ROGELIO E. RAMOS AND ERLINDA RAMOS, IN THEIR OWN BEHALF AND AS NATURAL GUARDIANS OF THE MINORS, ROMMEL RAMOS, ROY RODERICK RAMOS, AND RON RAYMOND RAMOS, PETITIONERS, VS. COURT O…

Ramos versus Court of Appeals

The Case

This is the case of Ramos versus Court of Appeals, a civil action for damages arising from medical negligence. Spouses Rogelio and Erlinda Ramos, for themselves and for their three minor children, sued the De Los Santos Medical Center, the surgeon Doctor Orlino Hosaka, and the anesthesiologist Doctor Perfecta Gutierrez, after Erlinda lapsed into a coma following what should have been a routine gall bladder operation and never regained consciousness. The case matters because the Supreme Court, on reconsideration, fixes the standards of care owed by a surgeon, an anesthesiologist, and a hospital to a patient, and settles the liability of each — including the hospital that engages visiting consultants.

Procedural History

The Ramos spouses filed a civil case for damages before the Regional Trial Court of Quezon City. After trial, the trial court rendered judgment in their favor, finding the private respondents negligent in the performance of their duties to Erlinda. On appeal, the Court of Appeals reversed the trial court and even directed the petitioners to pay their unpaid medical bills to the private respondents. The petitioners then came to the Supreme Court on a petition for review on certiorari. The Supreme Court, in a decision dated December 29, 1999, modified the appellate court and awarded damages in favor of the petitioners, solidarily against the private respondents. The private respondents moved for reconsideration; the motions of Doctor Hosaka and Doctor Gutierrez were denied, and they filed second motions for reconsideration. The Philippine College of Surgeons filed a petition in intervention, and the Court heard oral arguments with three amici curiae present. The Court then resolved the case anew in this decision.

Facts

Sometime in 1985, Erlinda Ramos was advised to undergo a cholecystectomy, the removal of a stone in her gall bladder. She was referred to Doctor Hosaka, a surgeon, who agreed to perform the operation, scheduled for nine in the morning of June 17, 1985, at the De Los Santos Medical Center. Since the spouses knew no anesthesiologist, Doctor Hosaka recommended Doctor Gutierrez. Erlinda was admitted the day before, and by seven thirty the next morning she was being prepared for operation. At her request, her sister-in-law Herminda Cruz, then Dean of the College of Nursing at the Capitol Medical Center, was allowed to accompany her inside the operating room.

By nine thirty Doctor Hosaka had not arrived, and Doctor Gutierrez informed Cruz that the operation might be delayed. By ten o'clock the husband wanted to pull his wife out of the operating room. Doctor Hosaka finally arrived at about twelve ten in the afternoon, more than three hours after the scheduled operation. Inside the operating room, Cruz saw Doctor Gutierrez trying to intubate the patient and heard her say that intubation was difficult and that the tube seemed wrongly inserted. Cruz noticed a bluish discoloration of Erlinda's nailbeds. Another anesthesiologist, Doctor Calderon, was called and also attempted to intubate; the nailbeds remained bluish and the patient was placed in a trendelenburg position. At almost three in the afternoon Erlinda was wheeled to the Intensive Care Unit. She stayed there for a month and was released from the hospital only four months later. Since that operation she remained comatose until she died on August 3, 1999.

Issues

• Whether or not Doctor Hosaka, the surgeon, is liable for negligence.
• Whether or not Doctor Gutierrez, the anesthesiologist, is liable for negligence.
• Whether or not the De Los Santos Medical Center is liable for any act of negligence committed by its visiting consultant surgeon and anesthesiologist.

Applicable Provisions

The decision rests on the civil law of damages and on the standards of medical practice. The governing provision on liability for fault or negligence is Article 2176 of the Civil Code, which provides:

Whoever by act or omission causes damage to another, there being fault or negligence, is obliged to pay for the damage done. Such fault or negligence, if there is no pre-existing contractual relation between the parties, is called a quasi-delict and is governed by the provisions of this Chapter.

This is the source of the doctors' liability, since the patient's injury arose from fault or negligence in the performance of their professional duties.

On the liability of the hospital for the acts of the physicians it engages, the Court applies Article 2180 of the Civil Code, which provides:

The obligation imposed by the preceding article is demandable not only for one's own acts or omissions, but also for those of persons for whom one is responsible. 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.

This provision is the basis for holding the hospital solidarily liable with the consultant physicians it employs, once the employer-employee relationship is established.

Ruling

On the first issue, the Court holds Doctor Hosaka liable. It applies the captain of the ship doctrine — the rule that the surgeon, as the one in command of the operating team, is responsible for the negligence of those under him during the operation. As the captain of the ship, he cannot escape liability for the faulty intubation that occurred under his charge.

On the second issue, the Court holds Doctor Gutierrez liable for negligence. The Court stresses that a preanesthetic and preoperative evaluation cannot be dispensed with. It involves taking the patient's medical history, reviewing current drug therapy, conducting physical examination, interpreting laboratory data, and prescribing preoperative medications. Physical examination includes the upper airway — cervical spine mobility, temporomandibular mobility, prominent incisors, teeth, ability to visualize the uvula, and thyromental distance. Doctor Gutierrez admitted she saw Erlinda for the first time on the day of the operation itself, one hour before it, and examined only the heart, lungs, and blood pressure, omitting the airway. The Court calls this an act of exceptional negligence and professional irresponsibility. It also rejects her theory of an anaphylactic reaction to pentothal, since no evidence of stridor, skin reactions, or wheezing appears on record, and the witness offered to support it was a pulmonologist, not an authority on anesthesia. The Court likewise gives no evidentiary weight to her synopsis, prepared only after the patient left the operating room, when the standard practice requires that every single act of the anesthesiologist be recorded. The faulty intubation was the proximate cause of the comatose condition.

On the third issue, the Court holds the De Los Santos Medical Center solidarily liable. An employer-employee relationship exists between the hospital and the visiting consultant physicians, and under Article 2180 the employer is answerable for the damages caused by its employees acting within the scope of their assigned tasks.

Doctrine

First, a physician is liable for damages under Article 2176 of the Civil Code when fault or negligence in the practice of the profession causes injury to the patient. Second, an anesthesiologist must perform a thorough preanesthetic and preoperative evaluation, including examination of the upper airway, before administering anesthesia; failure to do so is negligence, and faulty intubation that causes a comatose condition is the proximate cause of the injury. Third, under the captain of the ship doctrine, the surgeon in command of the operating team is liable for the negligence of those under him during the operation. Fourth, a hospital that employs visiting consultant physicians is solidarily liable with them under Article 2180 of the Civil Code for damages caused by their negligence within the scope of their assigned tasks.

Disposition

The Court denied the motions for reconsideration and held the De Los Santos Medical Center, Doctor Hosaka, and Doctor Gutierrez solidarily liable to the petitioners for actual, moral, temperate, and exemplary damages, attorney's fees, and the costs of the suit.

Remember This

The one line to memorize: the surgeon is the captain of the ship, the anesthesiologist must evaluate the airway before anesthesia, and the hospital answers solidarily for both. Examiners use this case for medical negligence, the captain of the ship doctrine, and the solidary liability of hospitals for visiting consultants.