A medical review panel concluded that there was insufficient evidence to support the claim. Subsequently, a jury found, in a 10 to 2 vote, that the Todds did not prove Dr. Sauls breached the standard of care. The Todds argue that the jury was misinstructed to consider a local standard of care instead of a national standard applicable to medical specialists. They believe the jury should have been instructed solely on the burden of proving the standard of care expected from specialists like Dr. Sauls and that his negligence resulted in Mr. Todd losing a chance for survival. The document emphasizes that jury instructions must accurately reflect the law relevant to the case and that errors do not automatically warrant a de novo review by appellate courts unless they are severe enough to prevent the jury from reaching a lawful verdict. If an instruction error likely influenced the verdict, it warrants reversal on appeal. The jury was instructed that the standard of care involves the skill exercised by local practitioners, which should have been specific to Dr. Sauls’ specialty, rather than a broader locality standard. It was established that Dr. Sauls is a board-certified cardiovascular surgeon, indicating that the proper standard of care should have reflected his specialized training rather than local norms. The trial judge provided conflicting jury instructions regarding the standard of care owed by Dr. Sauls, specifically introducing ambiguity by including Dr. Sauls' name in a context related to non-specialists and locality standards. This led to jury confusion, particularly because the Todds' medical experts were all from outside Louisiana, while Dr. Sauls' experts were local, with six practicing in Alexandria. The trial judge's mention of "similar community or locale" standards exacerbated this differentiation, misleading the jury. Although Dr. Sauls pointed out the Todds' references to not favoring local doctors, this did not rectify the trial judge's error, as he had emphasized the distinction between local and out-of-state experts. The jury was instructed that their decision should rely solely on evidence presented, which included expert testimony. The Todds' attorney indicated that the trial judge would clarify the applicable law, reinforcing the jury's obligation to follow his instructions. Consequently, it was determined that the jury could not properly evaluate the expert testimonies due to these flawed instructions, leading to the conclusion that the jury’s findings were compromised and necessitating the overturning of the verdict. The Todds' medical malpractice claim alleges that Dr. Sauls negligently handled infections in Mr. Todd's surgical wounds and failed to monitor his nutritional status post-surgery, resulting in severe medical complications. According to Louisiana law, the burden of proof in such a case lies with the plaintiff, as stipulated in LSA-R.S. 9:2794(A). In a medical malpractice context, the plaintiff must demonstrate that the defendant physician's treatment fell below the standard of care for their specialty and establish a causal link between the alleged negligence and the plaintiff's injuries. In cases involving patient death, the plaintiff only needs to show that the malpractice resulted in a loss of chance of survival, rather than proving the patient would have survived with proper treatment. The evaluation of a physician's conduct focuses on reasonableness at the time of treatment rather than outcomes. When assessing negligence by a specialist, testimony from qualified individuals in that specialty is required to determine the relevant standard of care, which is not confined to the local standard. In the case of Mr. Todd, the plaintiffs argue that his infected surgical wounds and malnourishment hindered his eligibility for a heart transplant, which was crucial for his survival. They assert that Dr. Sauls failed to meet the standard of care by not adequately treating Mr. Todd's infected wounds and addressing his nutritional needs, despite knowledge of his severely weakened condition. Evidence shows Mr. Todd had significant heart damage and a deteriorating heart function rating, with a notable decrease in performance following surgery. Medical experts, including Dr. Leatherman, indicated that the infection was a critical factor preventing Mr. Todd from being considered for a transplant. Dr. Leatherman observed that Mr. Todd's surgical wounds were the worst he had encountered in a decade, suggesting that with appropriate care, the wounds should not have appeared so severe. During the trial, medical testimony focused on whether Mr. Todd showed signs of systemic infection upon his admission to St. Luke's. Dr. Leatherman diagnosed Mr. Todd with systemic infection, despite negative blood cultures, arguing that prior antibiotic treatment could have led to a false negative result. Notably, he recorded "Sepsis" on Mr. Todd's death certificate as a significant condition contributing to his death. Dr. Leatherman criticized Dr. Sauls, the cardiac surgeon at Rapides General, for insufficient monitoring of Mr. Todd's surgical wounds, suggesting that he should have recognized signs of infection by October 8th, based on Mr. Todd's elevated temperature. He noted that a subsequent white blood cell count of 15,000 on October 10th confirmed infection. Dr. Leatherman stated that Dr. Sauls breached the standard of care by failing to initiate broad-spectrum antibiotics and not consulting an infectious disease specialist. He concluded that earlier antibiotic intervention could have improved Mr. Todd's condition and eligibility for a heart transplant. In addition to infection issues, Dr. Leatherman reported that Mr. Todd was malnourished upon arrival at St. Luke's and that tube feeding was initiated immediately. He indicated that Mr. Todd's nutritional decline had been ongoing during his treatment under Dr. Sauls, who failed to address the malnutrition. Dr. Leatherman emphasized the responsibility of both the surgeon and cardiologist to manage Mr. Todd's nutritional status, noting that malnourishment impairs wound healing. He asserted that Dr. Sauls deviated from the standard of care by not addressing Mr. Todd's weight loss adequately. Dr. Zeluff, an infectious disease specialist, cultured Mr. Todd's surgical wounds on October 26, 1988, confirming infections in all wounds, including staphylococcus aureus and pseudomonas at multiple sites. He noted significant deterioration of the surgical wounds, including purulent fluid and dead tissue, and highlighted the surgeon's responsibility for wound care and antibiotic initiation. Dr. Zeluff criticized Dr. Sauls for not recognizing signs of infection earlier, suggesting concern should have arisen around October 7th or 8th, while Dr. Sauls first considered antibiotics on October 17th. He indicated that Mr. Todd's pre-existing poor heart function necessitated increased vigilance regarding infection. Dr. Zeluff linked Mr. Todd's malnourishment, evidenced by significant weight loss, to impaired healing and suggested that proper nutritional support should have been initiated by October 20th. Dr. Robert D. Pipkin, a cardiac surgeon, corroborated that Dr. Sauls failed to monitor Mr. Todd effectively, particularly around October 17th, when signs of infection were evident. Pipkin, who typically finds no malpractice in 80% of cases he reviews, recommended pursuing legal action in this instance due to the standard of care deviations observed. Dr. Sauls considered starting broad-spectrum antibiotics for Mr. Todd but ultimately decided against it, believing the wounds were improving. In contrast, Dr. Pipkin reviewed the medical evidence and identified signs of infection, such as persistent fever, reddened incisions, blood drainage, and foul odor, indicating a need for antibiotic treatment. Dr. Pipkin emphasized the detrimental impact of malnourishment on healing and stated it was Dr. Sauls' duty to ensure Mr. Todd received adequate nutrition. He noted a decline in Mr. Todd's weight during the post-operative period, highlighting Dr. Sauls' responsibility for post-surgical care. Dr. Pipkin concluded that Dr. Sauls deviated from the standard of care regarding both infection management and malnutrition. Dr. Sauls defended his actions by claiming the medical records supported his appropriate wound care. He cited a decrease in Mr. Todd's white blood count as a reason for not administering antibiotics, expressing concerns about potential superinfection and exacerbating nutritional issues. He later cultured the drainage from the chest tube site, which tested positive for staph, leading Dr. Ertan to start treatment with methicillin. The review of testimonies and medical records revealed discrepancies in Dr. Sauls' assertions. He admitted responsibility for Mr. Todd's surgical wound care but acknowledged he did not regularly read the nursing notes and relied on his observations. Records indicated Mr. Todd's sternotomy wound was reddened and he had a fever of 99.6 on October 17, contradicting Dr. Sauls' claims of vigilance. Subsequent records showed continued signs of infection, including fever and wound redness, which Dr. Sauls failed to adequately address. Dr. Sauls did not order or obtain a wound culture for Mr. Todd, who was described as gravely ill with severely depressed heart function. On October 21, Mr. Todd was transferred to intensive care, but Dr. Sauls failed to note his wound status or a recorded temperature of 100.6°F, despite nurses documenting redness and drainage from the left leg wound. Dr. Sauls attributed Mr. Todd's infection to his heart condition but acknowledged that this should not preclude treatment for his wounds. On October 22, Mr. Todd was afebrile according to Dr. Sauls, although nurses noted an elevated temperature. The chest tube site was cultured for the first time, revealing foul-smelling drainage, and broad-spectrum antibiotics were considered after the culture report. The next day, Dr. Ertan, not Dr. Sauls, initiated treatment with methicillin after discovering a staph infection from the culture. Dr. Sauls maintained that Mr. Todd's fasciotomy wound remained clean throughout his stay, contradicting nurses' notes indicating yellow purulent drainage. While Dr. Sauls claimed the only infection was at the chest tube site, several doctors who testified in his defense did not comment on the appropriateness of his wound care. They emphasized the importance of monitoring Mr. Todd's wounds but believed Dr. Sauls' treatment was proper. Dr. Bernard Kaplan, another supporter of Dr. Sauls, was unaware that the fasciotomy site had been debrided due to infection. Testimony indicated that elevated temperatures and increased white blood cell counts are common in heart attack patients, complicating infection resistance. Dr. Sauls asserted he adequately monitored Mr. Todd's nutritional status, ordering daily weight checks, but records showed a consistent decline in weight. Dr. Sauls ascribed this to a lack of appetite post-surgery and low cardiac output syndrome, which he argued made additional fluid intake risky. Both Dr. Ertan and Dr. Kaimal also monitored Mr. Todd’s nutrition during his hospitalization. Dr. Sauls was found to have breached the standard of care owed to Mr. Todd regarding his nutritional management and treatment of surgical wound infections. Despite efforts to encourage Mr. Todd to eat, his nutritional status deteriorated, prompting Dr. Kaimal to recommend supplemental feeding on October 20th, which Dr. Sauls did not follow up on or pursue a nutritional consult for. While other physicians mostly supported Dr. Sauls' approach, Dr. Leyser indicated no contraindications for tube feeding, and Dr. Leatherman, who treated Mr. Todd later, argued that supplemental feeding was necessary despite Mr. Todd's complex health issues. The evidence showed Dr. Sauls did not adequately address the infections, ignored the nursing observations about them, and allowed Mr. Todd to rapidly lose weight, despite knowing the risks given his impaired heart condition. The condition of Mr. Todd's surgical wounds was deemed unacceptable, and Dr. Leatherman's prompt initiation of liquid nutrients at St. Luke’s underscored the need for early nutritional intervention, which was allegedly overlooked by Dr. Sauls at Rapides General. Furthermore, the record illustrated the detrimental relationship between malnourishment, infection, and heart function. Although Dr. Sauls' defense asserted that Mr. Todd's condition was irretrievable post-heart attack, evidence indicated that Dr. Sauls did not communicate the severity of Mr. Todd's situation to the family until October 20th. Before this date, there was a lack of documented heart function data, but it was established that malnourishment and infection negatively impact cardiac function. Consequently, the breach of duty may have contributed to Mr. Todd's decline, and the determination of whether this malpractice affected his survival is a factual question, with the principle that a substantial factor in causation need not be the sole cause of harm. In Hastings v. Baton Rouge General Hospital, the Louisiana Supreme Court clarified the burden of proof in medical malpractice cases involving deceased patients. Plaintiffs need only show that the patient had a chance of survival which was lost due to the physician's negligence, rather than proving that the patient would have survived with proper treatment. The defendant's actions must significantly increase the risk of harm but do not have to be the sole cause. In Mr. Todd’s case, his only chance for survival was a heart transplant, which was made impossible by severe infections. Expert testimony indicated that, absent these infections, a Left Ventricular Assistance Device (LVAD) could have been an alternative treatment. The court determined that Dr. Sauls’ malpractice was a substantial factor in Mr. Todd's critical condition and ultimately deprived him of a chance for survival. Despite Dr. Sauls’ claims regarding Mr. Todd's alcohol issues affecting transplant eligibility, the medical records did not support significant alcohol abuse during hospitalization. The court then moved to assess damages, addressing whether the $500,000 statutory cap on damages applies to each claimant individually or collectively. The Todds argued for separate claims, referencing prior jurisprudence on damage caps before a statute was declared unconstitutional. Under current Louisiana law, the total recoverable amount for malpractice claims is capped at $500,000, excluding future medical care, with specific limitations on the liability of healthcare providers for individual claimants. Any excess amounts awarded above $100,000 would be paid from the Patient's Compensation Fund. The Medical Malpractice Act may disadvantage severely injured individuals by imposing a cap on damages, which limits their recovery despite the severity of their injuries. Conversely, this cap is intended to encourage medical professionals to remain in Louisiana, thereby increasing the availability of healthcare. Injured parties can seek a minimum of $100,000 from healthcare providers and potentially an additional $400,000 from the Louisiana Patient's Compensation Fund (LPCF), establishing a specialized compensation framework for malpractice victims. The Act includes detailed provisions regarding caps and procedures. While the Louisiana Supreme Court has not directly addressed the current issue, it referenced the Rodriguez case, where an award exceeding $600,000 was reduced to comply with the $500,000 statutory limit. Furthermore, the LaMark v. NME Hospitals, Inc. case clarified that the statutory limit pertains to the total recoverable amount for all malpractice claims rather than individual claims, as accepting otherwise would create instability in surcharge calculations for healthcare providers, ultimately impacting patient costs. The clear language of the law indicates that the $500,000 limit applies to all claims related to medical malpractice. The Todds challenge the consistency of LaMark with prior rulings, particularly Williams v. Kushner, which upheld a $400,000 payment from the LPCF for a single plaintiff, and highlighted constitutional issues regarding unequal treatment of claims against the state versus private sector claims. The Louisiana Supreme Court found a violation of equal protection rights and reformed the private sector statute to align with claims pending at the time of a 1984 amendment. The court rejects the Todds' argument that the ruling in LaMark would differ had it been decided after the Williams case. It emphasizes that while the Civil Code allows for interpretation of related statutes, this is only necessary in the presence of ambiguity. In this instance, the court finds the medical malpractice cap in LSA-R.S. 40:1299.42(B)(1) to be clear and unambiguous, stating that the total recoverable amount for all claims against a single tortfeasor in a medical malpractice case is $500,000, regardless of the number of plaintiffs. The language emphasizes "total" and "a patient," indicating that the cap is applied per patient, not per plaintiff. The court asserts that allowing multiple caps would undermine the legislative intent behind the Medical Malpractice Act and disrupt the compensation scheme designed to benefit Louisiana citizens. Therefore, a single $500,000 cap applies to all claims related to Mr. Todd's death. The elements of damages for wrongful death include loss of love and affection, loss of services, loss of support, medical expenses, and funeral expenses. In *Pierre v. Lallie Kemp Charity Hospital*, the court addressed the damages related to the death of Mr. Todd. It was established that Mr. Todd had retired from the railroad prior to his surgery, and there was no evidence presented for loss of support or services. Mr. Todd's funeral expenses were determined to be $4,975, and his adjusted medical expenses amounted to $19,533.42. The court awarded these amounts. Mrs. Margaret Todd, Mr. Todd's wife of 33 years, was granted $150,000 for the loss of her husband's love and affection, despite a past brief marital difficulty; their relationship was described as close, with shared activities and a strong bond with their seven children. Each of Mr. Todd’s children was awarded $50,000 for the loss of their father’s love and affection, reflecting their frequent visits and activities together. The court also considered whether damages should be awarded for loss of survival or wrongful death if Dr. Sauls was found liable for medical malpractice, noting a lack of existing jurisprudence on this issue. It referenced the Louisiana Supreme Court's previous rulings on loss of chance of survival, indicating that plaintiffs must demonstrate a loss of a chance rather than proof of survival. Since the Todds provided evidence of damages beyond just loss of chance, the court decided to award traditional wrongful death damages. It concluded that although separate awards for loss of a chance of survival could be recognized, the existing damages awarded had already reached the malpractice cap, thus survival damages would not be granted. The trial court's judgment has been reversed, with a new ruling in favor of Margaret Todd against Dr. F. Clark Sauls for $174,508.42, including legal interest from the date of demand and trial costs. Additionally, judgment is awarded to Barbara Todd Parker, Donna Todd Duffell, Nancy Todd Rachal, James Deral Todd, William Todd, Kenneth Ray Todd, and Susan E. Todd, each receiving $50,000 from Dr. Sauls, also with legal interest and trial costs. Dr. Sauls' liability is capped at $100,000, plus legal interest, as per LSA-R.S. 40:1299.42, and the Louisiana Commissioner of Insurance is mandated to pay up to the statutory maximum of $500,000 upon receipt of the judgment. Dissenting opinions were noted from Justices Saunders, Thibodeaux, and Cooks regarding the medical malpractice cap. It was mentioned that the case involves only one doctor and one deceased patient, and that previous defendants, including the treating hospital, were dismissed before the jury trial. The issue regarding the cap's applicability per doctor is currently pending in a related case before the Louisiana Supreme Court. The court has limited its awards to comply with the $500,000 cap, and no expense evidence from Rapides General Hospital was presented by the Todds.