Pages-Ramirez v. Hospital Espaol Auxilio Mutuo De Puerto Rico, Inc.

Citations: 547 F. Supp. 2d 141; 2008 U.S. Dist. LEXIS 54459; 2008 WL 1213051Docket: Civil 07-1407 (JP)

Court: District Court, D. Puerto Rico; April 7, 2008; Federal District Court

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Plaintiffs Dilma Pagés-Ramírez, Michael Pietri-Pozzi, their conjugal partnership, and their child Giovanni Pietri-Pagés filed a medical malpractice lawsuit against Hospital Espanol Auxilio Mutuo (HEAM), its insurer Admiral Insurance Company, Dr. Antonio Ramírez-Gonzalez, and other defendants, alleging negligence during Giovanni's birth on May 19, 2005. The plaintiffs assert that Giovanni suffered severe injuries, including multi-organ damage and cerebral palsy, due to the defendants' failure to adhere to medical standards, encompassing issues such as inadequate prenatal care, improper monitoring during delivery, and delays in performing a Cesarean section.

Defendants HEAM and Admiral sought summary judgment, arguing that a hospital is not liable for the alleged malpractice of its nursing staff following a physician's orders or for the actions of a private physician with hospital privileges. The court denied the motion for summary judgment, indicating that the case would proceed. Plaintiffs claim that their limited financial resources have hindered Giovanni's access to necessary medical care, resulting in permanent and incapacitating injuries, alongside emotional distress for the parents. HEAM contends that it provided acceptable care per established standards.

HEAM asserts that its personnel did not breach their duty or contribute to the damages claimed by the Plaintiffs, arguing that the Plaintiffs have failed to provide sufficient evidence to counter the presumption of appropriate medical care. The material facts established during the Initial Scheduling Conference on September 14, 2007, include: 

1. Plaintiffs Pagés and Pietri are the parents of Giovanni.
2. HEAM is a Puerto Rico corporation operating a hospital in San Juan.
3. Defendant Ramírez, a medical doctor and obstetrician, provided prenatal care to Pagés and was involved in her labor and delivery. Ramírez is married to co-defendant Jane Doe and resides in Puerto Rico.
4. Ramírez was licensed to practice medicine in Puerto Rico and had privileges at HEAM.
5. Ramírez held a medical malpractice policy from SIMED with specific limits and conditions.
6. Pagés began prenatal care with Ramírez on October 22, 2004, at six weeks pregnant, with a history of four pregnancies and one abortion.
7. She was scheduled for follow-ups, with her estimated due date initially set for June 13, 2005, later adjusted to June 1, 2005.
8. Pagés was admitted to HEAM on May 19, 2005, at 2:09 p.m. in active labor, at thirty-six weeks of gestation.
9. Upon admission, laboratory work was performed, and by 3:00 p.m., she was evaluated, showing significant cervical dilation and contractions.
10. By 6:45 p.m., she was fully dilated, but attempts at vacuum extraction failed, leading to a switch from spinal to general anesthesia due to unavailability of resources. 

These points outline the procedural and factual context surrounding the medical care provided by Ramírez and the circumstances of Pagés' labor and delivery.

On May 19, 2005, Plaintiff Giovanni was born at 7:55 p.m. via low transverse Cesarean section performed by Defendant Ramírez. Giovanni weighed nine pounds and four ounces and had an Apgar score of 2/7, displaying poor muscular tone, cyanosis, and a heart rate of 120 beats per minute. A neonatologist intubated him and transferred him to the neonatal intensive care unit (NICU), where he was put on a ventilator. Laboratory tests of Giovanni's umbilical cord indicated concerning gas levels, including a pH of 6.92.

Post-delivery, Plaintiff Pagés experienced uterine atony, necessitating a blood transfusion of four units, and she was hospitalized until May 24, 2005. Giovanni remained in the hospital until August 5, 2005, when he was transferred for ongoing treatment. His discharge summary included multiple diagnoses such as birth asphyxia, respiratory failure, and urinary tract infection, among others.

Defendant HEAM holds a professional liability policy from Admiral Insurance Company with a $500,000 self-insured retention per claim and $1,000,000 policy limits. The court deemed several facts uncontested, including that Defendant Ramírez was Pagés' physician for all her pregnancies and was present during labor on the day of Giovanni's birth. Ramírez ordered the administration of pitocin at 4:30 p.m., which was executed by a nurse shortly afterward. Dr. Carolyn Crawford, an expert witness for the plaintiffs, emphasized the physician's responsibility for monitoring decisions and pitocin administration.

The legal standard for a motion for summary judgment is outlined, stating that summary judgment is appropriate when evidence shows no genuine issue of material fact, allowing the moving party to be entitled to judgment as a matter of law.

In Goldman v. First Nat'l Bank of Boston and Canal Ins. Co. v. Benner, the courts established that summary judgment is only precluded by factual disputes that could impact the case's outcome under the applicable law, as outlined in Anderson v. Liberty Lobby. A fact is deemed material if it could influence the case's resolution, with the movant responsible for demonstrating the absence of a genuine issue of material fact. If the movant meets this burden, the opposing party must show, through affidavits or other evidence, that a genuine issue exists.

The plaintiffs in this tort action for medical malpractice, based on Puerto Rico law, allege that the defendants’ failure to adhere to the medical standard of care resulted in severe birth defects in the plaintiff Giovanni. The federal court's jurisdiction relies on diversity of citizenship, thereby applying Puerto Rico substantive law. A prima facie case of medical malpractice in Puerto Rico requires proof of duty owed, a breach of that duty, and a causal link between the breach and the harm. The duty owed involves a standard of care reflective of contemporary medical practices, typically substantiated by expert testimony. For nurses, the standard includes exercising reasonable care to prevent unnecessary harm, aligned with local practices. Additionally, nurses and paramedics must urgently fulfill medical orders tailored to individual patient circumstances. Causation must be established by showing that the medical provider's negligence was the most likely cause of the harm, supported by a preponderance of evidence.

Causation in medical malpractice cases requires more than speculation; expert testimony is crucial to clarify complex medical issues. In Rivera v. Turabo Med. Ctr. P'ship, the defendants, HEAM and Admiral, sought summary judgment, asserting that HEAM's nurses were merely following the orders of the attending physician, Ramírez, and should not be held liable. However, Puerto Rico law mandates that nurses adhere to independent standards of care to prevent unnecessary patient harm. 

Expert witnesses for the plaintiffs, Dr. Crawford and Dr. Nathanson, identified multiple instances where HEAM's nurses failed to meet these standards. Specifically, Dr. Crawford noted that the nurses did not cease administering pitocin or notify the physician despite signs of fetal distress, which she argued was a direct violation of nursing duties. Furthermore, she stated that pitocin should not have been administered given the frequent contractions and problematic fetal heart rate.

Additionally, both experts criticized the nurses for not placing an internal heart monitor during delivery when external monitoring indicated fetal distress. They asserted that the absence of an internal monitor prevented accurate heart rate tracking. Dr. Crawford also highlighted a failure in monitoring the effects of epidural anesthesia, emphasizing that both anesthesiologists and nurses share responsibility for post-administration monitoring, including necessary interventions when fetal heart rate drops. The plaintiffs allege that HEAM's nurses neglected their responsibilities and, instead of advocating for patient safety, followed physician orders without question, leading to significant harm.

The anesthesiologist and nurses share a joint responsibility to administer a bolus of fluids before placing an epidural. Dr. Crawford's report indicates that HEAM's nursing staff and anesthesiologist deviated from standard care by not providing this fluid bolus to Plaintiff Pagés and by neglecting necessary follow-up actions after the epidural was placed. The Court concurs with the Plaintiffs, asserting that nurses cannot be regarded as merely following orders and denies the Defendants' motion for summary judgment regarding HEAM and Admiral's liability linked to the nursing staff's actions.

Regarding hospital liability, Defendants HEAM and Admiral contend that a hospital is not liable for the negligence of an unsalaried physician, Defendant Ramírez, who has hospital privileges. Under Puerto Rican law, hospitals owe their patients a duty of care comparable to that of a reasonable person under similar circumstances. The Supreme Court has established that hospitals can be held liable for malpractice due to the negligent actions of their employees, based on vicarious liability. When patients seek care directly from a hospital and are assigned a physician by the hospital, both the hospital and physician are jointly liable for malpractice. However, if a physician is not a hospital employee but uses hospital facilities for private patients, the hospital is not liable for that physician's exclusive negligence. Nonetheless, hospitals must uphold standards by selecting qualified physicians, ensuring ongoing professional development, monitoring physician performance, and responding to clear malpractice. Additionally, if a hospital shares in the profits of a physician it grants privileges to, it is also liable for that physician's malpractice, as established by the First Circuit Court of Appeals.

Defendant HEAM's motion for summary judgment is based on the assertion that it cannot be held liable for the alleged malpractice of Defendant Ramírez, who operates independently with privileges at HEAM rather than as an employee. HEAM contends that it fulfilled its responsibilities to safeguard patient health and adhered to the applicable standards of care. The relationship between Ramírez and Plaintiff Pagés is acknowledged; he acted as her private physician with admitting privileges at HEAM. However, determining HEAM's liability requires an examination of whether it adequately monitored its physicians and met its obligations to protect patients. The Court notes that deviations from medical standards are factual issues for a jury to resolve, as established in precedent. 

Plaintiffs have introduced expert testimony indicating potential failures by HEAM, including Dr. Crawford’s claims that delays and omissions in administering anesthesia and fluids contributed to adverse outcomes for Plaintiff Pagés and her child. Consequently, the Court finds there are significant factual disputes warranting a trial, leading to the denial of the motion for summary judgment from Defendants HEAM and Admiral. Other defendants, including Ramírez and his insurer, did not seek summary judgment, while the status of the anesthesiologist involved remains unclear. The Court lacks information regarding the financial arrangements between HEAM and Ramírez.