Robb v. Anderton
| Decision Date | 05 November 1993 |
| Docket Number | No. 920770-CA,920770-CA |
| Citation | 863 P.2d 1322 |
| Parties | Michael ROBB, as guardian ad litem for Jayci Robb, Plaintiff and Appellant, v. Barry ANDERTON, M.D., Defendant and Appellee. |
| Court | Utah Court of Appeals |
Raymond A. Hintze (Argued), Midvale, for plaintiff and appellant.
Elliot J. Williams (Argued), Bruce H. Jensen, Williams & Hunt, Salt Lake City, for defendant and appellee.
Before BILLINGS, P.J., RUSSON, Associate P.J., and BENCH, J.
Appellant Michael Robb, guardian ad litem for Jayci Robb, appeals from an adverse bench trial ruling in a medical malpractice action. We affirm.
Jayci Robb, age two months, was scheduled for a craniectomy at Primary Children's Medical Center. Dr. Barry Anderton, a specialist in pediatric anesthesiology, anesthetized Jayci with halothane and nitrous oxide. Once Jayci was asleep, he passed an endotracheal tube into her trachea for the administration of oxygen. Dr. Anderton checked the tube for proper placement and then connected it to a ventilator designed to perform the breathing process.
Dr. Anderton next established an intravenous (IV) line for the administration of fluids and medications into Jayci's bloodstream during surgery. He was assisted by a surgical nurse. The IV line was assembled prior to surgery and filled with fluid by the nurse for Dr. Anderton. Both Dr. Anderton and the nurse testified that while observing fluid dripping through the IV line they carefully inspected the tubing for air bubbles. Observing no air in the line, Dr. Anderton connected the tubing to a catheter in Jayci's foot. Because the IV system is closed, it remains free of air once it is properly filled with fluid.
Within minutes after completing these procedures and before the actual surgery began, Jayci suffered a cardiac arrest which lasted approximately twenty-three minutes. At the onset of the cardiac arrest, Dr. Anderton noted loud heart tones and a heart murmur. He first checked the position of the endotracheal tube and determined it was appropriately placed. Dr. Anderton next turned off the anesthesia suspecting that Jayci was suffering from a cardiac depression caused by the anesthetic agents. The IV line was also reexamined and was found to be functioning properly. Although Jayci was ultimately resuscitated, she sustained serious permanent injury, including cerebral palsy, spastic quadriplegia and seizures.
At trial, appellant presented the expert testimony of Maurice Zwass, M.D., an anesthesiologist from California. Appellant's theory was that Dr. Anderton had not removed the air from the IV line, which caused Jayci's cardiac arrest. Dr. Zwass testified that in his opinion Jayci's cardiac arrest was likely caused by one of two things: When asked by counsel to render an opinion on which of the two theories he believed was most likely, Dr. Zwass chose the venous air theory because in his experience the presence of loud heart tones is inconsistent with an anesthetic overdose.
Dr. Zwass testified that Dr. Anderton's care, if rendered as described and recorded, complied with the appropriate standard of care. He also testified he had not seen or heard of a case where a cardiac arrest was caused by an infusion of air occurring with an IV line and set-up of the type Dr. Anderton utilized.
The trial court also heard testimony on the standard of care from David Steward, M.D., Dr. Anderton's expert, over the foundational objection of appellant. Dr. Steward is a pediatric anesthesiologist who is the Director of the Anesthesiology Service at the Children's Hospital of Los Angeles, and a professor of anesthesia at the University of Southern California. Dr. Steward completed his medical education and post-graduate training in Canada and England. He is certified by the American Board of Anesthesiology and also holds the equivalent certification in Canada from the Royal College of Physicians. From 1972 to 1984, Dr. Steward was the Director of the Department of Anesthesiology at the Hospital for Sick Children, the largest children's hospital in North America. From 1984 until accepting the position in Los Angeles, Dr. Steward was the Director of Anesthesiology at the British Columbia Children's Hospital in Vancouver. He has been actively involved in the education of pediatric anesthesiologists in both Canada and the United States. As a visiting professor, he routinely supervises anesthesiology residents at medical schools in the United States. Dr. Steward has twenty-three years of experience as a pediatric anesthesiologist and during that time has personally administered anesthesia to approximately 10,000 children, in addition to supervising residents in an estimated additional 10,000 cases.
Dr. Steward testified he is knowledgeable about the standard of care practiced by competent pediatric anesthesiologists in the United States. In his opinion there is very little difference in the standard of care in the United States and Canada.
Based on this foundation, the trial court allowed Dr. Steward to give his professional opinion. Dr. Steward testified that Dr. Anderton complied in all respects with the appropriate standard of care expected of a pediatric anesthesiologist. In Dr. Steward's opinion, the most likely explanation for Jayci's cardiac arrest was a profound myocardial depression resulting from an abnormal response to the combination of anesthetic agents used. He testified the loud heart sounds Dr. Anderton noted were typical of those preceding profound depression of the heart. Further, Dr. Steward testified that an air embolism was not a possible explanation of Jayci's cardiac arrest. He explained that such an event has not been reported and simply is not possible with an IV apparatus of the type Dr. Anderton used. Additionally, he testified that air in the bloodstream causes damage which would have produced objective signs that were not present in Jayci's case, such as a low platelet count and pulmonary edema.
Dr. Anderton also relied on the testimony of a second expert witness, Richard Moon, M.D. Dr. Moon is board certified in anesthesiology, internal medicine and pulmonary medicine. He is an expert in hyperbaric medicine, which involves the use of oxygen under high pressure to treat patients who develop air bubbles in their blood.
Dr. Moon testified it would take sixteen or more cubic centimeters of air to cause a cardiac arrest in a patient of Jayci's size when administered in an IV line. Dr. Moon measured the entire volume contained in the IV tubing, which would have been the maximum amount of air that could have been introduced through the line, and found it to contain only thirteen cubic centimeters. Consequently, he concluded there could not have been sufficient air in the line to produce an air embolism.
Dr. Moon also described the symptoms of venous gas embolism. He testified that if air had been introduced through the IV line Jayci would have demonstrated several objective signs which were not reported. Dr. Moon testified that it was "inconceivable" that Jayci's cardiac arrest was the result of a large infusion of air into her venous system.
The trial court relied on the testimony of Dr. Anderton's expert witnesses. The court found Dr. Steward and Dr. Moon to "have impressive credentials which are beyond dispute, and were the more competent, credible and persuasive of the experts from whom opinions were received."
Further, the trial court specifically found that Dr. Anderton and the surgical nurse
examined the IV line and apparatus at the commencement of the procedure looking for air bubbles and checked the flow of fluid from the IV line prior to its insertion in Jayci Robb to insure that there was no significant amount of air in the line. Defendant's procedure for inspecting the IV line, which was followed in his treatment of Jayci Robb, complied with the applicable standard of care.
The court recognized that "[a] cardiac arrest after induction of anesthesia which leads to an injury such as Jayci Robb sustained in this case can and does occur in the absence of negligence and even with the best of care." The court continued "[t]here are alternative plausible explanations for the cause of the cardiac depression in this case which are not related to any negligence on the part of Defendant." Based on these findings, the trial court refused appellant's demand to apply the doctrine of res ipsa loquitur. The court ultimately determined that Dr. Anderton "clearly complied with the applicable standard of medical care in his treatment and care of Jayci Robb." This appeal followed.
Appellant argues on appeal: (1) Dr. Steward was not competent to testify concerning the standard of care in Salt Lake City; (2) the trial court erred in refusing to apply the doctrine of res ipsa loquitur; and (3) three of the trial court's findings of fact are clearly erroneous.
Appellant claims Dr. Anderton's expert witness, Dr. Steward, was not competent to testify about the standard of care for pediatric anesthesiologists in Salt Lake City because he was educated in England and practiced primarily in Canada. Appellant argues that even though Dr. Steward is an eminently qualified pediatric anesthesiologist, he was not competent to testify as an expert in this case because he has never practiced in Salt Lake City nor has he administered the exact combination of anesthetics Dr. Anderton used on Jayci.
Due to the technical nature of a medical doctor's services, "a plaintiff in a medical negligence case must introduce expert testimony to establish the standard of care by which the doctor's conduct is to be measured." Anton v. Thomas, 806 P.2d 744, 745 (Utah App.1991) (citing ...
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