Title: Rooney v. MCHV

State: vermont

Issuer: Vermont Supreme Court

Document:

ROONEY_V_MCHV.93-322; 162 Vt. 513; 649 A.2d 756

[Filed:  22-Jul-1994]

[Motion for Reargument Denied 6-Sep-1994]


 NOTICE:  This opinion is subject to motions for reargument under V.R.A.P.
 40 as well as formal revision before publication in the Vermont Reports.
 Readers are requested to notify the Reporter of Decisions, Vermont Supreme
 Court, 109 State Street, Montpelier, Vermont 05609-0801 of any errors in
 order that corrections may be made before this opinion goes to press.


                                 No. 93-322


 John Rooney, Individually and                Supreme Court
 as Administrator of the Estate
 of Margaret Orr Rooney
                                              On Appeal from
      v.                                      Chittenden Superior Court

 Medical Center Hospital of Vermont,          February Term, 1994
 Inc., Anesthesia Associates of
 Burlington, Inc., and E.A. Kristensen,
 M.D.


 Matthew I. Katz, J.

 Alan F. Sylvester, Geoffrey M. FitzGerald and Margaret A. Mangan of
    Sylvester & Maley, Inc., Burlington, for plaintiff-appellant

 Ritchie E. Berger and Philip C. Woodward of Dinse, Erdmann & Clapp,
    Burlington, for defendant-appellee Medical Center Hospital

 Robert D. Rachlin, Gary H. Barnes and Coddy Marx of Downs Rachlin & Martin,
    Burlington, for defendants-appellees Anesthesia Associates and Kristensen



 PRESENT:  Gibson, Dooley, Morse and Johnson, JJ., and Peck, J. (Ret.),
           Specially Assigned


      MORSE, J.   In this medical malpractice action, plaintiff John Rooney
 brought suit against defendants Dr. E. A. Kristensen, Anesthesia Associates,
 and the Medical Center Hospital of Vermont, Inc. (MCHV) for the wrongful
 death of his wife, Margaret Rooney, who was survived by plaintiff and their
 two children, then aged 16 months and 5 days.  Plaintiff claimed that
 defendants were negligent in the care provided to his wife, resulting in her
 death.  The jury returned a defendants' verdict.  On appeal, plaintiff's

 

 primary assertion is that the court's instruction on the standard of care
 improperly informed the jury in effect that the defendant anesthesiologist
 was not liable if she did her best under the circumstances.  We agree that
 the standard of care instruction with regard to the performance of Dr.
 Kristensen was error, requiring reversal and a remand for a new trial as to
 her and her employer, Anesthesia Associates.  We affirm as to defendant
 MCHV.
      On January 11, 1988, Mrs. Rooney was admitted to MCHV for an emergency
 cesarean section.  Dr. Kristensen was the attending obstetrical
 anesthesiologist for the surgery.  After a spinal anesthetic failed to
 relieve Mrs. Rooney's pain, Dr. Kristensen administered general anesthesia,
 which contained a paralytic agent that prevented Mrs. Rooney from breathing
 on her own.  Dr. Kristensen was also responsible for delivering oxygen to
 Mrs. Rooney during the operation.  The normal procedure for doing so, called
 intubation, is accomplished by introducing oxygen under pressure into the
 patient's lungs by a tube through the patient's mouth.
      After administration of the general anesthesia, Mrs. Rooney was unable
 to be intubated.  Apparently, she had suffered a rare allergic reaction to
 one of the anesthetic agents, which caused her tongue and upper airway to
 swell.  As Mrs. Rooney's oxygen saturation and pulse fell to life-
 threatening levels, Dr. Kristensen and Dr. Brackett, a resident physician,
 continued to attempt intubation.  They also tried, unsuccessfully, to
 ventilate Mrs. Rooney by forcing air down her windpipe into her lungs using
 a bag and mask.
      A short time after the breathing emergency began, Dr. Kristensen
 directed the obstetricians on hand to remove the baby in order to save the

 

 baby's life and to facilitate resuscitation.   The delivery took about one
 minute and Dr. Kristensen instructed an attending nurse to page for surgical
 help and a tracheostomy tray immediately after the baby was born.
      Dr. Kristensen rejected performing a surgical cricothyrotomy -- use of
 a scalpel to cut a passage through the neck to permit placement of a tube
 into the trachea --  because she did not feel comfortable doing it after not
 having performed surgery for twelve years.  Instead, Dr. Kristensen used a
 medical "Nu-Trake" device in an attempt to obtain an airway.  Use of the
 device, which is designed for emergency use to create an airway by placing a
 dilator through the trachea, was also unsuccessful.  The procedure produced
 profusive bleeding, later determined to have been caused by an anatomical
 anomaly of Mrs. Rooney's carotid artery, which crossed over the front of her
 trachea instead of down the side of it.
      Dr. Kristensen then attempted to obtain an airway by using a
 pressurized needle and catheter device called a transtracheal jet ventilator
 (TTJV).  This procedure proved futile because, as explained by defendants'
 expert witnesses, Dr. Jonathan Benumof and Dr. David Chestnut, the Nu-Trake
 device had created a larger hole in the tissue than necessary for the TTJV,
 allowing oxygen to enter surrounding tissue and swell Mrs. Rooney's neck.
      When the surgeons arrived, they successfully performed a tracheostomy.
 This procedure requires an incision through the trachea lower down on the
 neck than the surgical cricothyrotomy and is more complicated than the
 cricothyrotomy.  Oxygen was then introduced to Mrs. Rooney; however, by that
 time, Mrs. Rooney had suffered permanent and irreversible brain damage.  She
 died five days later.

 

      At trial, plaintiff advanced several factual theories of liability
 against Dr. Kristensen.  Plaintiff asserted that Dr. Kristensen had not
 formulated an adequate plan to deal with the "can't intubate/can't
 ventilate" emergency.  Plaintiff also maintained that Dr. Kristensen should
 have paged surgeons sooner and not hesitated to use other alternatives once
 initial efforts to intubate and ventilate had failed.  Additionally,
 plaintiff alleged that Dr. Kristensen should have had the skill and
 knowledge to perform a surgical cricothryrotomy or else performed a
 transtracheal jet ventilation instead of attempting the Nu-Trake device.  As
 argued by plaintiff, the Nu-Trake device was not an appropriate option under
 the circumstances, and because Dr. Kristensen had improperly used the Nu-
 Trake device, the subsequent TTJV attempt was ineffective.  Plaintiff's
 action against Anesthesia Associates was based upon vicarious liability as
 the employer of Dr. Kristensen.
      In defense, Dr. Kristensen argued that an extremely rare allergic
 reaction to the general anesthesia, in conjunction with Mrs. Rooney's
 aberrant carotid artery, caused the tragedy.  She maintained that her plan
 was appropriate and that she did everything she reasonably could, moving
 from one step to the next, i.e., intubation, mask ventilation, calling for
 surgeons, trying the Nu-Trake device, and further attempts at ventilation.
 She claimed that the Nu-Trake device was a reasonable choice in early 1988,
 and that she properly used it.  Finally, she argued that had she attempted
 the surgical cricothyrotomy, she unavoidably would have severed Mrs.
 Rooney's aberrant carotid artery, causing her to bleed to death.
      Plaintiff's theory of liability against MCHV was based upon the alleged
 unreasonable delay in getting surgeons to the operating room and in making a

 

 tracheostomy tray available.  MCHV's defense was that hospital personnel
 responded adequately to the crisis and that a tracheostomy tray was readily
 produced and duplicate instruments were already in the operating room.  At
 trial, the focus of the evidence and fault issues centered largely on the
 actions of Dr. Kristensen.
      Plaintiff argues on appeal that in addition to error in the trial
 court's standard-of-care jury instruction, there was error in the court's
 proximate cause instructions and in its instructions to the jury on
 deposition testimony.
                                     I.
      At the outset, we address a point raised by the hospital concerning
 plaintiff's requisite showing on appeal.  Defendant MCHV claims that
 plaintiff must show prejudicial error with respect to both the standard of
 care and proximate cause instructions to prevail on appeal.  Plaintiff had
 requested a general verdict, while the hospital had requested that the jury
 decide separately, and indicate in writing, the elements of the breach of
 care and proximate cause.  Defendants Dr. Kristensen and Anesthesia
 Associates did not request a form of the verdict one way or the other.  The
 trial court submitted a general verdict form to the jury, which simply
 stated: "We the jury ____ do ____ do not find [specific party] to have been
 negligent, which negligence proximately caused the death of Margaret
 Rooney."
       MCHV argues that the jury may have returned a verdict favorable to it
 on either the standard of care or proximate cause elements of medical
 malpractice.  MCHV points out that because plaintiff requested a general
 verdict, this Court is now unable to determine the precise reasons the jury

 

 returned a defendants' verdict.  Relying on Contractor's Crane Service, Inc.
 v. Vermont Whey Abatement Authority, 147 Vt. 441, 446,