Mark Arkin & Susan Arkin v. Roger Gittleson, Stephen Goldman, M.D., Douglas Held, John Doe, Dawn Marie Frankwick, L.I. Jewish Hospital, Shapiro, M.D., L.I. Jewish Medical Center, William Ladner, Jeffrey W. Marx, Richard Ira Roberts, Guillermo San Roman
Docket: 1249
Court: Court of Appeals for the Second Circuit; August 23, 1994; Federal Appellate Court
Mark and Susan Arkin appeal a judgment from the Eastern District of New York that granted Dr. Roger Gittleson judgment as a matter of law. The Arkins allege that Dr. Gittleson mistreated Susan after she developed a pulmonary embolism following a cesarean section at Long Island Jewish Medical Center, which resulted in permanent partial blindness. During a jury trial, expert testimony indicated that Dr. Gittleson's failure to provide appropriate treatment contributed to Susan's condition, while Dr. Gittleson argued that causation could not be established regarding the injuries. Initially, the jury found Dr. Gittleson liable and awarded $1,202,500 to the Arkins. However, the district court later overturned this decision, citing a lack of evidence linking Dr. Gittleson's negligence to Susan's injuries.
Susan, at age 40, sought Dr. Gittleson's care for a high-risk pregnancy and exhibited signs of edema during her visits, though later records did not consistently reflect this condition. On July 14, 1986, after an initial assessment, Dr. Roberts performed a cesarean section on Susan early the following morning. Post-surgery, Dr. Gittleson assessed Susan, who appeared stable, with no immediate signs of distress. However, on July 17, Susan's condition began to deteriorate, with noted symptoms such as abdominal pain and edema by July 18, leading to further complications. The appellate court ultimately reversed the district court's ruling, indicating that the Arkins had sufficient grounds to contest Dr. Gittleson's alleged negligence.
Susan experienced persistent dizziness, prompting multiple checks of her vital signs, which indicated low blood pressure (90/60) and elevated pulse (120). After encouragement to practice relaxed breathing, her blood pressure improved to 124/80 while her pulse remained elevated. Dr. Goldman advised monitoring for lightheadedness and orthostatic hypotension. At 5:15 p.m., she reported severe abdominal discomfort, and 2 mg of Dilaudid was administered, providing relief. By 6 p.m., she was resting comfortably, and at 7 p.m., she was with visitors, showing no complaints.
At 7:40 p.m., Dr. Gittleson assessed her, dismissing concerns about her breathing and attributing it to hyperventilation. He had her breathe into a paper bag. At 8:30 p.m., after being assisted to the bathroom, Susan complained of dizziness again, with vital signs showing blood pressure at 100/60 and pulse at 150. Dr. Gittleson noted these readings and the presence of circumoral cyanosis, suggesting hyperventilation as the cause. Another dose of Dilaudid was given at 8:50 p.m. The situation worsened at 9:45 p.m. when her blood pressure dropped significantly to 60/54, with a pulse of 170. Despite the absence of shortness of breath, she reported severe abdominal pain and chest tightness, prompting an emergency call.
By 10 p.m., arterial blood gas results were normal, but she complained of facial burning. Dr. Gittleson returned at 10:05 p.m., and upon transferring Susan to a recovery room, she lost consciousness. A cardiac arrest code was initiated, leading to emergency interventions, including endotracheal intubation and defibrillation. Ultimately, Susan suffered three cardiac arrests but was successfully resuscitated.
Susan experienced cardiac arrests, with pulmonary embolism suspected as the cause due to its potential development in postpartum women. The medical team identified this condition in the early hours of July 19 and initially administered heparin as a blood thinner. However, fearing possible brain damage, they later installed a Greenfield filter to prevent further clotting. By the afternoon of the same day, Susan reported vision loss, which expert testimony attributed to oxygen deprivation in the part of her brain responsible for processing visual information, resulting in cortical blindness with significant visual field defects.
In January 1989, Susan's family, the Arkins, filed a lawsuit against Dr. Gittleson and others, alleging negligent treatment that led to her injuries. The case against most defendants was dismissed before trial, and Dr. Goldman's case was dismissed during the trial. The jury trial occurred from July 19 to 26, 1993, where conflicting testimonies emerged regarding Dr. Gittleson’s responsibility for Susan's blindness.
Dr. Sivam Ramanathan, an expert in obstetric anesthesia, testified that pulmonary embolism is a leading cause of maternal fatalities and highlighted the increased risk of clots in postpartum women, particularly after cesarean sections. He asserted that the warning signs present in Susan's condition should have prompted Dr. Gittleson to suspect a pulmonary embolism prior to his departure from the hospital.
Dr. Gittleson's management, which included a paper bag for hyperventilation and a Dilaudid dose, was deemed inadequate and contrary to medical standards. The paper bag exacerbated Susan's oxygen deprivation, and the combined narcotic doses likely caused her to appear overly sedated. Dr. Ramanathan emphasized that timely treatment of pulmonary embolism is critical and outlined necessary interventions that Dr. Gittleson failed to perform.
Dr. Ramanathan expressed uncertainty about Dr. Gittleson's capability to administer necessary treatments at 8:30 p.m. and suggested that involving another specialist could have prevented the subsequent cardiac arrests and long-term hypoperfusion. He indicated that Dr. Gittleson's decision to leave the hospital without seeking assistance deviated from accepted medical standards. On cross-examination, Dr. Ramanathan noted that while pulmonary emboli cannot be prevented, their severe effects can be mitigated.
Dr. Ian Schorr testified that Susan's condition resulted directly from the cardiac arrest episode. Dr. Gittleson, during trial and deposition, struggled to recall critical details of his treatment for Susan, including observations of cyanosis and pulse rates. He remembered that Susan did not complain of shortness of breath and defended his treatment of hyperventilation with a paper bag, believing her condition had stabilized before leaving at 8:50 p.m.
Gittleson disagreed with nurse Lewis's record of a pulse of 150 and justified his lack of response to edema, claiming it was consistent with previous visits. He acknowledged that awareness of circumoral cyanosis would have prompted different actions, including calling for a medical consultation and documenting the observation. Despite stating that circumoral cyanosis is not always serious, he would have acted if he had recognized it, maintaining he was unaware of its presence in Susan's case. He concluded that while her condition was not optimal, he believed she would ultimately recover.
Dr. Gittleson testified that a pulmonary embolism could not be prevented and dismissed it as a diagnosis for Susan, believing her condition had stabilized. He expressed reluctance to treat for pulmonary embolism due to concerns about potential internal bleeding. Dr. Hausknecht corroborated that a pulmonary embolism was not preventable and could not determine if injuries were avoidable at the time of treatment. He stated that if a pulmonary embolism were imminent, there would be no preventive measures available. Despite a hypothetical scenario involving medical consultation and monitoring, he indicated it was impossible to predict injuries from a pulmonary embolism and subsequent cardiac arrest, even with hindsight.
On cross-examination, Dr. Hausknecht acknowledged he would have responded differently to Susan's symptoms but maintained that any alleged negligence by Dr. Gittleson had minimal impact on the outcome. After Susan's case concluded, Dr. Gittleson moved for judgment as a matter of law, citing a lack of evidence for proximate causation, with the court reserving its decision. The jury ultimately found Dr. Gittleson liable, awarding substantial damages to Susan and her husband.
Following the verdict, Dr. Gittleson filed a motion for judgment as a matter of law, which the district court granted, stating there was no evidence linking his actions to Susan's injuries, suggesting the jury's decision was influenced by sympathy rather than factual basis. The court ordered judgment in favor of Dr. Gittleson. The appeal process followed the standard of reviewing for judgment as a matter of law, which requires an absence of evidence supporting the jury's verdict that could only be based on speculation.
To establish a medical malpractice claim in New York, a plaintiff must prove that the defendant breached the standard of care and that this breach proximately caused the plaintiff's injuries. In this case, there is consensus that sufficient evidence supports the jury's conclusion that Dr. Gittleson deviated from ordinary care standards, as testified by Dr. Ramanathan, and acknowledged by Dr. Gittleson, who would have acted differently had he recognized the circumoral cyanosis. It is also undisputed that Susan's cardiac arrests led to her cortical blindness, with Dr. Schorr confirming that the sequence of events—clotting causing a pulmonary embolism, leading to cardiac arrests and subsequent oxygen deprivation—resulted in permanent blindness.
The key dispute centers on whether the jury's conclusion that Dr. Gittleson could have prevented the cardiac arrests is supported by the evidence. The court affirms that it is, citing Dr. Ramanathan's testimony that timely tests, monitoring, oxygen administration, anti-coagulants, and specialist consultations could have mitigated the pulmonary embolism's severe consequences. This established a complete chain of causation, with Dr. Schorr linking the cardiac arrests directly to the blindness. The question of liability was appropriately left to the jury.
The district court deemed the jury's damage award of $1,202,500, accruing post-judgment interest from August 3, 1993, as reasonable, a determination not contested by Dr. Gittleson except regarding liability. The judgment is reversed with instructions to enter judgment in favor of the plaintiffs, the Arkins, as determined by the jury. The document also clarifies terminology regarding "judgment as a matter of law" and notes minor discrepancies in the trial transcript terminology.
