RAMOS v. CA G.R. No. 124354, 29, December 1999 Medical Malpractice FACTS CHARLES:ErlindaRamos, is a 47-year old robust woman.

Except for occasional complaints of discomfort due to pains allegedly caused by the presence of a stone in her gall bladder, she was as normal as any other woman. However, because of the discomforts somehow interfered with her normal ways, she sought professional advice. She was advised to undergo an operation. She underwent a series of examinations which indicated that she was fit for surgery. On 10 June 1985, she and her husband Rogelio Ramos met for the first time Dr. Hosaka, one of the defendants, who advised that she should undergo Cholecystectomy. Dr. Hosaka assured them that he will get a good anesthesiologist. They agreed that the date of operation would be on 17 June 1985 at 9:00 A.M. At around 7:30 A.M. of 17 June 1985, while still in her room, she was prepared for the operation by the hospital staff. Her sister-in-law, Herminda Cruz, who was the Dean of the College of Nursing at the Capitol Medical Center, was there for moral support. At the operating room, Herminda saw about two to three nurses and Dr. Perfecta Gutierrez, the other defendant, who was to administer anesthesia. Herminda was allowed to stay inside the operating room. Contrary to the scheduled time of operation which is 9:00 A.M, Dr. Hosaka came late at the operating room or at about 12:15 P.M. When the operation began, Herminda saw Dr. Gutierrez intubating the patient. She thereafter heard Dr. Gutierrez say anghirapnaman ma-intubate nito, maliyataangpagkakapasok. O lumalakiangtiyan. Because of the remarks, she focused her attention on what Dr. Gutierrez was doing. She thereafter noticed bluish discoloration of the nailbeds of the patient. She then heard Dr. Hosaka issue an order for someone to call Dr. Calderon. The Dr. arrived and placed the patient in trendelenburg position, wherein the head of the patient is positioned lower thatn the feet, which indicates a decrease of blood supply in the brain. Herminda, told Rogelio that something wrong was happening. At almost 3:00 P.M. of that fateful day, she saw the patient taken to the ICU. About two days later, Rogelio was informed by Dr. Hosaka that something went wrong during the intubation. Rogelio told the Doctor that the condition of his wife would not have happened, had he looked for a good anesthesiologist. Doctors Gutierrez and Hosaka were asked by the hospital to explain what happened. The doctors explained that the patient had bronchospasm. On 8 January 1986, petitioners filed a civil case for damages with the Regional Trial Court against the respondents alleging negligence in the management and care of Erlinda Ramos.

CASE BEFORE THE RTC RIVA: During the trial, plaintiff presented the testimonies of Dean Herminda Cruz and Dr. Mariano Gavino to prove that the injury sustained by Erlinda was due to lack of oxygen in her brain 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, Pentothal. After considering the evidence from both sides, the RTC rendered judgment in favor of petitioners and holds the defendants guilty of negligence in the performance of their duty to the patient. On the part of Dr. Gutierrez, the court finds that she omitted to exercise reasonable care in not intubating the patient. On the part of Dr. Hosaka, the court finds him liable for the acts of Dr. 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 late. On the part of the Hospital, the 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. CASE BEFORE THE CA RIVA: Private respondent seasonably interposed an appeal to the Court of Appeals. The appellate court reversed the findings of the trial court and dismissed the complaint against the appellants. The appellate court likewise opined that private respondents were able to show that the brain damage sustained by Erlinda was not caused by the alleged faulty intubation but was due to the allergic reaction of the patient to the drug Pentothal, as testified on by their expert witness, Dr. Jamora. On the other hand, the appellate court rejected the testimony of Dean Herminda Cruz offered in favor of petitioners that the cause of the brain injury was traceable to the wrongful insertion of the tube since the latter, being a nurse, was allegedly not knowledgeable in the process of intubation. In other words, what the Court of Appeals is trying to impress is that being a nurse, and considered a layman in the process of intubation, witness Cruz is not competent to testify on whether or not the intubation was a success. Petitoners assail the decision of the CA.

ISSUE Whether or not the Court of Appeals erred in not applying the doctrine of RES IPSA LIQUITOR. Charles: In answering the principal issue, this group will also deal with the following: 1) The Definition and elements of Res IpsaLiquitor; 2) The Liability of the assisting surgeon (Dra. Gutierrez); 3) The Liability of the lead surgeon (Dr. Hosaka); 4) The captain of the ship doctrine, its definition and whether it is applicable here in our jurisdiction; and finally 5) The liability of the Hospital DECISION: The Court of Appeals erred in not applying the doctrine of RES IPSA LIQUITOR. The doctrine of res ipsa loquitur is applicable in the case at bar. The damage sustained by Erlinda in her brain prior to a scheduled gall bladder operation presents a case for the application of res ipsa loquitur. The real question, therefore, is whether or not in the process of the operation any extraordinary incident or unusual event outside of the routine performance occurred which is beyond the regular scope of customary professional activity in such operations, which, if unexplained would themselves reasonably speak to the average man as the negligent cause or causes of the untoward consequence. If there was such extraneous interventions, the doctrine of res ipsa loquitur may be utilized and the defendant is called upon to explain the matter, by evidence of exculpation, if he could.
In the present case, Erlinda submitted herself for cholecystectomy and expected a routine general surgery to be performed on her gall bladder. On that fateful day she delivered her person over to the care, custody and control of private respondents who exercised complete and exclusive control over her. At the time of submission, Erlinda was neurologically sound and, except for a few minor discomforts, was likewise physically fit in mind and body. However, during the administration of anesthesia and prior to the performance of cholecystectomy she suffered irreparable damage to her brain. Thus, without undergoing surgery, she went out of the operating room already decerebrate and totally incapacitated. Obviously, brain damage, which Erlinda sustained, is an injury which does not normally occur in the process of a gall bladder operation. In fact, this kind of situation does not in the absence of negligence of someone in the administration of anesthesia and in the use of endotracheal tube. Normally, a person being put under anesthesia is not rendered decerebrate as a consequence of administering such anesthesia if the proper procedure was followed. Furthermore, the instruments used in the administration of anesthesia, including the endotracheal tube, were all under the exclusive control of private respondents, who are the physicians-in-charge. Likewise, petitioner Erlinda could not have been guilty of contributory negligence because she was under the influence of anesthetics which rendered her unconscious. Considering that a sound and unaffected member of the body (the brain) is injured or destroyed while the patient is unconscious and under the immediate and exclusive control of the physicians, we hold that a practical administration of justice dictates the application of res ipsa loquitur. Upon these facts and under these circumstances the Court would be able to say, as a matter of common knowledge and observation, if negligence attended the management and care of the patient. Moreover, the liability of the physicians and the hospital in this case is not predicated upon an alleged failure to secure the desired results of an operation nor on an alleged lack of skill in the diagnosis or treatment as in fact no operation or treatment was ever performed on Erlinda. Thus, upon all these initial determination a case is made out for the application of the doctrine of res ipsa loquitur. Upon these facts and under these circumstances a layman would be able to say, as a matter of common knowledge and observation, that the consequences of professional treatment were not as such as would

ordinarily have followed if due care had been exercised. The appellate court, however, disbelieved Dean Cruz's testimony in the trial court by declaring that: A perusal of the standard nursing curriculum in our country will show that intubation is not taught as part of nursing procedures and techniques. Calderon who succeeded in doing so clearly suffer from lack of sufficient factual bases. In other words, what the Court of Appeals is trying to impress is that being a nurse, and considered a layman in the process of intubation, witness Cruz is not competent to testify on whether or not the intubation was a success. The Supreme Court does not agree with the above reasoning of the appellate court. Although witness Cruz is not an anesthesiologist, she can very well testify upon matters on which she is capable of observing such as, the statements and acts of the physician and surgeon, external appearances, and manifest conditions which are observable by any one. This is precisely allowed under the doctrine of res ipsa loquitur where the testimony of expert witnesses is not required. It is the accepted rule that expert testimony is not necessary for the proof of negligence in nontechnical matters or those of which an ordinary person may be expected to have knowledge, or where the lack of skill or want of care is so obvious as to render expert testimony 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 at Nursing, was fully capable of determining whether or not the intubation was a success.