Gianquitti v. Atwood Medical Associates

• Decision Date: 01 July 2009
• Docket Number: No. 2006-99-Appeal.,2006-99-Appeal.
• Citation: 973 A.2d 580
• Parties: Kenneth J. GIANQUITTI et al. v. ATWOOD MEDICAL ASSOCIATES, LTD. et al.
• Court: Rhode Island Supreme Court

973 A.2d 580

Kenneth J. GIANQUITTI et al. v. ATWOOD MEDICAL ASSOCIATES, LTD. et al.

No. 2006-99-Appeal.

Supreme Court of Rhode Island.

July 1, 2009.

Howard B. Klein, Esq., Providence, for Plaintiff.

Francis A. Connor, III, Esq., Matthew D. Kelly, Esq., Providence, for Defendant.

Present: GOLDBERG, Acting C.J., FLAHERTY, SUTTELL, ROBINSON, JJ., and WILLIAMS, C.J. (ret.).

OPINION

Justice FLAHERTY, for the Court.

On the Christmas weekend of 2000, James A. Warshaw, M.D. (Dr. Warshaw) was the on-call attending physician for the defendant, Atwood Medical Associates, Ltd. (Atwood), a medical group serving about 5,000 patients, including the plaintiff, Kenneth J. Gianquitti. Atwood had become involved in Gianquitti's care in August 2000 for the treatment of a deep-vein thrombosis, or blood clot, that had developed in his left leg after surgery. On December 22, 2000, Dr. Warshaw admitted Gianquitti to Roger Williams Medical Center (Roger Williams) and ordered that he receive intravenous heparin therapy. Soon thereafter, Gianquitti developed a priapism.¹ Because of the length of time that passed before the plaintiff was treated for this condition, he has been left with permanent tissue damage and erectile dysfunction.

Mr. Gianquitti and his wife, Denise Gianquitti (plaintiffs), filed a medical malpractice suit against Roger Williams, Dr. Warshaw, and Atwood. At the conclusion of all the evidence at trial, the trial justice granted defendant Atwood's motion for judgment as a matter of law on plaintiffs' claim of direct liability against it, pursuant to Rule 50 of the Superior Court Rules of Civil Procedure.² Thereafter, the jury returned a verdict in favor of Dr. Warshaw and Roger Williams, finding that they were not negligent in their care and treatment of Mr. Gianquitti. In plaintiffs' appeal to this Court, they assert that the trial justice committed reversible error by: (1) granting Atwood's Rule 50 motion for judgment as a matter of law; and (2) refusing to give the jury a requested instruction on the duty of interns and residents at Roger Williams. The plaintiffs have not appealed the jury's verdict in favor of Dr. Warshaw. For the reasons stated in this opinion, we affirm the judgment of the Superior Court in favor of Roger Williams and we vacate the judgment entered as a matter of law in favor of Atwood.

Facts and Procedural History

The Patient's Background

Gianquitti became a patient of Atwood in August 2000 for treatment of a deep-vein thrombosis (DVT) that had developed in his left leg after surgery to repair a rupture in his left patellar tendon in July 2000. When he reported to Atwood, he had been taking an anticoagulant medication called Coumadin for about a week. Kathleen Gordon, M.D. (Dr. Gordon), an internist associated with Atwood,³ directed that Gianquitti continue to take Coumadin to prevent any progression of the blood clot. But, on December 21, 2000, Gianquitti visited Dr. Gordon, complaining of leg swelling. The doctor ordered an ultrasound to determine whether the blood clot was resolving. The next day, on December 22, 2000, at approximately 5 p.m., Gianquitti went to Roger Williams to undergo the ultrasound, and based on the test results, Dr. Warshaw, an internist on call for Atwood, admitted Gianquitti to the hospital.

The Patient's Admission to Roger Williams

Doctor Warshaw began his on-call duties at 5 p.m. on December 22, 2000. As set forth above, based on an oral report he received from the radiology technician about the results of the ultrasound, Dr. Warshaw ordered that Gianquitti be admitted to Roger Williams. Doctor Warshaw believed that Gianquitti's DVT was of an emergency nature and that it required heparin to be administered to him intravenously.⁴ However, Dr. Warshaw testified that he admitted Gianquitti as a nonteaching patient, which meant that as the attending physician, he, and not the interns or residents working at the hospital, would be responsible for all communications with the nurses as well as all examinations of and orders for the patient. Doctor Warshaw said that one of the reasons the patient was admitted as nonteaching was because he did not have the time to deal with multiple telephone calls from the interns and residents. He also said that he did not have time for teaching duties because of the "intensity of the weekend."

On the evening of December 22, 2000, the nurses at Roger Williams placed Gianquitti on heparin as ordered by Dr. Warshaw. Gianquitti said that at around 11 p.m. he began to experience the priapism. He testified that at around midnight, the nurse on duty came into his room and that he informed her that he had an erection. Later on, at some point between 2 and 3 a.m., the nurse returned, and he told her that he wanted to see a doctor because he continued to experience an erection. He said that the nurse replied that he would have to wait until the morning.⁵ Gianquitti also said that at some time between 7 and 8 a.m., two young doctors came into his room. He said that he believed them to be interns, although he could not explain what led him to that conclusion. He testified that they examined him, asked him some questions, and told him he would have to wait to see his own doctor. Gianquitti also said that the nurse who was on duty at 7 a.m., Nurse Lorelle Lemoi-Brown, already was aware of his priapism when she attended to him, and that she tried to page Dr. Warshaw that morning.

However, Nurse Lemoi-Brown testified that she reported to work at the hospital at about 6:45 a.m. on December 23, 2000. She testified that at approximately 10 a.m. she went into the patient's room to adjust the heparin drip and that it was then that Gianquitti informed her that he had been experiencing a persistent erection since the previous evening. She acknowledged that she understood that the situation required urgent medical attention.⁶ She said that after she learned of the patient's condition, she immediately attempted to page the on-call doctor. The paging records reflected that the first call to Atwood's answering service took place at 10:49 a.m. and that a second call was made at 11:23 a.m.

Nurse Lemoi-Brown also testified that at some point after she called Dr. Warshaw, she mentioned the patient's condition to one or two male interns that she happened to see in the hallway. She recalled that the interns said that she would be required to address the problem because the patient was a nonteaching patient. She recalled that she replied that she already had addressed the problem by calling the on-call attending physician. She further testified that she did not know whether the interns to whom she spoke ever examined Gianquitti.

Dr. Warshaw's Response

Doctor Warshaw recalled that he was paged by Nurse Lemoi-Brown on December 23, 2000 between 11 a.m. and noon and that he returned the page at noon. Lemoi-Brown informed Dr. Warshaw that Gianquitti had reported a persistent erection since the night before. He testified that he knew that this was a condition requiring urgent medical attention and that he believed the "treatment window" was about twenty-four hours to avoid permanent injury. He ordered Lemoi-Brown to cease the patient's intravenous heparin and to give him Coumadin instead.

It is significant that when Dr. Warshaw received the call from Roger Williams, he was in the intensive care unit at Fatima Hospital attending to other patients of Atwood. On that day, Atwood had approximately twenty patients at Fatima for whom Dr. Warshaw was responsible. As a general practice, he said, when he was on duty, he rounded on the patients in intensive care first.⁷ He testified that he finished up at Fatima as quickly as possible, and shortly after returning Nurse Lemoi-Brown's call, he drove to Roger Williams.

Doctor Warshaw estimated that he arrived at Roger Williams between 1 and 2 p.m. He acknowledged that had he been notified the night before or early in the morning of the patient's persistent erection, he immediately would have ordered the nurse to stop the heparin, he would have come to see the patient, and after examining him, he would have called a urologist. Because he had had experience with specialists who were reluctant to visit hospital patients who had not been examined by their own physician, he said that he believed it necessary to examine the patient before contacting the urologist.

When Dr. Warshaw arrived at the hospital and spoke to Gianquitti, the patient told him that he had been experiencing an erection since about 10 p.m. the previous night. The doctor estimated that he spent thirty to forty-five minutes with Gianquitti and he then placed a call to a urologist for a consultation. He said that he first attempted to contact a urologist whom Atwood frequently used by leaving a message with the physician's answering service. Later that afternoon, the message was returned by Alan Rote, M.D. (Dr. Rote), the urologist on call. Doctor Warshaw informed Dr. Rote of the patient's condition, and Dr. Rote instructed Dr. Warshaw to apply an icepack and administer terbutaline, an oral medication. Doctor Warshaw followed Dr. Rote's directions, and he also prepared additional medications that Dr. Rote had indicated he would administer to the patient when he arrived at the hospital. Doctor Rote testified that he understood the patient's condition presented an "urgent situation," and so he traveled to the hospital as quickly as he could. He arrived at Roger Williams at approximately 6 p.m. and attempted to treat the priapism. However, despite the doctor's efforts, the patient was rendered permanently incapable of achieving an erection because of the length of time that his condition had remained untreated.

Testimony Pertaining to Atwood's Coverage

At trial, Dr. Gordon testified that there was no backup system in place at Atwood to provide on-call physician assistance if the demands of the group's patients became too much for one doctor. Counsel also...