Documente Academic
Documente Profesional
Documente Cultură
*
G.R. No. 124354. December 29, 1999.
________________
* FIRST DIVISION.
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585
586
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,
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587
588
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KAPUNAN, J.:
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
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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 mistakes—even 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 year—the 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 hadn’t
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
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591
592
593
6
Thus, on 8 January 1986, petitioners filed a civil case for
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6
Thus, on 8 January 1986, petitioners filed a civil case for
damages with the Regional Trial Court of Quezon City
against herein private respondents alleging negligence in
the management and care of Erlinda Ramos.
During the trial, both parties presented evidence as to
the possible cause of Erlinda’s injury. Plaintiff presented
the testimonies of Dean Herminda Cruz and Dr. Mariano
Gavino to prove that the damage sustained by Erlinda was
due to lack of oxygen in her brain caused by the faulty
management of her airway by private respondents during
the anesthesia phase. On the other hand, private
respondents primarily relied on the expert testimony of Dr.
Eduardo Jamora, a pulmonologist, to the effect that the
cause of brain damage was Erlinda’s allergic reaction to the
anesthetic agent, Thiopental Sodium (Pentothal).
After considering the evidence from both sides, the
Regional Trial Court rendered judgment in favor of
petitioners, to wit:
________________
5 Id. at 270275.
6 Docketed as Civil Case No. Q46885.
594
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supply to the patient’s brain. The evidence further shows that the
hapless patient suffered brain damage because of the absence of
oxygen in her (patient’s) brain for approximately four to five
minutes which, in turn, caused the patient to become comatose.
On the part of Dr. Orlino Hosaka, this Court finds that he is
liable for the acts of Dr. Perfecta Gutierrez whom he had chosen
to administer anesthesia on the patient as part of his obligation to
provide the patient a ‘good anesthesiologist,’ and for arriving for
the scheduled operation almost three (3) hours late.
On the part of DLSMC (the hospital), this Court finds that it is
liable for the acts of negligence of the doctors in their ‘practice of
medicine’ in the operating room. Moreover, the hospital is liable
for failing through its responsible officials, to cancel the scheduled
operation after Dr. Hosaka inexcusably failed to arrive on time.
In having held thus, this Court rejects the defense raised by
defendants that they have acted with due care and prudence in
rendering medical services to plaintiffpatient. For if the patient
was properly intubated as claimed by them, the patient would not
have become comatose. And, the fact that another
anesthesiologist was called to try to intubate the patient after her
(the patient’s) nailbed turned bluish, belie their claim.
Furthermore, the defendants should have rescheduled the
operation to a later date. This, they should have done, if
defendants acted with due care and prudence as the patient’s case
was an elective, not an emergency case.
xxx
WHEREFORE, and in view of the foregoing, judgment is
rendered in favor of the plaintiffs and against the defendants.
Accordingly, the latter are ordered to pay, jointly and severally,
the former the following sums of money, to wit:
595
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596
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10 Id. at 195.
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597
II
III
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11 Rollo, p. 19.
12 Id. at 9198.
598
________________
599
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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.
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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. John’s 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
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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 patient’s 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
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603
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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
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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
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609
________________
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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, petitioner’s 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 Erlinda’s
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?
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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 don’t do it except on
emergency
58
and on cases that have an abnormalities
(sic).
the other hand, are operative procedures that can wait for
days, weeks or even months. Hence, in these cases, the
anesthesiologist possesses the luxury of time to make a
proper assessment, including the time to be at the patient’s
bedside to do a proper interview and clinical evaluation.
There is ample time to explain the method of anesthesia,
the drugs to be used, and their possible hazards for
purposes of informed consent. Usually, the preoperative
assessment is conducted at least one day before the
intended surgery, when the patient is relaxed and
cooperative.
Erlinda’s case was elective and this was known to
respondent Dra. Gutierrez. Thus, she had all the time to
make a thorough evaluation of Erlinda’s case prior to the
operation and prepare her for anesthesia. However, she
never saw the patient at the bedside. She herself admitted
that she had seen
________________
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.
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616
witnesses states:
________________
617
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patient’s condition.
In view of the evidence at hand, we are inclined to
believe petitioners’ stand that it was the faulty intubation
which was the proximate cause of Erlinda’s comatose
condition.
Proximate cause has been defined as that which, in
natural and continuous sequence, unbroken by any
efficient intervening cause, produces injury,64
and without
which the result would not have occurred. An injury or
damage is proximately caused by an act or a failure to act,
whenever it appears from the evidence in the case, that the
act or omission played a substantial part in bringing about
or actually causing the injury or damage; and that the
injury or damage was either a direct result or a65reasonably
probable consequence of the act or omission. It is the
dominant, moving or producing cause.
Applying the above definition in relation to the evidence
at hand, faulty intubation is undeniably the proximate
cause which triggered the chain of events leading to
Erlindas brain damage and, ultimately, her comatosed
condition.
Private respondents themselves admitted in their
testimony that the first intubation was a failure. This fact
was likewise observed by witness Cruz when she heard
respondent Dra. Gutierrez remarked, “Ang hirap ma
intubate nito, mali yata ang pagkakapasok. O lumalaki ang
tiyan.” Thereafter, witness Cruz noticed abdominal
distention on the body of Erlinda. The development of
abdominal distention, together with respiratory
embarrassment indicates that the endotracheal tube
entered the esophagus instead of the respiratory tree. In
other words, instead of the intended endotracheal
________________
618
________________
619
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620
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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 physician’s
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 patient’s 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 petitioner’s condition.
________________
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________________
their functions.
Employers shall be liable for the damages caused by their employees
and household helpers acting within the scope of their assigned tasks,
even though the former are not engaged in any business or industry.
623
________________
624
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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 equitable—and certainly not in the
best interests of the administration of justice—for the
victim in such cases to constantly come before the courts
and invoke their aid in seeking adjustments to the
compensatory damages previously awarded—temperate
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
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626
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83 Id. at 327328.
627
________________
84 Id. at 328.
628
Judgment modified.
629
——o0o——
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