Noel Casumpang, et al vs.
Nelson Cortejo,
G.R. No. 171127, March
11, 2015
Facts:
Mrs.
Jesusa Cortejo brought her 11-year old son, Edmer Cortejo (Edmer), to the
Emergency Room of the San Juan de Dios Hospital (SJDH) because of difficulty in
breathing, chest pain, stomach pain, and fever. r. Ramoncito Livelo (Dr.
Livelo) initially attended to and examined Edmer. Dr. Livelo took his vital
signs, body temperature, and blood pressure.6 Based on these initial examinations and the
chest x-ray test that followed, Dr. Livelo diagnosed Edmer with
"bronchopneumonia.7 " Edmer’s blood was also taken for
testing, typing, and for purposes of administering antibiotics. Afterwards, Dr.
Livelo gave Edmer an antibiotic medication to lessen his fever and to loosen
his phlegm.
At
5:30 in the afternoon of the same day, Dr. Casumpang for the first time
examined Edmer in his room. Using only a stethoscope, he confirmed the initial
diagnosis of "Bronchopneumonia.
At
that moment, Mrs. Cortejo recalled entertaining doubts on the doctor’s
diagnosis. She immediately advised Dr. Casumpang that Edmer had a high fever,
and had no colds or cough10 but Dr. Casumpang merely told her that her
son’s "blood pressure is just being active,"11 and remarked that "that’s the usual
bronchopneumonia, no colds, no phlegm."12 Dr. Casumpang next visited and examined
Edmer at 9:00 in the morning the following day.13 Still suspicious about his son’s illness,
Mrs. Cortejo again called Dr. Casumpang’s attention and stated that Edmer had a
fever, throat irritation, as well as chest and stomach pain. Mrs. Cortejo also
alerted Dr. Casumpang about the traces of blood in Edmer’s sputum. Despite
these pieces of information, however, Dr. Casumpang simply nodded, inquired if
Edmer has an asthma, and reassured Mrs. Cortejo that Edmer’s illness is
bronchopneumonia.
In
the morning of April 23, 1988, Edmer vomited "phlegm with blood
streak"15 prompting the respondent (Edmer’s father) to
request for a doctor at the nurses’ station.16 Forty-five minutes later, Dr. Ruby
Miranda-Sanga (Dr. Sanga), one of the resident physicians of SJDH, arrived. She
claimed that although aware that Edmer had vomited "phlegm with blood
streak," she failed to examine the blood specimen because the respondent
washed it away. She then advised the respondent to preserve the specimen for
examination.
Thereafter,
Dr. Sanga conducted a physical check-up covering Edmer’s head, eyes, nose,
throat, lungs, skin and abdomen; and found that Edmer had a low-grade
non-continuing fever, and rashes that were not typical of dengue fever.17 Her
medical findings state:
the patient’s rapid breathing and then the lung showed
sibilant and the patient’s nose is flaring which is a sign that the patient is
in respiratory distress; the abdomen has negative finding; the patient has low
grade fever and not continuing; and the rashes in the patient’s skin were not
"Herman’s Rash" and not
typical of dengue fever.
Dr.
Sanga then examined Edmer’s "sputum with blood" and noted that he was
bleeding. Suspecting that he could be afflicted with dengue, she inserted a
plastic tube in his nose, drained the liquid from his stomach with ice cold
normal saline solution, and gave an instruction not to pull out the tube, or
give the patient any oral medication.
Dr.
Sanga advised Edmer’s parents that the blood test results showed that Edmer was
suffering from "Dengue Hemorrhagic Fever." One hour later, Dr.
Casumpang arrived at Edmer’s room and he recommended his transfer to the
Intensive Care Unit (ICU), to which the respondent consented. Since the ICU was
then full, Dr. Casumpang suggested to the respondent that they hire a private
nurse. The respondent, however, insisted on transferring his son to Makati
Medical Center.
After the respondent had signed the
waiver, Dr. Casumpang, for the last time, checked Edmer’s condition, found that
his blood pressure was stable, and noted that he was "comfortable."
The respondent requested for an ambulance but he was informed that the driver
was nowhere to be found.
At
12:00 midnight, Edmer, accompanied by his parents and by Dr. Casumpang, was
transferred to Makati Medical Center.
Dr. Casumpang immediately gave the
attending physician the patient’s clinical history and laboratory exam results.
Upon examination, the attending physician diagnosed "Dengue Fever Stage
IV" that was already in its irreversible stage.
Edmer died at 4:00 in the morning
of April 24, 1988. Believing that Edmer’s death was caused by the negligent and
erroneous diagnosis of his doctors, the respondent instituted an action for
damages against SJDH, and its attending physicians: Dr. Casumpang and Dr. Sanga
(collectively referred to as the "petitioners") before the RTC of
Makati City.
RTC held that the doctors were
negligent. CA affirmed the decision of RTC in toto.
Issue:
Whether or
not the petitioning doctors had committed "inexcusable lack of
precaution" in diagnosing and in treating the patient.
Held:
YES.
Dr. Casumpang is Liable. àAttending
physician
Dr.
Sanga is Not Liable for Negligence because the latter is only a resident doctor
The elements of medical negligence are: (1) duty; (2) breach; (3)
injury; and (4) proximate causation.
Duty
refers to the standard of behavior that imposes restrictions on one's conduct.35 It requires proof of professional
relationship between the physician and the patient. Without the professional
relationship, a physician owes no duty to the patient, and cannot therefore
incur any liability.
A
physician-patient relationship is created when a patient engages the services
of a physician,36 and the latter accepts or agrees to provide
care to the patient.37 The establishment of this relationship is
consensual,38 and the acceptance by the physician
essential. The mere fact
that an individual approaches a physician and seeks diagnosis, advice or
treatment does not create the duty of care unless the physician agrees.
Once
a physician-patient relationship is established, the legal duty of care
follows. The doctor accordingly becomes duty-bound to use at least the same
standard of care that a reasonably competent doctor would use to treat a
medical condition under similar circumstances.
Breach
of duty occurs when the doctor fails to comply with, or improperly performs his
duties under professional standards. This determination is both factual and
legal, and is specific to each individual case. If the patient, as a result of
the breach of duty, is injured in body or in health, actionable malpractice is
committed, entitling the patient to damages.
To
successfully claim damages, the patient must lastly prove the causal relation
between the negligence and the injury. This connection must be direct, natural,
and should be unbroken by any intervening efficient causes. In other words, the
negligence must be the proximate cause of the injury.44 The injury or damage is proximately caused
by the physician’s negligence when it appears, based on the evidence and the
expert testimony, that the negligence played an integral part in causing the
injury or damage, and that the injury or damage was either a direct result, or
a reasonably probable consequence of the physician’s negligence.
First, we emphasize that we
do not decide the correctness of a doctor’s diagnosis, or the accuracy of the
medical findings and treatment. Our duty in medical malpractice cases is to
decide – based on the evidence adduced and expert opinion presented– whether a
breach of duty took place.
Second, we clarify that a wrong diagnosis is not by itself medical
malpractice.65 Physicians are generally not liable for
damages resulting from a bona fide error of judgment. Nonetheless, when the
physician’s erroneous diagnosis was the result of negligent conduct (e.g.,
neglect of medical history, failure to order the appropriate tests, failure to
recognize symptoms), it becomes an evidence of medical malpractice.
Third, we also note that medicine is not an exact science;66 and doctors, or even specialists, are not
expected to give a 100% accurate diagnosis in treating patients who come to
their clinic for consultations. Error is possible as the exercise of judgment
is called for in considering and reading the exhibited symptoms, the results of
tests, and in arriving at definitive conclusions. But in doing all these, the
doctor must have acted according to acceptable medical practice standards.
In the present case, evidence on record established that in confirming the
diagnosis of bronchopneumonia, Dr. Casumpang selectively appreciated some and
not all of the symptoms presented, and failed to promptly conduct the
appropriate tests to confirm his findings. In sum, Dr. Casumpang failed to
timely detect dengue fever, which failure, especially when reasonable prudence
would have shown that indications of dengue were evident and/or foreseeable,
constitutes negligence.
Apart from failing to promptly detect
dengue fever, Dr. Casumpang also failed to promptly undertake the proper medical
management needed for this disease.
As Dr. Jaudian opined, the standard medical
procedure once the patient had exhibited the classic symptoms of dengue fever
should have been: oxygen inhalation, use of analgesic, and infusion of fluids
or dextrose;67 and once the patient had twice vomited fresh blood, the doctor
should have ordered: blood transfusion, monitoring of the patient every 30
minutes, hemostatic to stop bleeding, and oxygen if there is difficulty in
breathing. Dr. Casumpang failed to measure up to these standards.
Also
in Evans v. Ohanesian, the court set a guideline in qualifying an expert
witness:
To qualify a witness as a medical expert, it must be shown
that the witness (1) has the required professional knowledge, learning and
skill of the subject under inquiry sufficient to qualify him to speak with
authority on the subject; and (2) is familiar with the standard required of a
physician under similar circumstances; where a witness has disclosed sufficient
knowledge of the subject to entitle his opinion to go to the jury, the question
of the degree of his knowledge goes more to the weight of the evidence than to
its admissibility.