Marcano Rivera v. Turabo Medical Center

• Decision Date: 15 July 2005
• Docket Number: No. 04-2494.,04-2494.
• Citation: 415 F.3d 162
• Parties: Maria Yolanda MARCANO RIVERA; Jorge Rodriguez Matos; Fabiola Rodriguez Marcano, Plaintiffs, Appellees, v. TURABO MEDICAL CENTER PARTNERSHIP d/b/a Hospital Interamericano De Medecina Avanzada, Defendant, Appellant.
• Court: U.S. Court of Appeals — First Circuit

415 F.3d 162

Maria Yolanda MARCANO RIVERA; Jorge Rodriguez Matos; Fabiola Rodriguez Marcano, Plaintiffs, Appellees, v. TURABO MEDICAL CENTER PARTNERSHIP d/b/a Hospital Interamericano De Medecina Avanzada, Defendant, Appellant.

No. 04-2494.

United States Court of Appeals, First Circuit.

Heard April 8, 2005.

Decided July 15, 2005.

COPYRIGHT MATERIAL OMITTED

Orlando H. Martinez-Echeverría, with whom Fernando E. Agrait was on brief, for appellant.

Jorge M. Suro Ballester, with whom Carlos A. Ruiz was on brief, for appellees.

Before LYNCH, LIPEZ, and HOWARD, Circuit Judges.

LIPEZ, Circuit Judge.

Defendant Hospital Interamericano de Medicina Avanzada ("HIMA") appeals from a jury verdict finding that it was negligent in monitoring the birth of Fabiola Rodríguez Marcano and that its negligence caused Fabiola severe and permanent neurological damage. HIMA argues that there was insufficient evidence to establish its liability and that the evidence showed instead that Dr. Pedro Roldán Millan ("Dr.Roldán"), the non-employee obstetrician who delivered Fabiola, was solely responsible for Fabiola's injuries. HIMA further claims that the district court erred in allowing testimony by one of the plaintiffs' experts and in not remitting the damages award or awarding a new trial on apportionment of liability. We affirm.

I.

A. Factual background

We take the facts from the trial record, reciting them in the light most favorable to the verdict. See Grajales-Romero v. Am. Airlines, 194 F.3d 288, 292 (1st Cir.1999).

On the morning of September 14, 2000, plaintiff Maria Marcano Rivera ("Marcano") was admitted to HIMA, a hospital in Caguas, Puerto Rico, pursuant to her obstetrician's decision to induce labor. The obstetrician, Dr. Roldán, was not an employee of HIMA but had privileges there.

At 10 a.m., HIMA nurses attached Marcano to a fetal monitor, which monitors both the fetus's heart rate and the mother's uterine contractions. A fetal monitor provides a digital display of the fetal heart rate and prints out a paper record, known as a tracing, of the heart rate and the contractions. HIMA protocol dictates that nurses check the fetal monitor and record the fetal heart rate every 15 minutes during high-risk deliveries, including induced labor. HIMA protocol also provides that the nurse monitoring the delivery is responsible for notifying the physician of any abnormal fetal heart rate or uterine contraction findings.

At 11:45 a.m., Dr. Roldán induced labor by simultaneously administering Oxytocin through an intravenous drip and inserting in Marcano's vagina a 100 mcg tablet of Cytotec from his personal supply. Dr. Roldán's simultaneous administration of the two drugs was contrary to HIMA protocol and medical standards established by the American College of Obstetricians and Gynecologists ("ACOG"). Both Oxytocin and Cytotec stimulate uterine contractions; together they have a multiplier effect and can produce contractions that are too intense or too close together, thereby decreasing the flow of oxygen to the fetus. ACOG thus recommends a four-hour waiting period between administering Oxytocin and Cytotec. Moreover, the recommended dose of Cytotec — when taken alone — is only 25 mcg. The higher 100 meg dose administered by Dr. Roldán also risks producing contractions which are too intense or too close together.

Shortly after Dr. Roldán administered the drugs, he left Marcano's room. Marcano soon began to feel intense contractions. Although she rang the nurse call button repeatedly, the nurse monitoring the delivery, Brenda Marrero, did not respond.

When Marcano's husband, Jorge Rodríguez Matos ("Rodríguez"), joined her at approximately 2:30 p.m., he found her in a desperate state because of frequent contractions. She told him that the contractions were not like the ones she experienced with the delivery of her first child and that she could not stand the pain. Rodríguez went to the nurses' station and asked them to summon Dr. Roldán. At approximately 2:45, Dr. Roldán returned to Marcano's room and administered Demerol, a pain killer. He remained in the room throughout the rest of the delivery.

Oddly, the tracing from the fetal heart rate monitor is missing for the period between 10 a.m. and 3:27 p.m., meaning there is no way to evaluate the fetus's heart rate and oxygen supply while Marcano was alone in her hospital room.¹ The tracing between 3:27 p.m. and 3:45 p.m. appears normal, but that reading does not preclude the possibility that the fetus was deprived of oxygen during the period for which the tracing is missing. Between 3:45 p.m. and 5 p.m., the tracing reveals a continuing pattern of contractions that were too intense and too close together, accompanied by a low fetal heart rate. These factors suggest that the fetus was not receiving sufficient oxygen. The tracing ends at approximately 5 p.m., when Marcano was transferred to the delivery room and the monitor was disconnected.

Baby Fabiola was born at 6:19 p.m. She was taken immediately to the neonatal intensive care unit, where she was diagnosed with neonatal asphyxia and seizures secondary to neonatal asphyxia, and where she spent approximately two weeks before being discharged to her parents. Marcano and Rodríguez did not learn until four months later that Fabiola had permanent neurological damage as a result of neonatal asphyxia. Fabiola continues to suffer from daily seizures, and her prognosis is grim. Although she has an anticipated life span of 45 years, she will never see, walk, or communicate, and will require a care-giver for the rest of her life.

B. Procedural history

On January 16, 2002, the plaintiffs sued Dr. Roldán and HIMA² in federal district court for medical malpractice resulting in severe neurological damage to Fabiola. Early in the litigation, the plaintiffs reached a settlement with Dr. Roldán, who is no longer in practice. Their malpractice claims against HIMA proceeded to trial in October 2003, principally on the theory that HIMA employees failed to adequately monitor the labor and childbirth process and that HIMA's failure contributed to Fabiola's injuries.³ Specifically, the plaintiffs suggested that the neurological damage occurred during the period for which the tracing is missing, and that regular monitoring would have alerted Dr. Roldáan to Fabiola's distress in enough time to avert permanent damage.

Following a five-day trial, the jury returned a verdict in favor of the plaintiffs. The jury found that both HIMA and Dr Roldán had been negligent and that their negligence was the proximate cause of the plaintiffs' damages. It awarded $5.5 million in damages, apportioning 47% of the liability to HIMA and 53% of the liability to Dr. Roldán. Accordingly, the court entered judgment against HIMA for $2.585 million (i.e., 47% of $5.5 million). The court subsequently denied HIMA's post-verdict motion for judgment as a matter of law, a new trial on apportionment of liability, or remittitur.

II.

HIMA raises several arguments on appeal. First, it asserts that the district court erred in denying its motion for judgment as a matter of law pursuant to Federal Rule of Civil Procedure 50. Second, it assigns error to the district court's decision to admit testimony by one of the plaintiffs' expert witnesses. Finally, HIMA contends that the district court abused its discretion in failing to grant its motion for a new trial or remittitur under Federal Rule of Civil Procedure 59. We consider these claims in turn.

A. Motion for Judgment as a Matter of Law

While conceding that Fabiola suffered permanent neurological damage during birth, HIMA argues that the evidence at trial was insufficient to allow a reasonable jury to conclude that the damage was causally linked to negligent monitoring. The district court rejected this argument in denying a post-verdict motion for judgment as a matter of law, concluding that

there was ample evidence presented to the jury, which if believed, could sustain a finding that HIMA was indeed negligent in monitoring plaintiff's labor and that said negligence proximately caused the alleged injuries.... [T]he jury heard evidence that the monitoring was done every thirty minutes as opposed to every 15 minutes, as was standard in induced labors. Most importantly, the jury was allowed to make reasonable inferences from the fact that a significant portion of the tracing of the fetal heart rate and uterine contractions monitoring machine was missing, and HIMA was unable to give any explanation therefor.

A party seeking to overturn a jury verdict faces an uphill battle. "Courts may only grant a judgment contravening a jury's determination when the evidence points so strongly and overwhelmingly in favor of the moving party that no reasonable jury could have returned a verdict adverse to that party." Rivera Castillo v. Autokirey, Inc., 379 F.3d 4, 9 (1st Cir.2004) (internal quotation marks omitted). We review de novo the district court's denial of a motion for judgment as a matter of law, viewing the evidence in the light most favorable to the nonmoving party. Tapalian v. Tusino, 377 F.3d 1, 5 (1st Cir.2004).

The substantive law of Puerto Rico governs this diversity suit. See Rojas-Ithier v. Sociedad Española de Auxilio Mutuo y Beneficiencia de P.R., 394 F.3d 40, 43 (1st Cir.2005). To prevail on a medical malpractice claim under Puerto Rico law, "a party must establish (1) the duty owed; (2) an act or omission transgressing that duty; and (3) a sufficient causal nexus between the breach and the harm." Id. HIMA cites deficiencies in the plaintiffs' evidence as to both the first and third prongs of this test.

1. Duty

Puerto Rico courts have explained the standard of care owed to patients as "[t]hat [level of care] which, recognizing the modern means of communication and education, ... meets the professional requirements generally acknowledged by the medical profession." Lama v. Borras, 16 F.3d 473, 478 (1st Cir.1994) (q...