Title: Powell v. Mullins

State: alabama

Issuer: Alabama Supreme Court

Document:

479 So. 2d 1119 (1985)
Christine POWELL
v.
Julius MULLINS, M.D.
84-173.

Supreme Court of Alabama.
August 23, 1985.
Rehearing Denied November 1, 1985.
M.A. Marsal of Seale, Marsal & Seale and Irvin J. Langford of Howell, Johnston & Langford, Mobile, for appellant.
W. Boyd Reeves and Edward A. Dean of Armbrecht, Jackson, DeMouy, Crowe, Holmes & Reeves, Mobile, for appellee.
BEATTY, Justice.
This is an appeal by the plaintiff, Christine Powell, from a judgment in favor of the defendant, Julius Mullins, M.D., based upon a directed verdict entered at the close *1120 of the plaintiff's evidence in a medical malpractice case. It is undisputed that the defendant left an 18-inch-square surgical lap sponge inside the plaintiff when closing the abdominal incision necessary for the cesarean delivery of the plaintiff's third child. The trial court, believing the case to be controlled by Gilbert v. Campbell, 440 So. 2d 1048 (Ala.1983), granted the defendant's motion for directed verdict because the plaintiff failed to "put on medical testimony to say that the standard of care accepted in that particular field was not followed." We reverse and remand.
The relevant facts of the case are as follows:
The plaintiff entered the University of South Alabama Medical Center for delivery of her third child. Plaintiff had received her pre-natal care through the Medical Center and, initially, her doctors there felt she would be able to deliver her baby vaginally. However, because plaintiff is a diabetic on insulin, the baby (weighing 9½ lbs.) had grown too large to deliver vaginally, and the decision was made to deliver the baby by cesarean section. The defendant, Dr. Mullins, was the chief resident in obstetrics at the Medical Center and the attending physician in charge of performing the cesarean section on the plaintiff. Dr. Mullins was assisted by two other doctors. Also present in the operating room were several people from the anesthesiology department, several nurses, a respiratory therapist, and a pediatrician. Plaintiff was given a general anesthetic despite the fact that her obesity and heavy smoking posed a greater risk in using general anesthesia. These factors, as well as plaintiff's low blood count and profuse bleeding during surgery, established her to be a high-risk patient overall.
While performing the cesarean surgical procedure, which lasted over two hours, the defendant used two rolled up 18-inchsquare lap sponges, placing them inside plaintiff's abdomen on either side of the uterus. Twenty-eight other sponges were used during the procedure to soak up blood, but only the two 18-inch-square lap sponges were actually placed inside the plaintiff's abdomen. Despite the defendant's own search of the operative field in preparing to close the incision, as well as two reports given by a nurse that the sponge count was correct, one of the 18inch-square lap sponges was left inside the plaintiff.
Approximately four days after her surgery, the plaintiff began to complain of pain and swelling on one side. X-rays were taken, revealing the presence of the sponge in plaintiff's abdomen. Five days after the cesarean section, plaintiff underwent a second surgical procedure to remove that sponge.
The only issue presented by this case is whether, on these facts, in order to defeat a motion for directed verdict, plaintiff was required by law to put on expert medical testimony to establish that the defendant's treatment fell below the professional standard of care. We hold that she was not required to do so under these facts.
The general rule in Alabama is that in medical malpractice cases expert medical testimony is required to establish what is and what is not proper medical treatment and procedure. An exception to this general rule exists where an understanding of the doctor's alleged lack of due care or skill requires only common knowledge or experience. This rule and the exception were explained by this Court in Parrish v. Spink, 284 Ala. 263, 266-267, 224 So. 2d 621, 623-624 (1969):
This general rule, as well as the exceptions thereto, were reiterated by this Court in the recent case of Holt v. Godsil, 447 So. 2d 191, 192-193 (Ala.1984):
See also Tant v. Women's Clinic, 382 So. 2d 1120, 1121 (Ala.1980), where this Court stated:
Thus, this case falls squarely under the exception applied in Sellers v. Noah, 209 Ala. 103, 95 So. 167 (1923), where the defendant doctor performed an appendectomy on the plaintiff, leaving a needle or part of a needle inside the plaintiff. The defendant, however, argues to this Court (and persuaded the trial court) that the present case is controlled by Gilbert v. Campbell, 440 So. 2d 1048 (Ala.1983), in which this Court stated:
As defendant admits in his brief, Gilbert is "a case which appears on first blush to fall within the exceptional rule, obviating the need for expert testimony, [but] is actually one involving complex medical circumstances beyond the comprehension of a layman." However, it is precisely this factor that distinguishes Gilbert from the present case and which indicates that the holding in Gilbert is in no way contrary to the exception applied in Sellers v. Noah, supra, and stated in Parrish v. Spink and Holt v. Godsil, supra.[1]
The defendant doctor in Gilbert had performed surgery on the plaintiff to remove a tumor in the colon. Twice, five months and six months following his surgery, the plaintiff was readmitted to the hospital for treatment of infections in the same area of the abdomen. During both stays, Penrose drains were inserted through his rectum to drain infected material from a pelvic abcess. The first drain came out on its own and the second was pulled out routinely. The plaintiff's infections persisted and, eventually, a fistula, or tunnel between the abcess and the exterior left buttock developed. The following year, the plaintiff was referred to another physician, who closed off the fistula surgically from the inside. While performing this procedure, the physician found and removed a 2-inch-long piece of Penrose drain in the tract of the fistula.
In affirming a verdict directed in favor of the defendant at the close of the defendant's case,[2] this Court held that expert testimony was required "to describe the proper use, purpose, insertion and removal of a Penrose drain." 440 So. 2d  at 1049.
Without question, the circumstances in Gilbert, supra, involved complex medical procedures beyond the comprehension of a layman. In that case, the mere presence of the broken piece of drain in the plaintiff's body was not enough to establish a prima facie case of negligence for several reasons. First, the drain did not show up on X-rays, and it could not have been seen by an external examination. Second, due to the nature and severity of the plaintiff's illness, the defendant had no reason to *1123 believe that plaintiff's suffering was caused by something other than his disease. Third, in presenting his case, the defendant put on undisputed expert testimony that not only was there no standard practice or procedure whereby a doctor, after removal, could determine whether the full length of the drain had been removed, but also that the defendant had engaged in no substandard medical practice in the course of his treatment of the plaintiff.
In the present case, the plaintiff's obesity and profuse bleeding probably made locating the sponges more difficult. Also, because the procedure had taken over two hours, and because the plaintiff, a smoker, was a higher risk for general anesthesia, the defendant was understandably anxious to complete the procedure and close the patient. Nevertheless, it is precisely these factors that put the plaintiff in a high-risk category warranting an X-ray immediately following the surgical procedure.
At trial, the defendant testified that the plaintiff was a high-risk patient, but that it was not customary to do a post-operative X-ray unless the patient began having problems:
However, admitted into evidence was an article entitled "Natural History of the Retained Surgical Sponge," written by John W. Hyslop, M.D., and Kimball J. Maull, M.D., which appeared in the June 1982 edition of the Southern Medical Journal, Volume 75, No. 6, at pages 657-680. Counsel for the defendant conceded the article to be a recognized medical text. The article contained the following explanation especially relevant to the facts of this case:
In addition to the portion of the defendant's testimony quoted above, the following excerpts from his testimony indicate that the high-risk factors outlined in the abovequoted article were present in this case:
Under the sub-heading entitled "Prevention," the Southern Medical Journal article provides the following:
In Zills v. Brown, 382 So. 2d 528 (Ala.1980), this Court stated with approval another exception to the general rule requiring expert testimony in a medical malpractice case:
In view of the defendant's own testimony that the plaintiff was a high-risk patient, the article quoted from above, which was admitted into evidence, can be viewed as proof of what is or is not proper practice, treatment, or procedure. While the article does not mandate that X-rays be taken in all cases, it does indicate that the proper practice should be at least to consider taking X-rays of high-risk patients before they leave the operative suite. This the defendant did not do. In fact, he testified, in effect, that X-rays are not considered unless the patient begins to experience problems post-operatively.
Furthermore, the facts of the present case are substantially dissimilar to those in Gilbert. It cannot be said that the "proper, use, purpose, insertion, and removal," Gilbert, supra, of a surgical sponge during a cesarean section is a medical procedure as complex as the use, purpose, insertion, and removal of a Penrose drain in a patient on whom colonic surgery had been performed to remove a tumor and who had subsequently suffered with serious infections related to his diseased colon. Thus, in Gilbert, the mere fact that a small piece of a Penrose drain remained in the patient, after all the drains used were actually removed (and appeared to have been removed in their entirety) did not demonstrate an apparent lack of skill or due care on the part of the defendant which was capable of being understood by a layman. In the factual context of this case, however, the complete failure of the defendant to remove the sponge at all demonstrates a lack of care that is within the comprehension of a layman and requires only common knowledge and experience to understand it. Parrish v. Spinks; Sellers v. Noah, supra. See also Lloyd Noland Foundation, Inc. v. Harris, 295 Ala. 63, 322 So. 2d 709 (1975). Therefore, the plaintiff was not required to put on expert testimony in order to overcome defendant's motion for directed verdict at the close of plaintiff's case.
Despite the defendant's own testimony that his failure to find the sponge during his search of the body cavity was "human error," on appeal the defendant contends that he cannot be liable in negligence to the plaintiff because, he argues, the sponge was left in due to the error of the nurse in charge of the sponge count, on whose "correct" count the defendant claims he reasonably relied. We cannot agree. At trial, the defendant gave the following testimony regarding the sponge count:
Unquestionably, it was the defendant's responsibility to remove all sponges from inside the plaintiff before closing the abdominal incision. This rule is stated generally at 61 Am.Jur.2d, Physicians and Surgeons, etc., § 258, p. 397 (1981):
Under our cases, a failure to remove sponges, needles, etc., which are placed inside the patient during the operation constitutes prima facie evidence of negligence. See Sellers v. Noah and Parish v. Spinks, supra. The responsibility to remove the sponges was that of the doctor and not that of the nurses assisting him. He exercised exclusive control over the sponges from the time he placed them inside the plaintiff until he removed them. The mere fact that the defendant delegated the task of counting the sponges, once he had removed them from the patient, does not, in any way, relieve the defendant of his responsibility to remove them in the first instance. He had the duty and responsibility of removing all the sponges. The nurses' responsibility of counting them afterward amounts to only an added precaution taken by the defendant to help insure that he had properly performed his duty.
The general rule with respect to the "sponge nurse" is stated and explained at 61 Am.Jur.2d at 399:
We adopt the general rule as stated above as well as the reasoning of the Louisiana Court of Appeal, which addressed this same issue in the case of Guilbeau v. St. Paul Fire and Marine Ins. Co., 325 So. 2d 395 (La.Ct.App.1975), a case similar to the present one. In Guilbeau, it was undisputed *1127 that a surgical pad or sponge was left inside the plaintiff's abdomen following a surgical procedure performed by the defendant doctor. Just as in the present case, the defendant received more than one "correct" sponge count before closing the incision. He argued that it was within the standard of care "to rely on the `sponge count' of the nurses and a visual inspection of the area of surgery prior to closure to prevent the error committed in this case." Guilbeau, at 397. The Louisiana Court of Appeal followed the holding of the Louisiana Supreme Court in Grant v. Touro Infirmary, 254 La. 204, 223 So. 2d 148 (1969), and explained that case as follows:
Based on the foregoing, we conclude that this case does "fall within the exception that would allow a jury to exercise its fact-finding prerogative to adjudge liability absent expert testimony." Tant v. Women's Clinic, 382 So. 2d 1120, 1121 (Ala.1980) (exception recognized, but issue not presented). Accordingly, the trial court erred in directing a verdict in favor of the defendant, and, therefore, the judgment is due to be, and it hereby is, reversed and the case remanded for further proceedings.
REVERSED AND REMANDED.
TORBERT, C.J., and MADDOX, JONES and SHORES, JJ., concur.
[1]  It is worth noting that neither Sellers nor Parrish was cited in Gilbert, and the Holt opinion was issued subsequent to Gilbert.
[2]  Another distinguishing factor worth noting is that the verdict in the present case was directed at the close of the plaintiff's case.