Daniels v. Hadley Memorial Hospital, No. 76-1563

• Court: United States Courts of Appeals. United States Court of Appeals (District of Columbia)
• Writing for the Court: John Jude O'Donnell; Before TAMM and WILKEY; Opinion for the Court filed by WILKEY; WILKEY
• Citation: 566 F.2d 749,185 U.S.App.D.C. 84
• Parties: Frances P. DANIELS, Mother and Next of Kin and Personal Representative of Horace Lee Miller, Deceased and Administratrix of the Estate of Horace Lee Miller, Deceased, Appellant, v. HADLEY MEMORIAL HOSPITAL et al.
• Decision Date: 27 October 1977
• Docket Number: No. 76-1563

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566 F.2d 749 185 U.S.App.D.C. 84 Frances P. DANIELS, Mother and Next of Kin and Personal
Representative of Horace Lee Miller, Deceased and
Administratrix of the Estate of Horace
Lee Miller, Deceased, Appellant,
v.
HADLEY MEMORIAL HOSPITAL et al. No. 76-1563. United States Court of Appeals,
District of Columbia Circuit. Argued 3 June 1977.
Decided 26 Sept. 1977.
Rehearing Denied Oct. 27, 1977.

George W. Shadoan, Rockville, Md., for appellant.

John Jude O'Donnell, J. Roy Thompson, Jr., Washington, D.C., for appellees.

Before TAMM and WILKEY, Circuit Judges and WILLIAM B. JONES, ^* United

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States Senior District Judge for the United States District Court for the District of Columbia.

Opinion for the Court filed by WILKEY, Circuit Judge.

WILKEY, Circuit Judge:

On the morning of 14 August 1973, Horace Miller, a 43-year-old government worker, went to Hadley Memorial Hospital's emergency room ¹ for treatment of abrasions received in a bicycle fall the previous week. The hospital gave him a penicillin injection at 9:05 a. m., and he departed the hospital between 9:20 and 9:25 a. m. At 9:30 a. m. he was discovered in the hospital's parking lot suffering from an anaphylactic reaction to the penicillin; he was in shock. He was rushed back into the hospital, and at 9:36 a. m. hospital personnel started resuscitation efforts. At 10:10 a. m. Mr. Miller was pronounced dead.

Frances P. Daniels, the deceased's mother and personal representative, brought this malpractice action ² in the U.S. District Court for the District of Columbia ³ against the Hadley Memorial Hospital, ⁴ contending that the hospital violated the standard of care it owed her son and proximately caused his death by (1) failing to retain him for observation for a sufficient period of time after the injection; (2) failing to give him adequate respiratory assistance during the resuscitation effort; and (3) failing to give him an intravenous injection of adrenalin as soon as possible during the resuscitation attempt. The parties waived a jury trial, and on 29 March 1976 the trial court filed its findings of fact and conclusions of law, entering judgment for the hospital. ⁵ The case is before us on plaintiff's appeal from that judgment.

In its "Findings", the trial court rejected all three of plaintiff's contentions:

First, it found that plaintiff had failed to prove that a thirty-minute post-injection observation period was the applicable standard of care at the time of the occurrence. Rather, the court found that the applicable standard was a fifteen- to twenty-minute period, which was not breached by the hospital. ⁶ This finding of fact is sufficiently sustained by the record evidence, and we leave it undisturbed.

Second, the trial court found that the hospital's failure to give proper respiratory assistance, though a breach of duty, was not the proximate cause of Mr. Miller's death. ⁷ This finding is based on a serious misapprehension of the medical evidence presented at trial, and we set it aside as clearly erroneous.

Third, the trial court found that the hospital did not breach its duty to Mr. Miller by failing to give him a timely intravenous injection of adrenalin because such an injection was impossible under the circumstances. ⁸ This finding is against the clear weight of the evidence, and we set it aside as clearly erroneous. Accordingly, we reverse the judgment below and remand for a new trial consistent with the instructions in Part IV of this opinion.

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Because we uphold the trial court's conclusion that the hospital was not negligent in its post-injection observation of the deceased, we deal here only with those aspects of the case bearing on the possible negligence of the hospital in its efforts at resuscitating Mr. Miller.

I. OVERVIEW OF PLAINTIFF'S CASE

Before recounting the sequence of events immediately preceding Horace Miller's death, we think it useful at the outset to consider the basic framework of plaintiff's case. ⁹

Plaintiff acknowledges that Horace Miller was in grave condition when he was rushed from the hospital's parking lot back into the emergency room. It is not disputed that he was in shock. ¹⁰ His respiration was severely impaired; he was already unconscious and breathing only four times a minute, too slowly to provide sufficient oxygen to his body. ¹¹ His circulation was also impaired; his heart was beating forty times a minute, too inefficiently to provide proper circulation of the blood. ¹² Moreover, his circulatory system was collapsing, confining the flow of blood to larger vessels supporting the major body organs. This meant that there was little if any circulation in the small veins and capillaries near the body surface. ¹³ Mr. Miller's condition was rapidly deteriorating, and when the resuscitation effort began at 9:36 a. m. quick action was necessary if he was to be saved.

Plaintiff contends that, faced with this emergency, the hospital had a duty to do three things without delay. The first, and most important, action was to get oxygen into the patient, for without oxygen the patient's brain would die in a matter of minutes. This required giving the patient respiratory assistance by (1) establishing a clear airway and (2) using positive pressure to force oxygen into the patient's lungs by means of mouth-to-mouth resuscitation, an ambu bag unit, or an endotracheal tube and respiration machine.

The second action was to get adrenalin into the patient's circulatory system where it could begin to counteract the effects of the anaphylactic reaction. This required that either an intravenous ¹⁴ or intracardiac ¹⁵ injection be made, because without circulation near the body surface subcutaneous ¹⁶ or intramuscular ¹⁷ injections would have little value.

The third action was to restore the patient's blood circulation so that both the oxygen and the adrenalin could be transported through the patient's blood stream. This required external cardiac massage, which makes the heart muscle expand and

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contract, thereby causing the blood to circulate.

Plaintiff concedes that the hospital did take the third proper action to restore Mr. Miller's circulation as soon as he was brought into the emergency room. Cardiac massage was started immediately and was continued throughout the resuscitation effort. However, the hospital made no attempt to provide proper respiratory assistance to the patient for the first four minutes of the resuscitation effort from 9:36 to 9:40 a. m. despite the fact that the patient stopped breathing altogether during those four minutes. ¹⁸ During these critical minutes, the patient's brain was not receiving enough oxygen. ¹⁹ This was indicated at 9:43 a. m. when one of the attending doctors noticed that the patient's pupils were dilated, a sign of neurological death. ²⁰ Moreover, although the hospital administered a subcutaneous injection of Sus-phrine ²¹ within the first two minutes of the resuscitation attempt, it did not make an intravenous injection of adrenalin until 9:42 a. m. six minutes into the resuscitation effort. ²² Plaintiff argues that it was possible to make an intravenous injection during these initial six minutes and that failure to do so was inexcusable.

In short, then, the crux of plaintiff's case is that the hospital had a duty to get both oxygen and adrenalin into Horace Miller's blood stream as quickly as possible, that the hospital failed to do this, and that its failure effectively eliminated whatever chance the patient had of surviving.

II. THE ACTION TAKEN

As one might suspect, the action during an emergency resuscitation attempt, or "Code Blue" in hospital parlance, is fast and furious. However, the District Court was able to reconstruct the approximate sequence of events on the basis of hospital records. Chief Nurse Curry, in charge of the emergency room, was present during the whole course of the Code Blue and one of her duties included a minute-by-minute recordation of what was done. The hospital records also include the notes of Dr. Hassan Vaziri, the emergency room physician who had originally ordered the penicillin injection. As Dr. Vaziri was not at trial and was never deposed, ²³ these two documents, as supplemented by Nurse Curry's testimony, furnish the only source of factual information as to what occurred during the critical early stages of the resuscitation attempt. For this reason, and because they are brief, the two documents are set forth verbatim here. Dr. Vaziri's notes, made after the incident, read: ²⁴

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Nurse Curry's contemporary handwritten account reads: ²⁵

At trial, the other fact witnesses, besides Nurse Curry, included other Hadley Hospital employees who participated in the Code Blue. Also, the plaintiff and defendant each produced one independent expert witness.

The District Court found that it was 9:35 a. m. when Horace Miller was returned to the emergency room in a wheelchair, unconscious, diaphoretic, moaning but trying to talk, with a pulse of forty and a respiration of about four. ²⁶ At 9:36 he was placed on a hard couch and resuscitation efforts were started. ²⁷ Sometime within the next four minutes the patient's voluntary respiration

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ceased and did not thereafter resume. ²⁸ For approximately the first two minutes there were, aside from several practical nurses, a doctor (Vaziri) and a nurse (Curry) attending to Miller.

Within the first minute, nasal cannulas ²⁹ were installed and oxygen was started. At 9:38 a. m., Dr. Vaziri gave Mr. Miller an injection of Sus-phrine subcutaneously. ³⁰ He also made an injection of Solu-Cortef. ³¹ Whether Dr. Vaziri gave Mr. Miller the injection of Solu-Cortef intravenously or subcutaneously is a major dispute in the case. At approximately 9:38 a. m., Dr. Arthur Jones, a staff physician at the hospital, arrived. ³² There is some evidence to suggest that Mr. Miller had already stopped voluntary breathing by this time. ³³ At about the same...