Professional Documents
Culture Documents
4 Ramos v. CA
4 Ramos v. CA
*
G.R. No. 124354. December 29, 1999.
________________
* FIRST DIVISION.
585
VOL. 321, DECEMBER 29, 1999 585
Same Same Same Same When the doctrine of res ipsa loqui
tur is availed by the plaintiff, the need for expert medical
testimony is dispensed with because the injury itself provides the
proof of negligence.Although generally, expert medical
testimony is relied upon in malpractice suits to prove that a
physician has done a negligent act or that he has deviated from
the standard medical procedure, when the doctrine of res ipsa
loquitur is availed by the plaintiff, the need for expert medical
testimony is dispensed with because the injury itself provides the
proof of negligence. 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
any one may be given by nonexpert witnesses.
Same Same Same Same 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.
Despite the fact that the scope of res ipsa loquitur has been
measurably enlarged, it does not automatically apply to all cases
of medical negligence as to mechanically shift the burden of proof
to the defendant to show that he is not guilty of the ascribed
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 in malpractice cases 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 as
would ordinarily have followed if due care had been exercised.
Same Same Same Same 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.It must be
conceded that the doctrine of res ipsa loquitur can have no
application in a suit against a physician or surgeon which
involves the merits of a diagnosis or of a scientific treatment. The
physician or surgeon is not required at his peril to explain why
any particular diagnosis was not correct, or why any particular
scientific treatment did not produce
587
588
KAPUNAN, J.:
The Hippocratic Oath mandates physicians to give
primordial consideration to the health and welfare of their
patients. If a doctor fails to live up to this precept, he is
made accountable for his acts. A mistake, through gross
negligence or incompetence or plain human error, may
spell the difference
589
Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985,
a 47year old (Exh. A) robust woman (TSN, October 19, 1989, p.
10). Except for occasional complaints of discomfort due to pains
allegedly caused by the presence of a stone in her gall bladder
(TSN, January 13, 1988, pp. 45), she was as normal as any other
woman. Married to Rogelio E. Ramos, an executive of Philippine
Long Distance Telephone Company, she has three children whose
names are
________________
1 In the United States alone, a great number of people die every year as a result
of medical mishaps. The 13 December 1999 issue of TIME MAGAZINE featured an
article on medical negligence entitled Doctors Deadly Mistakes which is quoted
in part: It is hardly news that medical professionals make mistakeseven dumb,
deadly mistakes. What is shocking is how often it happens. Depending on which
statistics you believe, the number of Americans killed by medical screwups is
somewhere between 44,000 and 98,000 every yearthe eighth leading cause of
death even by the more conservative figure, ahead of car crashes, breast cancer
and AIDS. More astonishing than the huge numbers themselves, though, is the
fact that public health officials had known about the problem for years and hadnt
made a concerted effort to do something about it.
2 Cholecystectomy is the surgical excision of the gall bladder.
3 CA Rollo, pp. 129140.
4 Records, pp. 270279.
590
591
592
593
________________
5 Id. at 270275.
6 Docketed as Civil Case No. Q46885.
594
595
________________
596
________________
10 Id. at 195.
597
II
III
________________
11 Rollo, p. 19.
12 Id. at 9198.
598
________________
599
________________
14 Africa, et al. vs. Caltex (Phil.), Inc., et al., 16 SCRA 449, 454 (1966).
15 57B Am Jur 2d, supra note 13 at 499.
16 Ibid.
17 Id. at 502.
18 Ibid.
19 Id.
600
20
of going forward with the proof. Still, before resort to the
doctrine may be allowed, the following requisites must be
satisfactorily shown:
________________
20 Id. at 503.
21 Voss vs. Bridwell, 364 P2d 955, 970 (1961) citing Worden v. Union
Gas System, 182 Kan. 686, 324 P.2d 501 Lamb v. Hartford Accident and
Indemnity Co., Primm v. Kansas Power & Light Co., 173 Kan. 443, 249
P.2d 647.
22 St. Johns Hospital and School of Nursing vs. Chapman, 434 P.2d
160, 166 (1967).
23 57B Am Jur 2d, supra note 13, at 513.
24 It is the type of claim which a victim has available to him or her to
redress a wrong committed by a medical professional which has caused
bodily harm. (GarciaRueda vs. Pascasio, 278 SCRA 769, 778 [1997]).
25 Voss vs. Bridwell, supra note 21.
601
________________
602
31
occurred. When the doctrine is appropriate, all that the
patient must do is prove a nexus between the particular act
or omission complained of and the injury sustained while
under the custody and management of the defendant
without need to produce expert medical testimony to
establish the standard of care. Resort to res ipsa loquitur is
allowed because there is no other way, under usual and
ordinary conditions, by which the patient can obtain
redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the
doctrine in the following situations: leaving of a foreign 32
object in the body of the patient after an operation,
injuries sustained on a healthy part of the33 body which was
not under, or in the area, of treatment, removal of the 34
wrong part of the body when another part was intended,
knocking out a tooth while a patients 35
jaw was under
anesthetic for the removal of his tonsils, and loss of an eye
while the patient plaintiff was under the influence of
anesthetic, 36during or following an operation for
appendicitis, among others.
Nevertheless, despite the fact that the scope of res ipsa
loquitur has been measurably enlarged, it does not
automatically apply to all cases of medical negligence as to
mechanically shift the burden of proof to the defendant to
show that he is not guilty of the ascribed 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 in malpractice cases
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 as would
37
ordinarily have
followed if due care had been exercised. A distinction must
________________
603
________________
38 Id. at 968.
39 Rhodes vs. De Haan, 337 P. 2d. 1043, 1047 (1959).
40 Voss vs. Bridwell, supra note 21, at 968.
41 Sanders vs. Smith, 27 So. 2d 889, 893 (1946).
42 Ibid.
43 Voss vs. Bridwell, supra note 21.
604
________________
44 Id. at 971.
605
________________
607
ATTY. PAJARES:
Q: In particular, what did Dra. Perfecta Gutierrez do, if
any on the patient?
A: In particular, I could see that she was intubating the
patient.
Q: Do you know what happened to that intubation process
administered by Dra. Gutierrez?
ATTY. ALCERA:
She will be incompetent Your Honor.
COURT:
Witness may answer if she knows.
A: As I have said, I was with the patient, I was beside the
stretcher holding the left hand of the patient and all of
a sudden I heard some remarks coming from Dra.
Perfecta
608
________________
609
________________
610
49
unnecessary. We take judicial notice of the fact that
anesthesia procedures have become so common, that even
an ordinary person can tell if it was administered properly.
As such, it would not be too difficult to tell if the tube was
properly inserted. This kind of observation, we believe,
does not require a medical degree to be acceptable.
At any rate, without doubt, petitioners witness, an
experienced clinical nurse whose long experience and
scholarship led to her appointment as Dean of the Capitol
Medical Center School of Nursing, was fully capable of
determining whether or not the intubation was a success.
She had extensive clinical experience starting as a staff
nurse in Chicago, Illinois staff nurse and clinical instructor
in a teaching hospital, the FEUNRMF Dean of the
Laguna College of Nursing in San Pablo City and then 50
Dean of the Capitol Medical Center School of Nursing.
Reviewing witness Cruz statements, we find that the same
were delivered in a straightforward manner, with the kind
of detail, clarity, consistency and spontaneity which would
have been difficult to fabricate. With her clinical
background as a nurse, the Court is satisfied that she was
able to demonstrate through her testimony what truly
transpired on that fateful day.
Most of all, her testimony was affirmed by no less than
respondent Dra. Gutierrez who admitted that she
experienced difficulty in inserting the tube into Erlindas
trachea, to wit:
ATTY. LIGSAY:
Q: In this particular case, Doctora, while you were
intubating at your first attempt (sic), you did not
immediately see the trachea?
DRA. GUTIERREZ:
A: Yes sir.
Q: Did you pull away the tube immediately?
A: You do not pull the . . .
________________
611
________________
612
________________
613
ATTY. LIGSAY:
Q: Would you agree, Doctor, that it is good medical
practice to see the patient a day before so you can
introduce yourself to establish good doctorpatient
relationship and gainthe trust and confidence of the
patient?
DRA. GUTIERREZ:
A: As I said in my previous statement, it depends on the
operative procedure of the anesthesiologist and in my
case, with elective cases and normal cardiopulmonary
clearance like that, I usually dont do it except on
emergency
58
and on cases that have an abnormalities
(sic).
________________
614
________________
615
ATTY. LIGSAY:
Q: In your line of expertise on pulmonology, did you have
any occasion to use pentothal as a method of
management?
DR. JAMORA:
A: We do it in conjunction with the anesthesiologist when
they have to intubate our patient.
Q: But not in particular when you practice pulmonology?
A: No.
Q: In other words, your knowledge about pentothal is
based only on what you have read from books and not
by your own personal application of the medicine
pentothal?
A: Based on my personal experience also on pentothal.
Q: How many times have you used pentothal?
A: They used it on me. I went into bronchospasm during
my appendectomy.
Q: And because they have used it on you and on account of
your own personal experience you feel that you can
testify on pentothal here with medical authority?
A: No. That
61
is why I used references to support my
claims.
________________
616
________________
617
________________
618
________________
619
69
thesia. Nevertheless, ninetyeight percent (98%) or the
vast majority of difficult intubations may be anticipated by
performing a thorough70 evaluation of the patients airway
prior to the operation. As stated beforehand, respondent
Dra. Gutierrez failed to observe the proper preoperative
protocol which could have prevented this unfortunate
incident. Had appropriate diligence and reasonable care
been used in the preoperative evaluation, respondent
physician could have been much more prepared to meet the
contingency brought about by the perceived anatomic
variations in the patients neck and oral area, defects which
would have been easily overcome by a prior knowledge 71
of
those variations together with a change in technique. In
other words, an experienced anesthesiologist, adequately
alerted by a thorough preoperative evaluation, would have
had little difficulty
72
going around the short neck and
protruding teeth. Having failed to observe common
medical standards in preoperative management and
intubation, respondent Dra. Gutierrez negligence resulted
in cerebral anoxia and eventual coma of Erlinda.
We now determine the responsibility of respondent Dr.
Orlino Hosaka as the head of the73surgical team. As the so
called captain of the ship, it is the surgeons
responsibility to see to it that those under him perform
their task in the proper manner. Respondent Dr. Hosakas
negligence can be found in his failure to exercise the proper
authority (as the captain of
________________
620
________________
621
75
the application. This is particularly true with respondent
hospital.
After a physician is accepted, either as a visiting or
attending consultant, he is normally required to attend
clinicopathological conferences, conduct bedside rounds for
clerks, interns and residents, moderate grand rounds and
patient audits and perform other tasks and responsibilities,
for the privilege of being able to maintain a clinic in the
hospital, and/or for the privilege of admitting patients into
the hospital. In addition to these, the physicians
performance as a specialist is generally evaluated by a peer
review committee on the basis of mortality and morbidity
statistics, and feedback from patients, nurses, interns and
residents. A consultant remiss in his duties, or a consultant
who regularly falls short of the minimum standards
acceptable to the hospital or its peer review committee, is
normally politely terminated.
In other words, private hospitals, hire, fire and exercise
real control over their attending and visiting consultant
staff. While consultants are not, technically employees, a
point which respondent hospital asserts in denying all
responsibility for the patients condition, the control
exercised, the hiring, and the right to terminate
consultants all fulfill the important hallmarks of an
employeremployee relationship, with the exception of the
payment of wages. In assessing whether such a
relationship in fact exists, the control test is determining.
Accordingly, on the basis of the foregoing, we rule that for
the purpose of allocating responsibility in medical
negligence cases, an employeremployee relationship in
effect exists between hospitals and their attending and
visiting physicians. This being the case, the question now
arises as to whether or not respondent hospital is solidarily
76
liable with respondent doctors for petitioners condition.
________________
622
________________
623
________________
624
80
with certainty. In other words, temperate damages can
and should be awarded on top of actual or compensatory
damages in instances where the injury is chronic and
continuing. And because of the unique nature of such cases,
no incompatibility arises when both actual and temperate
damages are provided for. The reason is that these
damages cover two distinct phases.
As it would not be equitableand certainly not in the
best interests of the administration of justicefor the
victim in such cases to constantly come before the courts
and invoke their aid in seeking adjustments to the
compensatory damages previously awardedtemperate
damages are appropriate. The amount given as temperate
damages, though to a certain extent speculative, should
take into account the cost of proper care.
In the instant case, petitioners were able to provide only
homebased nursing care for a comatose patient who has
remained in that condition for over a decade. Having
premised our award for compensatory damages on the
amount provided by petitioners at the onset of litigation, it
would be now much more in step with the interests of
justice if the value awarded for temperate damages would
allow petitioners to provide optimal care for their loved one
in a facility which generally specializes in such care. They
should not be compelled by dire circumstances to provide
substandard care at home without the aid of professionals,
for anything less would be grossly inadequate. Under the
circumstances, an award of P1,500,000.00 81
in temperate
damages would therefore be reasonable. 82
In Valenzuela vs. Court of Appeals, this Court was
confronted with a situation where the injury suffered by
the plaintiff would have led to expenses which were
difficult to
________________
626
________________
83 Id. at 327328.
627
________________
84 Id. at 328.
628
Judgment modified.
629
o0o
Copyright2016CentralBookSupply,Inc.Allrightsreserved.