Robinson v. Oklahoma Nephrology Associates, Inc.

• Decision Date: 16 January 2007
• Docket Number: No. 100,081.,100,081.
• Citation: 154 P.3d 1250,2007 OK 2
• Parties: Carmilita ROBINSON and Don R. Robinson, Plaintiffs/Appellants, v. OKLAHOMA NEPHROLOGY ASSOCIATES, INC., d/b/a Oklahoma Nephrology Associates, Defendant, and Integris South Oklahoma City Hospital Corporation d/b/a Integris Southwest Medical Center of Oklahoma; and Integris Health, Inc., d/b/a Integris Health, Defendants/Appellees.
• Court: Oklahoma Supreme Court

154 P.3d 1250

2007 OK 2

Carmilita ROBINSON and Don R. Robinson, Plaintiffs/Appellants, v. OKLAHOMA NEPHROLOGY ASSOCIATES, INC., d/b/a Oklahoma Nephrology Associates, Defendant, and Integris South Oklahoma City Hospital Corporation d/b/a Integris Southwest Medical Center of Oklahoma; and Integris Health, Inc., d/b/a Integris Health, Defendants/Appellees.

No. 100,081.

Supreme Court of Oklahoma.

January 16, 2007.

Rehearing Denied March 12, 2007.

Certiorari to Court of Civil Appeals, Division III.

¶ 0 The plaintiffs sued two groups of defendants in this action for medical malpractice: their family physician and his employer, and a specialist and his employer. The matter proceeded to a jury trial against the employers. At the close of the plaintiffs' evidence, the trial court granted the demurrer of the defendant family physician's employer. Following the jury verdict against the defendant specialist's employer, the trial court denied the plaintiffs' motion for new trial as to the demurrer. The plaintiffs appealed and the Court of Civil Appeals affirmed. On certiorari previously granted:

THE OPINION OF THE COURT OF CIVIL APPEALS IS VACATED, THE ORDER OF THE DISTRICT COURT IS REVERSED, AND THE MATTER IS REMANDED FOR FURTHER PROCEEDINGS.

Lauren LeBlanc Day, Newalla, OK, and Howard K. Berry, Jr., Oklahoma City, OK, for Plaintiffs/Appellants.

Glen D. Huff, Susan A. Short, Robert D. Hoisington, Foliart, Huff, Ottaway & Bottom, Oklahoma City, OK, for Defendants/Appellees.

COLBERT, J.

¶ 1 On Friday, October 13, 1995, Carmilita Robinson's long-time physician, Craig Engles, M.D., a board-certified family practitioner, diagnosed her with an inner ear infection. When Mrs. Robinson returned to Dr. Engles' office on Monday morning, October 16, 1995, complaining of vomiting, nausea, and lethargy, Dr. Engles ordered a blood test. The laboratory called Dr. Engles as soon as the results were available that afternoon because they showed a dangerously low blood sodium level of 102 milliequivalents per liter of blood compared to a normal level of 135. Dr. Engles called Mrs. Robinson at home and instructed her to drink Gatorade and Ensure instead of water and to return to his office the next morning. Mrs. Robinson's sodium level had risen to only 103 by the next morning. Dr. Engles kept her at his office for most of the day and administered two liters of an intravenous (IV) normal saline solution. Two blood tests taken during the day showed sodium levels of 105 and 104.3. Dr. Engles consulted Anthony Czerwinski, M.D., an internist specializing in nephrology including the treatment of low blood sodium levels and, based on that consultation, hospitalized Mrs. Robinson Tuesday evening.

¶ 2 Dr. Czerwinski examined Mrs. Robinson in the hospital Tuesday night and ordered an IV of highly concentrated saline at a slow rate. Because she had passed very little urine during the day, Dr. Czerwinski also had Mrs. Robinson catheterized and requested a urinalysis. A blood test taken early Wednesday morning showed that Mrs. Robinson's sodium level had risen to 120, while the urinalysis indicated that she was passing a great deal of dilute urine (almost pure water). Although Dr. Czerwinski believed there was an error in the test results, he ordered no further tests that day. He did, however, order the IV discontinued. There is no record of the time when the IV was actually discontinued, but if it was allowed to run until it was empty, as indicated in Dr. Czerwinski's notes, it would have continued throughout the day until early evening.

¶ 3 The next blood test was ordered "stat" by Dr. Engles at 8:30 a.m. on Thursday and showed that Mrs. Robinson's sodium level had continued to rise to 126. Nevertheless, Dr. Engles ordered the IV of highly concentrated saline restarted. That IV was subsequently discontinued by Dr. Czerwinski. Later that day, Mrs. Robinson began having difficulty speaking. Her condition deteriorated over the next few days, she began to behave oddly, and she lost the ability to speak or move. Only after she was transferred to another hospital under the care of different doctors was Mrs. Robinson diagnosed with a brain stem injury called central pontine myelinolysys, a permanent neurologic condition caused by too rapidly raising a chronically low blood sodium level.

¶ 4 Mrs. Robinson and her husband brought this lawsuit against Dr. Engles and his employer, Integris South Oklahoma City Hospital Corporation (with its parent corporation, Integris Health, Inc.), as well as Dr. Czerwinski and his employer, Oklahoma Nephrology Associates, Inc., d/b/a Oklahoma Nephrology Associates. The matter proceeded to trial against the two employers only. Integris demurred at the close of the Robinsons' evidence and asserted that there was no evidence that Dr. Engles' care caused Mrs. Robinson's injury and that, regardless, Dr. Czerwinski's negligence was a supervening cause of her injury. The district court sustained Integris's demurrer and the trial proceeded against Dr. Czerwinski's employer. The jury found Dr. Czerwinski negligent and awarded damages of $8,341,158.62 to Mrs. Robinson and $2,566,511.46 to her husband. The district court entered judgment on the demurrer in favor of Integris and on the jury's verdict in favor of the Robinsons. See Okla. Stat. tit. 12, § 577 (Third) (2001), It denied the Robinsons' motion for new trial.

¶ 5 The Robinsons appealed the denial of their motion for new trial. The Court of Civil Appeals affirmed and we granted the Robinsons' petition for certiorari.

STANDARD OF REVIEW

¶ 6 We review a trial court's order denying a motion for new trial for error of a pure question of law or for an abuse of discretion which is arbitrary, clearly against the evidence, and manifestly unreasonable. See State v. Vaughn, 2000 OK 63, ¶ 8, 11 P.3d 211, 214; Dominion Bank of Middle Tenn. v. Masterson, 1996 OK 99, ¶ 16, 928 P.2d 291, 294. Here, the motion for new trial was based on alleged error in granting a demurrer to the evidence. When considering a demurrer to the evidence, the trial court must assume the truth of all facts, along with all reasonable inferences to be drawn from those facts, favorable to the party against whom the demurrer is directed. Thompson v. Presbyterian Hosp., Inc., 1982 OK 87, ¶ 6, 652 P.2d 260, 262. The court may not sustain a demurrer "unless there is an entire absence of proof to show" that a plaintiff has any right to recover. Id. ¶ 6, 652 P.2d at 262-63.

DISCUSSION

¶ 7 Taken in the light most favorable to the Robinsons and with all reasonable inferences in their favor, the evidence presented thus far is as follows: Mrs. Robinson had chronic hyponatremia. Hyponatremia is considered chronic when it has persisted long enough that the body and brain have adjusted to the low sodium level. "Chronic" in this sense does not necessarily refer to a long-term condition and can develop within hours. It occurs when blood sodium levels drop very gradually or when a critically low level has persisted for more than a few hours. The primary indicator is a lack of significant external symptoms such as seizures or even death. Mrs. Robinson's hyponatremia was certainly chronic by the time she was hospitalized and was probably chronic when it was first diagnosed by Dr. Engles on Monday. A blood sodium level as critically low as Mrs. Robinson's requires immediate hospitalization.

¶ 8 When hyponatremia has become chronic, the blood sodium level must be raised gradually to allow the body and brain to become re-accustomed to the higher level. Mrs. Robinson's blood sodium level rose too quickly and she suffered an irreversible brain injury as a result. It has been established that Dr. Czerwinski was negligent in his care of Mrs. Robinson because he failed to closely monitor her blood sodium level and allowed it to rise too quickly. The issue before us is whether the trial court erred in holding that the Robinsons did not submit sufficient evidence as a matter of law that any negligence by Dr. Engles was also a cause of Mrs. Robinson's brain injury.

¶ 9 A prima facie case of medical malpractice, like all negligence claims, contains three elements: "(a) a duty owed by the defendant to protect the plaintiff from injury, (b) a failure to properly exercise or perform that duty and (c) plaintiff's injuries proximately caused by the defendant's failure to exercise his duty of care." Thompson, 1982 OK 87, ¶ 7, 652 P.2d at 263. A defendant whose conduct contributed to cause a plaintiff's injury is liable for the injury even if his conduct was not sufficient by itself to cause the injury. Johnson v. Hillcrest Health Ctr., Inc., 2003 OK 16, ¶ 18 n. 25, 70 P.3d 811, 819 n. 25. The cause of a plaintiff's injury is normally a question of fact for the jury to decide. Id. Causation becomes a question of law only when there is no evidence and no reasonable inference from the evidence "from which the jury could reasonably find a causal link between the negligent act and the injury." Id. Rephrased, the legal question is narrowly focused on whether a reasonable person could believe that the defendant's negligent conduct was a cause of the plaintiff's injury. McKellips v. St. Francis Hosp., Inc., 1987 OK 69, ¶ 10, 741 P.2d 467, 471.

¶ 10 The Robinsons' expert witness, Richard Sterns, M.D., who is board-certified in internal medicine and nephrology, testified that Dr. Engles violated acceptable standards when he did not hospitalize Mrs. Robinson as soon as he knew of her critically low blood sodium level. Dr. Sterns' conclusion was seconded by another of the Robinsons' experts, Jerome M. Daniel, M.D., who is board-certified in family practice. Dr. Sterns also testified that Dr. Engles' initial treatment created the conditions that caused Mrs. Robinson's blood sodium levels to rise so quickly in the hospital. He explained that there are two ways to raise the concentration of sodium in the blood, by adding sodium (or saline) or by...