Doctors Hosp. of Augusta, Inc. v. Bonner
| Decision Date | 15 March 1990 |
| Docket Number | Nos. A89A2006,A89A2007,s. A89A2006 |
| Citation | 195 Ga.App. 152,392 S.E.2d 897 |
| Parties | DOCTORS HOSPITAL OF AUGUSTA, INC. v. BONNER et al. ANESTHESIA GROUP v. BONNER. |
| Court | Georgia Court of Appeals |
Smith, Gambrell & Russell, David M. Brown, Stephen M. Forte, Marianne Maher Elizabeth S. Haley, Atlanta, for appellant (case no. A89A2006).
Long, Weinberg, Ansley & Wheeler, Robert G. Tanner, Ronald R. Coleman, Jr., Stephen Sparwath, Atlanta, for appellant (case no. A89A2007).
Bell & Bell, John C. Bell, Jr., Augusta, Walbert & Hermann, Paul D. Hermann, Atlanta, James F. Findlay, Augusta, for appellees.
Anesthesia Group and Doctors Hospital of Augusta, Inc., d/b/a Humana Hospital, appeal the judgments entered on jury verdicts against each of them in this medical malpractice case brought by the representative and family of Ada Hammonds Pierce.
The evidence at trial is construed so as to uphold the verdict. Pendley v. Pendley, 251 Ga. 30, 31(1), 302 S.E.2d 554 (1983). Ms. Hammonds, the name she used professionally, was a 38-year-old Licensed Practical Nurse who worked in the delivery room at St. Joseph's Hospital. She slipped in the delivery room and injured her knee, requiring arthroscopic surgery. She was admitted by orthopedist Dr. Brand to Humana Hospital on October 4, 1983.
Humana Hospital had contracted in 1981 with Anesthesia Group, a partnership composed of Dr. Horseman and Dr. Mahoney, for the partnership to "provide full-time Anesthesiology services and assume general responsibility for the conduct and operation of Hospital's Anesthesiology Department, subject to approval of Hospital." The contract provided that services under it would be performed as scheduled by the Hospital Administration and that Group was required to provide an anesthesiologist from 7:00 a.m. to 3:30 p.m. Monday through Friday and otherwise as required by the Hospital. The partnership had to be available on 30 minutes notice for emergencies. The emergency services could be provided by a Certified Registered Nurse Anesthetist (CRNA) with an anesthesiologist available for supervision. The two partners were members of the hospital staff.
Surgery was scheduled by Hospital based on the requests for surgery made by surgeons such as Dr. Brand. A surgery schedule was prepared around 1:00 p.m. each day, typed up by Hospital's Director of Surgery and given to Group, which would decide how to staff the needed anesthesia services. Group set a fee schedule under the contract, which was subject to approval of Hospital. Hospital did not have approval rights of fees set by other doctors. When surgery was completed, the doctor or CRNA gave a charge slip, with the patient and surgery information and anesthesia charge on it, to Hospital's administrative staffer in the operating suite. The anesthesia was billed on the hospital bill. The notation on Ms. Hammonds' bill was "Anesthesia supplies 90.88 Anesthesia hosp empe 286.00." Hospital paid Group 86 percent of the total anesthesia charges, retaining 5 percent as administrative costs and 9 percent to cover "bad debts." There was a chargeback provision in the contract: if any third party provider did not pay or paid only partially, Group would reimburse Hospital. Hospital owned the accounts. Bill disputes with patients and collection were its responsibility.
Group in turn had contracted with five Certified Registered Nurse Anesthetists who worked under the partnership at Hospital. One of these CRNAs, Sarafin, visited Ms. Hammonds the evening of her admission. He introduced himself to all patients as being from the "anesthesia department." Nurses, including CRNAs, were required to wear uniforms of certain colors denoting their position. They were also provided name tags with their and the Hospital's names on it. Sarafin did the preoperative workup on Ms. Hammonds and prescribed preoperative medication. He signed Dr. Horseman's name to the orders. Dr. Horseman did not see Ms. Hammonds, nor did Sarafin consult with him concerning her.
On October 5, after having been given morphine at 6:00 a.m. for the surgery, Ms. Hammonds was taken to the pre-op holding area. She was visited by CRNA Jimenez, who was scheduled to administer anesthesia. He introduced himself to patients as a CRNA or nurse anesthetist with the "anesthesia service."
Dr. Mahoney was the floating anesthesiologist that day. He reviewed Ms. Hammonds' records in the pre-op holding area, approved the pre-op medications after they had been given, discussed for a minute or two the anesthesia plan with Jimenez, and spoke briefly with the patient.
Dr. Mahoney was not present in the operating room when anesthesia was induced nor during the surgery. Ms. Hammonds was put to sleep and then given a 100 mg. dose of Anectine at 7:05 a.m. Anectine paralyzes a patient so that the vocal cords will remain open, allowing insertion of an endotracheal tube to aid breathing during surgery. The surgery, uneventful, was completed at 7:46 a.m.
At 7:48 a.m., the endotracheal tube was suctioned out and removed. Ms. Hammonds was suctioned again and preparations were being made to roll her onto a gurney when a laryngospasm, which interferes with breathing, was observed by Jimenez. He administered 20 mg. of Anectine at 7:51 a.m. to break the spasm. It broke for approximately three breaths but reoccurred. Dr. Brand, the surgeon, had noticed Ms. Hammonds' toes and toenails becoming cyanotic, or turning blue, about five minutes after the surgery ended. He told Jimenez, who responded that he was administering medicine.
A second 20 mg. dose of Anectin was given at 7:56 a.m. but had no effect on the ability of Jimenez to ventilate the patient. At 8:00 a.m., circulating nurse Duffy left the operating room, went to the desk in the operating suite, and told the nurse there to find Dr. Mahoney. She got the code cart and returned to the operating room. Dr. Mahoney arrived and began to assist Jimenez. At 8:02 a.m., Jimenez gave a 100 mg. dose of Anectine, reintubated the patient, and started an i.v. drip of Anectine.
Jimenez saw no improvement in his ability to ventilate Ms. Hammonds. Both he and Dr. Mahoney listened to her chest, but her weight (250 pounds, height 5 feet) made chest sounds less clear. Both believed she had developed a bronchospasm, which causes the small sacs in the lungs to constrict, in addition to the laryngospasm. Bronchospasm under these circumstances is extremely rare and is seldom fatal.
During this period, Ms. Hammonds' heart rate became very slow, including at least two incidents of asystole or stoppage. Cardiac massage was used at intervals. Medications, effective both to stimulate the heart and to relax bronchospasm, were administered. At 8:07 a.m., due to the continuing difficulty, Dr. Mahoney decided to remove the second endotracheal tube and replace it with another. At 8:10 a.m., improvements in respiration began as it finally brought air to the lungs and ultimately to the brain.
Upon arrival at the intensive care unit, the nurses noted that the abdomen was "distended and tympanic sounding." This can be caused by pumping air into the stomach from an improperly placed endotracheal tube. Ms. Hammonds never regained consciousness and remained on a respirator until she was declared brain dead and life support was removed on October 11.
1. Group's first two enumerations allege error in the trial court's denial of their motion for directed verdict on the issue of negligence per se based on violation of OCGA § 43-26-9(b) and the court's charge on it.
That section provides that anesthesia may lawfully be administered by a CRNA "provided that such anesthesia is administered under the direction and responsibility of a duly licensed physician with training or experience in anesthesia." (Emphasis supplied.)
The allegations against Group and Hospital were that there had been a failure to exercise the degree of care generally required in the administration of anesthesia. See OCGA § 51-1-27. It was further alleged that Dr. Mahoney and CRNA Jimenez were agents and employees of Hospital.
The contracts entered into between Group and its CRNAs described the arrangement as one not between employer and employee, but between a "contractor," Group, and "subcontractors," the CRNAs. They further stated that the arrangement was meant to make the CRNAs "independent contractors."
Central Anesthesia Assoc. v. Worthy, 173 Ga.App. 150, 152, 325 S.E.2d 819 (1984), affirmed 254 Ga. 728, 333 S.E.2d 829 (1985).
Dr. Horseman, while acknowledging that he did not understand the meanings of the terms "employee and independent contractor," believed the contract did not diminish his ability to control the CRNAs and to direct their activities in the administration of anesthesia. Nonetheless, he had given no instructions to the CRNAs as to when they should call an anesthesiologist to the operating room. He believed the understanding of the CRNAs was that they should call when they needed the doctor for "consultation."
Dr. Mahoney stated he was unaware of any written guidelines which delineated when the CRNA should request assistance from the anesthesiologist, and he mentioned no verbal guidelines.
Jimenez said he was an independent practitioner but elected to work in a hospital "where I work with anesthesiologists so that I have their expertise to use along with my own." He described the anesthesiologist as "a consulting person and a resource person and an assistant who has a little more medical background or a lot more...
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