Cappuccilli v. Carcieri

• Decision Date: 15 December 2017
• Docket Number: No. 2015–46–Appeal. (PC 09–1491),2015–46–Appeal. (PC 09–1491)
• Citation: 174 A.3d 722
• Parties: Sevan (Bjorklund) CAPPUCCILLI v. David A. CARCIERI, M.D., d/b/a Medical Office of David A. Carcieri, M.D. et al.
• Court: Rhode Island Supreme Court

174 A.3d 722

Sevan (Bjorklund) CAPPUCCILLI

v.David A. CARCIERI, M.D., d/b/a Medical Office of David A. Carcieri, M.D. et al.

No. 2015–46–Appeal. (PC 09–1491)

Supreme Court of Rhode Island.

December 15, 2017

For Plaintiff: Mark B. DeCof, Esq., Douglas E. Chabot, Esq., Michael P. Quinn, Jr., Esq.

For Defendants: Ryan K. Deady, Esq., William F. White, Esq.

Present: Suttell, C.J., Goldberg, Flaherty, Robinson, and Indeglia, JJ.

Justice Indeglia, for the Court.

The plaintiff, Sevan (Bjorklund) Cappuccilli¹ (Ms. Cappuccilli or plaintiff),² appeals from a Providence County Superior Court judgment in favor of the defendants, David A. Carcieri, M.D., d/b/a Medical Office of David A. Carcieri, M.D. (Dr. Carcieri or defendant), and Women & Infants Hospital of Rhode Island (Women & Infants).

The plaintiff's claim against defendants arises from an injury that she alleges that she suffered at Women & Infants when she underwent an emergency cesarean section

(C-section). After a three-and-a-half-week trial, the jury returned a verdict for defendants. The plaintiff subsequently moved for a new trial pursuant to Rule 59 of the Superior Court Rules of Civil Procedure. The trial justice denied the motion on November 25, 2014, concluding that reasonable minds could differ as to whether Dr. Carcieri's conduct fell below the appropriate standard of care. For the reasons set forth, we affirm the judgment of the Superior Court.

IFacts and Travel

On March 15, 2006, Ms. Cappuccilli was admitted to Women & Infants. Doctor Carcieri, who specializes in obstetrics and gynecology, was also at Women & Infants that day, supervising and teaching Brown University medical residents. At the time she was admitted, Ms. Cappuccilli was full term and in labor with her fifth child. Although he was not Ms. Cappuccilli's primary obstetrician, Dr. Tawfik "Fred" Hawwa cared for her upon her admittance.³ Ms. Cappuccilli testified that "everything [was] fine, the baby's heart rate [,] everything was going great."

But Ms. Cappuccilli's labor soon took a turn for the worse when her baby began evidencing signs of distress between 12:22 p.m. and 12:29 p.m. At trial, Ms. Cappuccilli recalled "all of a sudden * * * his heart rate was dropping tremendously." As a result of the fetal bradycardia,⁴ Dr. Hawwa determined that Ms. Cappuccilli needed an emergency C-section. Doctor Hawwa, unavailable to do the surgery himself, called Dr. Carcieri and asked him to perform the procedure as soon as possible. Doctor Carcieri had had no previous contact with Ms. Cappuccilli, but he nevertheless agreed; and he began the emergency C-section.

A. The C–Section

Doctor Carcieri delivered "a very healthy baby" without any complications. Soon after the baby's delivery, however, problems arose with Ms. Cappuccilli. Doctor Carcieri testified that Ms. Cappuccilli's uterus had an "odd coloration" of a "purplish appearance" and resembled what is referred to as a "Couvelaire uterus

."⁵ Doctor Carcieri exteriorized⁶ the uterus to get a closer look at the uterine incision, encountering no resistance in doing so. Upon further observation, Dr. Carcieri discovered a two-centimeter extension of the uterine incision,⁷ which is a horizontal cut in the uterus through which the baby is removed.

Doctor Carcieri stitched the incision along with its lengthened extension and returned the uterus.

Nevertheless, the extension continued bleeding. Doctor Hawwa, who had since joined Dr. Carcieri in the operating room, "scrubbed in" to help stop the bleeding. They soon discovered that the bleeding derived from the retroperitoneum,⁸ which is where the ovarian vein is located. Doctor Carcieri testified that Dr. Hawwa "proceeded to open the retroperitoneum * * * and clean out all that clot and clean out all that irregular blood" and that it was then that the bleeding intensified. Doctor Carcieri described the bleeding as like "cranberry sauce * * * it just came pouring out." Doctor Hawwa recalled that the blood "clotted and it looked like it had been there for a while. It almost looked like * * * jello." Doctor Hawwa estimated based on the blood's appearance and consistency that it had been there for "a while. Between 45, 30 minutes to an hour."

Doctor Carcieri and Dr. Hawwa testified that they soon discovered the source of the massive bleeding: the ovarian vein had separated into two pieces, referred to in the medical records as an ovarian vein laceration. Doctor Carcieri testified that he and Dr. Hawwa attempted to "tie [the vein] off twice," but "it was very odd. It was almost like tissue paper so when we tied it, put a tie on it * * * it immediately broke away." Doctor Hawwa testified that "the vein was very, very friable, like, it just crumbled." After Dr. Carcieri and Dr. Hawwa were unable to stop the bleeding, Dr. Richard Moore assisted. Doctor Moore ultimately succeeded in controlling the bleeding, but not before Ms. Cappuccilli lost between 5,000 and 8,000 cubic centimeters of blood—more blood than she had in her body.⁹

B. C–Section Aftermath

Following her surgery, Ms. Cappuccilli was transferred to the Trauma Intensive Care Unit at Rhode Island Hospital, where she required two more surgeries and remained in a medically-induced coma for a short time. After the procedure, Ms. Cappuccilli was "terribly traumatized by [the] whole thing." When released from the hospital, she experienced severe abdominal pains and swelling in her limbs. She continues to receive treatments for what she testified was diagnosed as lymphedema

, a condition that causes swelling in her abdomen, legs, and upper body.¹⁰ She also testified that she began seeing a psychiatrist—Dr. Carmen Monzon—for treatment of depression, anxiety, and nightmares, and started taking medication at Dr. Monzon's direction. Doctor Monzon believed that Ms. Cappuccilli could be suffering from Post–Traumatic Stress Disorder. Ms. Cappuccilli alleges that Women & Infants' risk-management team paid for her prescription for Zoloft¹¹ in August 2006; the admission of evidence concerning that payment is at issue in this appeal.

Moreover, although her son—Robert—was delivered successfully, he received a two-to-three centimeter wound

to his right temple, described in a record as a "laceration from scalpel." The admissibility of a photograph of Robert's injury and of a medical record referencing it is also at issue in this appeal.

C. Timing and Nature of Lacerated Ovarian Vein

At trial, Ms. Cappuccilli and defendants disputed the condition of her ovarian vein, as well as the timing of its opening. Doctor Carcieri testified that he believed that the vein was abnormal. Based on this belief, he testified that the vein ruptured by itself prior to the C-section. Further, he thought that the bleeding from the vein rupture caused the fetal distress that necessitated the emergency C-section. Doctor Carcieri testified that neither he nor Dr. Hawwa were able to tie the vein off because "it was not a normal vein." Doctor Carcieri described that the vein felt "like tissue paper when [he] touched it," unlike any other vein he had encountered.

Ms. Cappuccilli disputed Dr. Carcieri's characterization of the vein as abnormal in part because Dr. Carcieri did not notify either Ms. Cappuccilli or Women & Infants about the alleged abnormality, nor did he reference it in his operative note.¹² Ms. Cappuccilli instead believed that the vein injury occurred during the C-section at the hands of Dr. Carcieri. She pointed to numerous records kept at Women & Infants and Rhode Island Hospital to support that claim.¹³ Doctor Carcieri disputed the reliability of this evidence, testifying that often the person dictating these records is the "low man on the totem pole" and is not someone intimately involved in the case. In addition, Dr. Moore testified that "there are many records made in the medical records that are not fact." He further described some of the records as "medical record notes that were cut and paste, whether they were done by an intern or medical assistant * * *."

In line with Dr. Carcieri and Dr. Hawwa's testimony, Dr. Moore testified that, based on the injury's location, he did not believe a scalpel lacerated the vein, stating: "I don't see how you get to that area in the span of doing a C-section." He believed that the "bleeding had been happening in that retroperitoneum space long before [Dr. Carcieri and Dr. Hawwa] opened it," based on the large collection of blood already in the area. Doctor Moore also reiterated that "[t]his was a vein that was like tissue paper. In fact, it was like wet tissue paper * * *. This was an abnormal vein." He continued, "the difficulty of ligating that vein off was because it was friable, it was venous complex, it was torturous and it was very abnormal and very difficult to tie off. I have tied up thousands of infundibulum ligaments, ovarian veins and this is not a normal vein that I have tied off before." Similarly, Dr. Hawwa testified that, after he had trouble tying the vein, he determined that "this vein is not a normal vein. I have never seen anything like it before and I have never seen anything like it since then. It is, it is a tough vein. * * * [W]e were discussing that something must be wrong with this vein, otherwise it would have taken the tie. A vein should take a tie and hold steady."

D. Expert Testimony at Trial

On March 20, 2009, Ms. Cappuccilli filed a medical malpractice action against defendants alleging that they negligently cut or tore her ovarian vein during the C-section. Over the course of a three-and-a-half-week trial, each side presented expert testimony, and a total of fifteen witnesses testified: eleven on behalf of plaintiff and four on behalf of defendants. The plaintiff presented Dr. Fred Duboe, an obstetrician gynecologist, who gave his opinion that the injury occurred during the C-section and is not an injury that would occur absent negligence. Doctor Duboe further noted that "the most likely mechanism for the injury was through forceful...