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.
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