Alisa Ansley, administrator of the Estate of James W. Ansley, deceased
Inmed Group, Inc., d/b/a Bullock County Hospital, et al.
from Bullock Circuit Court (CV-13-900050.80)
wrongful-death action was tried to a jury, which returned a
verdict in favor of "all defendants, " which
included the entity that operates Bullock County Hospital,
ERMDS, LLC, and the estate of Dr. Ireneo
Domingo, Jr. The Bullock Circuit Court ("the trial
court") entered a judgment on that verdict. The
plaintiff, Alisa Ansley, administrator of the estate of James
W. Ansley, deceased ("Ansley"), filed a
postjudgment motion for a new trial. The trial court denied
that motion, and Ansley appealed. We affirm.
Facts and Procedural History
p.m. on July 20, 2012, James W. Ansley ("James")
presented to the emergency room of Bullock County Hospital
("BCH"), complaining of chest pain he had been
experiencing for one or two days. James's condition
deteriorated, and, at approximately 4:30 p.m., the decision
was made to transfer James to a different hospital, Baptist
Medical Center South ("Baptist South"). James later
died at Baptist South of pulmonary emboli (blood clots that
had traveled to his lungs).
Domingo examined James when he arrived at the BCH emergency
room. At that time, Dr. Domingo was employed as an
emergency-room physician by ERMDS, LLC, which had contracted
with the entity that operates BCH to provide medical staff to
care for patients in BCH's emergency room. Dr. Domingo
was also employed as a hospitalist by the operator of BCH.
The parties agree that a hospitalist is a physician who works
in a hospital and decides whether to admit patients to the
hospital, primarily from the emergency room. The evidence in
this case indicates that it is common in small hospitals for
a hospitalist to also serve as an emergency-room physician.
approximately 2:58 p.m., Dr. Domingo created a differential
diagnosis identifying the medical conditions that could
possibly be causing James's symptoms. Those conditions
included, among others, myocardial infarction; coronary
artery disease; pulmonary embolism; and aortic dissection. At
that time, Dr. Domingo believed that myocardial infarction
was most likely responsible for James's symptoms. It is
undisputed, however, that James was suffering from a
parties agree that the best method of detecting a pulmonary
embolism is a CT scan with intravenous contrast dye. BCH
could not diagnose a pulmonary embolism with its CT scanner,
however, because the scanner did not have a contrast-dye
p.m., results of basic lab tests that had been performed on
James were returned. Shortly thereafter, Dr. Domingo entered
an order calling for James to be admitted to BCH. The record
is not entirely clear, but it appears that the order of
admission was entered at or around 3:42 p.m. Ansley argued in
the trial court that, upon entering the order to admit James
to BCH, Dr. Domingo began providing care to James in his
capacity as a hospitalist, as opposed to his capacity as an
emergency-room physician. Ansley argues on appeal that,
because BCH did not have the capability of diagnosing a
pulmonary embolism, Dr. Domingo, acting as a hospitalist,
should not have admitted James to BCH and should have instead
transferred him immediately to Baptist South.
record indicates that Dr. Domingo received the results of
James's cardiac lab tests at 3:56 p.m. Those test
results showed that James had elevated levels of troponin, a
protein that assists in muscle contractions and is released
in the event of a myocardial infarction or a pulmonary
embolism. Dr. Domingo believed that James's increased
troponin levels were caused by myocardial infarction. He
later agreed, however, that the elevated troponin was most
likely caused by the pulmonary emboli that killed James.
Dr. Domingo's deposition, portions of which were read to
the jury, Ansley's counsel asked Dr. Domingo if there
"was anything done between 2:58 [when the differential
diagnosis was created] and 4:30 [when the decision was made
to transfer James to Baptist South] to rule out pulmonary
embolism." Dr. Domingo responded:
"There was no indication to rule out [pulmonary
embolism] because the patient was stable. And ... the patient
wasn't complaining of shortness of breath. He said he
felt better. So the plan of action was really to admit the
patient to rule out [myocardial infarction]."
Domingo testified that James was at a low risk for pulmonary
embolism and was more likely suffering from myocardial
infarction. According to Dr. Domingo, the American Cardiology
Society recommends that, if there is a strong suspicion that
a patient has a myocardial infarction, the patient's
troponin level should be monitored. Dr. Domingo testified
that, before 4:30 p.m., "[t]here was no indication to do
a [pulmonary-embolism] workup."
approximately 4:30 p.m., James went to the restroom in
BCH's emergency room and became short of breath,
diaphoretic, hypotensive, and hypoxic. Dr. Domingo testified
that, at that time, he reexamined James and discovered that
his condition had changed significantly. Accordingly, Dr.
Domingo informed a BCH nurse that James was "not going
to be admitted [to BCH]." Instead, Dr. Domingo ordered
that James be transferred to Baptist South; James left BCH in
an ambulance at 5:40 p.m. and arrived at Baptist South at
6:28 p.m. Dr. Domingo testified that "[t]he
[pulmonary-embolism] event when [James] became hypotensive
was not foreseeable in [Dr. Domingo's] initial
assessment." In Dr. Domingo's opinion, he did what
he had believed "was best for the patient."
approximately 6:55 p.m., test results were obtained at
Baptist South that suggested the possibility of a pulmonary
embolism. Physicians at Baptist South, however, suspected
that James could have a dissection of the thoracic aorta.
Accordingly, heparin, an anticoagulant, was not administered
because it can cause a patient with aortic dissection to
bleed to death.
angiogram was performed at Baptist South at approximately
9:00 p.m. The results were provided to James's Baptist
South physicians at 9:20 p.m. and confirmed that James was
suffering from bilateral pulmonary emboli. James went into
cardiopulmonary arrest around that time and was pronounced
dead at 9:42 p.m.
she was appointed as representative of James's estate,
Ansley sued the entity that operates Baptist South, which
settled with her. Ansley also sued Dr. Domingo and, based on
his actions, ERMDS, LLC. In addition, based on Dr.
Domingo's actions and the actions of BCH nurses, Ansley
sued Inmed Group, Inc., d/b/a Bullock County Hospital, which
Ansley claimed was the entity that operates BCH. See
note 1, supra. Dr. Domingo died before the trial began, and
his estate was substituted as a defendant. In her complaint,
Ansley alleged that James's death resulted from the
defendants' medical malpractice.
Ansley's expert witnesses, Dr. Benny Gavi, a hospitalist,
testified as follows regarding the role of a hospitalist:
"A hospitalist is a doctor that works in the hospital
and they take admissions into the hospital primarily from the
emergency department. [A]nd so[, as a hospitalist, ] I would
get a call from the emergency department doctor, who says, I
have a patient who needs to come into the hospital, are you
willing to accept the patient? This is the medical history.
And then I say, yes, I accept; or, no, I don't accept if
there [are] issues. And then I take care of that patient in
the hospital until they go home."
Gavi testified that Dr. Domingo began functioning as a
hospitalist when he entered the order to admit James to BCH.
It appears undisputed that Dr. Domingo, in his capacity as an
emergency-room physician at BCH, could not admit a patient to
BCH. Ansley, however, has not pointed to evidence
establishing that an emergency-room physician at BCH cannot
make the decision to transfer a patient to a different
to Dr. Gavi, the standard of care requires a hospitalist to
be aware of the capabilities of his or her hospital. He
testified that a hospitalist should not accept a patient if
the patient has "a condition that you couldn't
treat" and that "it would not be safe to take
someone with a potentially life threatening problem or
problems to put them in a place where you couldn't
evaluate those problems or treat them in the most effective
manner." He also testified that BCH did not have
equipment capable of ruling out a pulmonary embolism.
According to Dr. Gavi, Dr. Domingo, acting as a hospitalist,
breached the applicable standard of care by admitting James
to BCH instead of transferring him to a more capable
expert witness called by Ansley, Dr. Jeffrey Kline, testified
as to Dr. Domingo's alleged breach of the standard of
care applicable to an emergency-room physician. He testified
that Dr. Domingo should have transferred James to Baptist
South when he received notice that James's troponin
levels were elevated.
Alan Jones, an emergency-room physician, testified for the
defendants. Before Dr. Jones was called as a witness, Ansley
objected to his providing "a standard-of-care opinion
for the entire time that James ... was at [BCH]." She
argued that, when the admission order was entered at 3:42
p.m., Dr. Domingo began caring for James as a hospitalist and
that Dr. Jones, an emergency-room physician, "would not
be similarly situated to Dr. Domingo after 3:42 p.m."
The trial court denied Ansley's motion to limit Dr.
Jones's testimony. According to Dr. Jones, Dr. Domingo
acted appropriately in waiting to transfer James until 4:30
p.m., when his condition changed in the BCH emergency-room
restroom. In her appellant's brief, Ansley does not
discuss Dr. Jones's testimony, other than to point out
that the trial court refused to limit its scope as she had
Court notes that Dr. Jones's responses to questions
regarding Dr. Domingo's duty to transfer a patient to a
more capable facility suggest that, for purposes of this
case, the standard of care applicable to an emergency-room
physician is very similar to the standard of care Ansley has
argued applies to a hospitalist. Specifically, Dr. Jones
testified as follows in response to questioning by
"Q. Dr. Domingo should always make a determination of
whether or not the patient is within the capability of the
hospital. He should have done that here, right?
"A. And I believe he did.
"Q. He should do it, right?
"A. Yes, he should do it.
"Q. Right. And in order to comply with the standard of
care, he has to make a determination as to whether or not
this patient fits within this capacity of this hospital here,
"Q. And if the patient doesn't, the obligation is to
transfer the patient to somewhere that is within that
the testimony of Dr. Kline, Ansley's expert
emergency-room physician, indicates that an emergency-room
physician should know the capabilities of his or her hospital
and should transfer patients to a more capable facility if
causation, Dr. Gavi testified that, if Dr. Domingo had
transferred James to Baptist South at 3:42 p.m. rather than
admitting him to BCH, he would have lived. Dr. Kline
testified that, if James had been transferred to Baptist
South an hour earlier than he was (or if the CT angiogram at
Baptist South had been performed an hour earlier), he would
have lived. Dr. William Alleyne, an expert witness called by
the defendants, testified as follows regarding
"Q. [By defendants' attorney:] Dr. Kline testified
that in his causation testimony that if Mr. Ansley had gotten
to [Baptist South] an hour earlier, he would have survived.
Do you agree with that?
"Q. Why not?