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Ansley v. Inmed Group, Inc.

Supreme Court of Alabama

May 4, 2018

Alisa Ansley, administrator of the Estate of James W. Ansley, deceased
Inmed Group, Inc., d/b/a Bullock County Hospital, et al.

          Appeal from Bullock Circuit Court (CV-13-900050.80)

          SELLERS, Justice.

         This 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, [1]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.

         I. Facts and Procedural History

         At 2:07 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).

         Dr. 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.

         At 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 pulmonary embolism.

         The 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 injector.

         At 3:36 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.

         The record indicates that Dr. Domingo received the results of James's cardiac lab tests at 3:56 p.m.[2] 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.

         During 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]."

         Dr. 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."

         At 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."

         At 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.

         A CT 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.

         After 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.

         One of 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."

         Dr. 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 facility.

         According 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 hospital.

         Another 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.[3]

         Dr. 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 requested.

         The 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 Ansley's counsel:

"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, right?
"A. Yes.
"Q. And if the patient doesn't, the obligation is to transfer the patient to somewhere that is within that capacity?
"A. Yes."

         Similarly, 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 necessary.

         As for 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 causation:[4]

"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?
"A. No.
"Q. Why not? ...

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