Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca10-90-07025/USCOURTS-ca10-90-07025-0/pdf.json

Nature of Suit Code: 362
Nature of Suit: Medical Malpractice
Cause of Action: 

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( 

PUBLISH 

UNITED STATES COURT OF APPEALS 

TENTH CIRCUIT 

ROGER BIRD, Individually and . . as surviving spouse of Delaine: 

Bird, deceased, : 

. • 

FILED 

United States Court of Appeals Tenth Circuit 

NOV 2 5 1991 

ROBERT L. HOECKER 

Clerk 

Plaintiff-Appellant, : No. 90-7025 

vs. 

: 

: 

: 

UNITED STATES OF AMERICA, : 

: 

Defendant-Appellee. : 

Appeal from the United States District Court 

for the Eastern District of Oklahoma 

(D.C. No. 89-014-C) 

Steven R. Hickman, of Frasier & Frasier, Tulsa, Oklahoma, for 

Appellant. 

Ralph F. Keen, Assistant United States Attorney (John Raley, 

United States Attorney, with him on the brief), Muskogee, 

Oklahoma, for Appellee. 

Before SEYMOUR and TACHA, Circuit Judges, and CHRISTENSEN, 

District Judge.* 

CHRISTENSEN, District Judge. 

This appeal arises from a suit under the Federal Tort Claims 

Act (FTCA) in which it was alleged that negligence on the part of 

a certified registered nurse anesthetist (CRNA) as an employee of 

the government caused the death of Delaine Bird, wife of the 

* A. Sherman Christensen, Senior Judge, United States District 

Court for the District of Utah, sitting by designation. 

Appellate Case: 90-7025 Document: 010110097030 Date Filed: 11/25/1991 Page: 1 
plaintiff-appellant Roger Bird. 1 The central issue is whether the 

CRNA was an employee of the government within the contemplation of 

the FTCA. The district court in a bench trial held that he was an 

independent contractor and on that basis denied recovery against 

the government. 

I. 

The issue before us pertains to both coverage and 

jurisdiction. The FTCA provides a limited waiver of sovereign 

immunity, see United States v. Orleans, 425 U.S. 807, 813 (1976), 

and 11 [t]he terms of the government's consent to be sued define the 

court's jurisdiction." Ewell v. United States, 776 F.2d 246, 248 

(10th Cir. 1985). The government's consent to be sued under the 

FTCA extends only to claims against the United States for money 

damages, for injury or loss of property, or personal injury or 

death caused by the negligent or wrongful act or omission of any 

employee of the government while acting within the scope of his 

office or employment, under circumstances where the United States, 

if a private person, would be liable to the claimant in accordance 

with the law or the place where the act or omission occurred. 28 

u.s.c. § 1346(b). The consent to be sued does not extend to acts 

of independent contractors or their employees. See id.§§ 1346, 

1 The nurse Bernard Bullon, the placement service which 

referred him to the hospital (Jack Grinovich & Associates, Inc.), 

and the manufacturers of an anesthesia machine (OHMEDA and Ohio 

Metal Products), were named as third-party defendants and filed 

cross-claims among themselves. The district court severed the 

claim of the plaintiff against the government and its employees 

and certified its judgment of no cause of action as final pursuant 

to Fed. R. Civ. P. 54(b). No appeal was taken from the trial 

court's decision exonerating the government's physician employees. 

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2671. Being of the opinion that at the time in question the CRNA 

was not an independent contractor but was an employee of the 

government, we reverse. 

II. 

The facts are largely without dispute. 

W.W. Hastings Indian Hospital, Tahlequah, Oklahoma, is a 

full-service hospital generally staffed by its own employees. At 

the time of the decedent's death, the clinical director of the 

hospital was Brian Birdwell, M.D., a commissioned officer in the 

Public Health Service. The chief of surgery, Joel Malobrigo, 

M.D., was a member of the Public Health Service. He was also head 

of the hospital's anesthesia services. Prior to Mrs. Bird's 

hospitalization, there had been a full-time medical doctor 

anesthesiologist on the hospital staff, but at the time Mrs. Bird 

was admitted, CRNA David Forsythe, who was also a commissioned 

officer in the Public Health Service, was the only permanent 

employee in the anesthesia department. The surgeon operating on 

Mrs. Bird was Wayne Clairborne, M.D., who was also a government 

employee. 

After the physician-anesthesiologist left, there being more 

anesthesia work than one person could do, the hospital obtained an 

additional CRNA through the temporary placement services of Jack 

Grinovich & Associates, Inc. (Grinovich), as had been done on 

other occasions. The usual procedure was for Grinovich to take a 

brokerage fee for arranging such services with the government 

directly paying the anesthetist, but as to the services of nurse 

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( 

Bullen the hospital, apparently for the convenience of writing one 

check, paid Grinovich a lump sum with the understanding that it 

would pay the anesthetist. 

There was no written agreement between the government and 

Grinovich except as reflected in requisitions for service of which 

government's exhibit B-2 is representative: 

Provide anesthesia coverage for surgeries performed on 

eligible Indian patients of thew. w. Hastings Hospital. 

This service shall cover 5 days. 5 days [sic) with call 

back and 2 weekend days during the period of March 28, 

1988 through April 11, 1988.2 

There were written recitations that the government would not be 

responsible for the negligence of the "contractor"; that the 

"vendor" would provide his own insurance, and that all equipment 

would be supplied by the government. The writings did not address 

the particular nature of the anesthesia coverage to be provided, 

the status of the person to be supplied for the contemplated 

surgeries, any standards, guides or directions concerning the 

performance expected by the government, or any end result to be 

achieved. 

CRNA Bullen considered himself an employee of the Indian 

hospital and recognized the ultimate authority over him to be the 

operating surgeon. He testified that his functions, including 

attire, hours and the like, did not differ from those of the other 

employees. His authority was that of a nurse anesthetist to 

administer anesthesia under supervision. He did not have 

2 The Oklahoma statute authorized CRNAs to perform under 

supervision of a physician some limited services not directly 

connected with surgeries and the evidence does not disclose 

whether Bullen did or did not do so. 

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authority to have someone replace him on any particular day. 

State law provided that CRNAs administering anesthesia were 

to be "under the supervision of and in the immediate presence of a 

physician licensed to practice medicine," and that violation of 

this rule was punishable as a misdemeanor. 3 The service had to 

be "under the direct supervision and control" of a physician to 

avoid the practice of medicine without a license in violation of 

4 state law. 59 o.s. § 491-492. 

Thew. w. Hastings Medical Staff Rules and Regulations 

contained some similar provisions. They stated under a section on 

"Relationships-Anesthetist-Surgeon," that anesthesia is 

"administered under the supervision of the surgeon." In the event 

of disagreement between the surgeon and the anesthetist, it was 

provided that the licensed physician would make the final 

determination. Supervision by the government's medical doctor 

3 59 o.s. § 567.51 now provides that a CRNA can "[a]dminister 

anesthesia under the supervision of a medical doctor, an osteopath 

physician or a dentist licensed in this state and under conditions 

in which timely on-site consultation by such doctor, or dentist is 

available. This provision replaced, effective April 12, 1988 -- five days after Mrs. Bird's death -- a provision that CRNAs who 

held a registered nurse license could administer "anesthesia under 

the supervision of and in the immediate presence of a physician 

licensed to practice medicine, an osteopath or a dentist." Laws 

1978, c. 76 § 1. 

4 59 o.s. § 491 provided for a fine of not less than $100 nor 

more than $500 for the first offense of practicing medicine 

without a license, and for the second offense imprisonment for not 

less than 30 days and not more than 180 days. Included in the 

definition of "practicing medicine," was the treatment "of 

disease, injury or deformity of persons by any drugs, surgery, 

manual or mechanical treatment whatsoever." The pertinent 

exception to this prohibition was "service rendered by a 

physician's trained assistant, a registered nurse or a licensed 

practical nurse if such service be rendered under the direct 

supervision and control of a licensed physician ...• " Id. 

§ 492. 

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over the nurse anesthetist was also covered in the Medical Staff 

Rules and Regulations, as well as in the Policy and Procedure 

Manual for anesthesia service develop~d at the.hospital. This 

manual stated, among other things, that the "nurse anesthetists 

are under the overall airection of the surgeon or obstetrician 

responsible for the patient's care." It required that when 

anesthesia was administered "a physician must be immediately 

available in the facility to provide care in the event of a 

medical emergency. 11 

While there were some differences in detail and 

interpretation, all of the expert witnesses generally agreed upon 

the controlling principles. 

Dr. Parmley, an anesthesiologist called by the plaintiff, 

testified that in the absence of an anesthesiologist to head the 

department the operating surgeon was the one in full charge of the 

nurse anesthetist; that the nurse didn't have a patient; that the 

CRNAs worked under the direction of the physician or the operating 

surgeon. The government's expert witness, Dr. Mayle, testified 

that anesthesia cannot be administered by a CRNA except under the 

direction and supervision of the operating surgeon or an 

anesthesiologist; that if there is a problem concerning the 

anesthesia, the surgeon's decisions and judgment prevail over the 

decision of the CRNA. Dr. Clairborne, the operating surgeon, 

stated his understanding of the law to be that a CRNA must have a 

physician present in the surgical suite when he administers 

anesthesia; that the CRNA was "more or less" under the charge of 

the surgeon and was to follow the instructions of the surgeon "if 

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insisted upon." The Chief of Surgery, Dr. Malobrigo, testified 

that when a surgery is being performed the CRNA must obey the 

surgeon. 

The evidence shows that apart from the right of control, the 

practice of control varied depending upon capacities, 

personalities, competency and other factors. It was indicated 

that a surgeon working with an anesthesiologist will generally 

defer to him because of his expertise, and to an extent the same 

could be said with respect to a nurse anesthetist, but all 

witnesses were agreed that the surgeon, even in the absence of an 

anesthesiologist, had the right of control with respect to a nurse 

practicing under his license. This practical situation is well 

summarized by the district judge's interrogation of the 

anesthesiologist Dr. Parmley: 

THE COURT: Well, suppose it's an M.D. 

anesthesiologist. Does the operating physician have any 

authority to direct him what to do? 

THE WITNESS: That's a hard question. 

THE COURT: I know. I've heard of a lot of other 

cases, that's why I ask it. 

THE WITNESS: A matter of authority, usually it's 

done by discussion and there's not a battle for --

THE COURT: Well, if an operation is in progress, 

it's hardly time for discussion, is it? 

THE WITNESS: That's why the surgeon -- well, 

unfortunately, there are times when you have to, but the 

surgeon will, in medical matters, routinely concede to 

the expertise of the anesthesiologist in that setting. 

THE COURT: All right. So the role is reversed 

then as far as that particular responsibility is 

concerned? 

THE WITNESS: The role is reversed? 

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THE COURT: Yes. 

THE WITNESS: When there is an --

THE COURT: The anesthesiologist really will then 

prevail, but in this particular instant [sic], because 

this is -- was a CRNA, the physician, the M.D. has the 

senior role, in essence? 

THE WITNESS: Yes. He's the medical license that 

the nurse is practicing under. 

Transcript pp. 249-250. 

III. 

The trial judge made no further comment on his views during 

the trial, but in written findings of fact filed April 10, 1990, 

he found in substance that Delaine Bird died at the age of twentynine on April 7, 1988, while undergoing a surgical procedure 

(Caesarian section) performed by Dr. Clairborne at the W.W. 

Hastings Indian Health Service Facility; that Bernard Bullon, a 

Certified Registered Nurse Anesthetist, was on duty and was 

assigned to administer the anesthesia; that Bullon was provided to 

the hospital by contract between the United States of America and 

Jack Grinovich & Associates, Inc.; that soon after the patient 

arrived in the operating room, Bullon began preparing the patient 

for surgery and initiated and administered anesthesia; that Bullon 

did not check out all of the necessary items prior to using the 

machine as required by standards of nursing anesthesia care; that 

he admitted that he deviated from the appropriate standards of 

nursing anesthesia care; that he did not discover prior to the 

intubation and initiation of anesthesia that there was a 

misconnection in the breathing circuit; that after he prepared 

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Mrs. Bird for surgery by presedating her with sodium pentothal, 

paralyzing her with anectine, intubating her and connecting her to 

the anesthetic machine, he attempted ventilation through the 

machine and gave the go-ahead for Dr. Clairborne to begin his 

incision for the Caesarean section but was unable to ventilate the 

patient, and that afterwards with the help of nurse David Forsythe 

the machine was properly connected up but that when Bullon pressed 

the oxygen flush button to deliver oxygen a flush volume at high 

pressure entered directly into the patient's lungs causing both to 

rupture and air to escape in the abdominal cavity creating two 

collapsed lungs under tension or pressure, with cardiopulmonary 

arrest ultimately causing the death of Delaine Bird as a 

consequence. 

The trial judge exonerated the surgeon, Dr. Clairborne, as 

well as Dr. Malobrigo, by reason of insufficient evidence of 

negligence, and concluded that while nurse Bullon was in multiple 

respects guilty of negligence proximately causing the death of 

Mrs. Bird, the government was not liable because he was an 

"independent contractor at all relevant times." 

No findings of fact, as such, were made to support the 

conclusion of law that nurse Bullon was an independent contractor 

rather than a government employee. But interspersed among 

reference to Lurch v. United States, 719 F.2d 333, 336-37 (10th 

Cir. 1983), cert. denied, 466 U.S. 927 (1984), in the conclusions 

of law are the following statements which we shall accept as 

findings of fact for the purposes of this opinion, interpreting 

them in the light of the undisputed evidence. 

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No evidence was presented that the Hospital controlled 

Bullon's day-to-day activities. Indeed, plaintiff 

adduced evidence that Bullon once left for London while 

he was on call. If relevant at all, this evidence 

demonstrates a lack (emphasis in original] of control by 

the Hospital .... In the case at bar, the Government 

expressly declined to accept responsibility for the 

contractor's negligence. (Govt's Exh.B-3). 

From Conclusion numbered 2. 

No evidence of such [affirmative misconduct relating to 

possible estoppel under Lurch] was presented. The 

testimony of Steven Fastwolf that, in his view, a 

personal services contract existed between Bullen and 

the Government, does not rise to this level. There was 

no contract between the Government and Bullen, but 

rather between the Government and Grinovich. The Court 

is aware of Grinovich's testimony that he did not 

ordinarily pay the employees he provided, but did so in 

this instance as an accommodation to the Government 

(Grinovich deposition, p. 18-19). However, this Court's 

focus must be on day-to-day control, and here the 

evidence is lacking. 

From Conclusion numbered 3. 

Appellant has not specifically questioned the foregoing 

statements of the trial court, and while we do not regard them of 

substantial significance in light of other undisputed evidence, 

neither do we consider them clearly erroneous. 

IV. 

Under the FTCA the United States is liable for the acts of 

employees of federal agencies. 

"Employee of the government" includes officers or 

employees of any federal agency •.. and persons acting 

on behalf of a federal agency in an official capacity, 

temporarily or permanently in the service of the United 

States, whether with or without compensation. 

28 u.s.c. § 2671. 

The independent contractor exception is explained by the 

Supreme Court in United States v. Orleans: "A critical element in 

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distinguishing an agency from a contractor is the power of the 

Federal Government 'to control the detailed physical performance 

of the contractor.'" Orleans at 814, quoting United States v. 

Loque, 412 U.S. 521, 528 (1973). 

Orleans and Loque involved circumstances quite different from 

those of the present case, but we already have had occasion to 

apply their principle to alleged medical malpractice issues in 

Lurch v. United States, 719 F.2d 333, supra, and Lilly v. 

Fieldstone, 876 F.2d 857 (10th Cir. 1989). 

We have searched without success among the numerous state and 

federal cases cited in the briefs, and independently, to find 

interpretive authority more helpful than Lurch and Fieldstone in 

the light of Orleans and Logue for the purposes of the appeal now 

before us. 

The issue in Lurch was the power of "control" over a surgeon 

employed by the New Mexico School of Medicine but with a contract 

for service for a Veteran's Administration hospital. This court 

held that the physician was not an employee of the hospital for 

the purposes of the FTCA. The case is plainly distinguishable on 

the facts, but to the extent that its reasoning is applicable, it 

supports the position of the appellant here. 

Judge Holloway, for the Court, relied inter alia upon the 

district court's finding that the VA hospital did not control the 

manner in which the doctor rendered medical treatment to the 

plaintiff at the hospital. It was emphasized that a physician's 

professional ethics require that he have "free and complete 

exercise of his medical judgment and skill" and that no one else 

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could control the detailed physical performance of his duties. 

"Given this, by strictly following the traditional control test it 

is doubtful whether a physician could ever be found to be a 

federal employee under the FTCA," Judge Holloway observed, but he 

added that "such a result would not comport with the Congressional 

intent" and hence it was logical that some modified or different 

"control test" should apply with respect to physicians. Id. at 

337. 

However, on the facts before it, the Court concluded that 

"the contract arrangement itself and its application placed the 

doctor outside the parameters of an employer-employee relationship 

with the Government." The contract expressly stipulated that such 

medical personnel should not be considered VA employees for any 

purpose. The university provided workman's compensation, 

insurance, health examinations and social security payments. 

Thus, the areas of general supervision of [the 

doctor's] activity, which plaintiff seems to say should 

be considered, were confided to the University of New 

Mexico School of Medicine under the contract arrangement 

between the V.A. and the University. Because of that 

contract, which was not a sham, and the working 

arrangement under it between the V.A. and the 

University, we conclude that we must hold that the 

independent contractor exemption from FTCA liability 

applies. We do so without reaching the troublesome 

point whether control of the minutiae of medical 

decisions and procedures should not be considered 

because they are always reserved to the individual 

physician. [Footnotes omitted.] 

719 F.2d at 338. 

In the present case, few, if any, of the factors found 

determinative in Lurch are present. No one contends that 

Grinovich exercised directly or indirectly any influence, control 

or review over the performance of nurse Bullon. While the matters 

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of non-liability and insurance were addressed between the 

government and Grinovich, there was no provision that nurse Bullen 

should not be considered an employee of the hospital. Insofar as 

the record before us disclosed there were no legal, professional 

or ethical considerations that would have warranted him to 

disregard the control of the operating surgeon on the occasion of 

Mrs. Bird's death. The record indicates that Grinovich's position 

bore no resemblance to that of the University in Lurch, but was 

similar to any other employment agency providing references of 

prospective employees to employers, in this case by form of 

contract-requisition in a course of practice to meet the special 

procedural requirements of the government. 

Nor are we confronted here with the problem of applying 

control rationale to physicians who under professional standards 

must reserve to themselves free from outside control or 

supervision full responsibility for professional decisions whether 

employees or independent contractors. On the contrary, the very 

existence of such a problem with respect to physicians and the 

contrasting relationship and division of responsibilities between 

physicians and nurses presage a different result under the 

circumstances of the present case. 

In Lilly v. Fieldstone, this court again confronted the issue 

whether in a malpractice suit a physician was a government 

employee as the district court had held or, as determined on 

appeal, an independent contractor of the government hospital which 

had hired him as a consultant in urology. Finding it unnecessary 

to adopt in terms a discrete "modified" control test concerning 

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physicians, Judge McKay for the Court observed that the "control 

test" is subject to a doctor's medical and ethical obligations 

irrespective of whether the test is labeled "control" or "modified 

control." 

What we must do in the case of professionals is 

determine whether other evidence manifests an intent to 

make the professional an employee subject to other forms 

of control which are permissible. A myriad of doctors 

become employees by agreement without surrendering their 

professional responsibilities. The United States is 

equally capable of making such an arrangement by 

express, unambiguous agreement. Our conclusion in this 

case is that it simply has failed on this record to 

demonstrate that that was the nature of its agreement 

with Dr. Fieldstone [the consulting urologist who 

performed an emergency operation at the government 

hospital]. 

Id. at 859. 

In Fieldstone, the following factors convinced the Court that 

the consulting urologist was an independent contractor. Dr. 

Fieldstone did not have an arrangement with the hospital whereby 

he was always required to see patients there. He could refuse to 

treat a military patient if he wanted to. He was free to see 

patients at his private office. He billed the Army separately at 

his standard speciality fee rates. He maintained a private offbase office and had exclusive control over his patients and 

records. The Army did not furnish him with permanent and private 

office space or secretarial help at the hospital. He only 

occasionally used a temporary hospital office when he dictated his 

operative reports. He did not work under a written contract with 

the government and was never regularly scheduled on the hospital 

duty roster, nor did he maintain regular or prescribed office 

hours as a civilian consultant. The Army controlled little about 

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the end result or the manner and method of reaching a result. 

While he was subject to the same rules, regulations and hospital 

control as other military physicians and had limited contact and 

no control over military patients he treated in emergencies after 

his work was completed, nothing in the record suggested that this 

relationship was any different than it would be for a doctor in a 

private hospital with staff privileges -- "[s]urely being subject 

to hospital's rules as a condition of staff privileges does not 

remotely make a private physician an employee of that hospital." 

Id. at 860. Judge McKay agreed with the trial court that the 

"control" determination is difficult to make, 

but, on balance, viewing these factors as a whole, we 

cannot agree that the government "controlled" Dr. 

Fieldstone enough to render him a government employee. 

We cannot fairly say that the government "supervise[d] 

the day-to-day operations" of Dr. Fieldstone. Lurch, 

719 F.2d at 337. 

876 F.2d at 860. 

The foregoing enumerated circumstances deemed critical in 

Lilly v. Fieldstone strongly suggest that the answer must be 

different with respect to the status of nurse Bullon. In most 

respects his situation was the antithesis of that of Dr. 

Fieldstone. 

Nurse Bullon was not a physician bound to exercise his 

judgment independently of a government supervisor. He was not 

only subject to the rules and regulations and, indeed, a statute 

placing him under the control and supervision of physician 

employees of the hospital, but he was under their actual control 

to the extent they chose to exercise it. He was required to work 

with patients designated by others. He maintained no separate 

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office. He used hospital equipment exclusively. He could see 

patients in no other place nor under any other circumstance than 

as directed by government employees. He was under the control and 

supervision of the government surgeon at the hospital to the same 

extent that nurse Forsythe, a regular employee of the government, 

was. 

v. 

The trial court found as a part of its conclusions of law 

that there was no evidence that the hospital controlled Bullon's 

day-by-day activities, and that there was no contract between the 

government and Bullen, but rather it was between the government 

and Grinovich. Such findings if interpreted in total disregard of 

the context of the case and the other undisputed evidence might be 

thought to weigh against an employer-employee relationship. The 

trial court obviously was referring to the requisition the 

hospital furnished Grinovich, and obviously could not have meant 

that Bullon's services at the hospital were somehow apart from any 

contractual relationship between the hospital and Bullon, whether 

for service as an independent contractor or an employee. 

Similarly it should be understood that while there may have been 

no direct or detailed evidence as to the control of Bullon's dayto-day activities prior to the day of Mrs. Bird's death upon which 

the evidence was focused, the evidence concerning the preceding 

period as a whole and on the day in question that Bullon 

considered and handled himself as an employee was consistent with 

the regimen of CRNA Forsythe, a government employee. And of 

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course the trial court could not have meant to question in light 

of the entire record the continuing effect of the rules and 

regulations defining the subordinate nature of the authority of 

nurse anesthetists. 

The government further argues that actual control of the 

nurse's activities was minimal or nonexistent; that Grinovich was 

under contract to provide nurse support independently; that the 

same rules apply to employees of independent contractors as apply 

to their employees and that Grinovich and Bullen are to be treated 

without distinction; that the only supervision exercised over 

Bullon's work was the general supervision of the Chief of 

Anesthesia and the general supervision of the attending surgeon 

for each individual surgical patient; that Bullen was certified 

and had special training and expertise in his duties beyond that 

of the operating surgeons who relied upon him; that the seven 

prong tests adopted by Norton v. Murphy, 661 F.2d 882 (10th Cir. 

1981), and assertedly approved in Fieldstone were either not 

applicable or require a holding that nurse Bullen was an 

independent contractor; that the United States is not liable under 

the general doctrines of respondeat superior, loaned servant or 

estoppel, and that the rules applying to physicians in 

interpreting the independent contracts exemption should be held to 

apply to CRNAs. We find none of these arguments persuasive. 

Norton held that one contracting to deliver mail in a rural 

area who was involved in an accident with his own vehicle was an 

independent contractor rather than an employee under the 

circumstances of that case. While Fieldstone cited Norton and 

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enumerated its criteria, it did not apply them as such to the case 

before it in reaching the conclusion that the physician involved 

there was an independent contractor. On the contrary, the only 

further reference made to those criteria was to the "first factor 

in Norton, the intent of the parties [which] we are unpersuaded 

adds anything which illuminates the intent of the parties on the 

issue of whether Dr. Fieldstone was an employee or a private 

contractor." Id. at 859. The same can be said here consistently 

with a conclusion opposite that reached in Fieldstone. The other 

factors actually considered critical there stand in sharp contrast 

to the circumstances of the present case, as has already been 

detailed. 

The procurement contract between Grinovich and the hospital 

was ill designed to control the anesthetist's status. Assuming 

that Grinovich as designated "vendor" or "contractor" was itself 

an independent contractor, there was no provision making Bullon an 

independent contractor. Even though the government disclaimer of 

liability for the negligence of the contractor, as referred to by 

the trial court, applied to Bullon, it would be an ineffectual 

provision as to one otherwise determined to be an employee. 

The circumstance that Bullon obtained his position through 

Grinovich is largely immaterial. It seems clear that a nurse 

hired directly by the hospital to perform the services Bullon 

performed would have been an employee rather than an independent 

contractor for the purposes of the FTCA. The Grinovich 

interpositioning should not alter our analysis or our conclusion. 

It is immaterial that Grinovich itself was an independent 

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contractor for the supplying or reference of nurses or other 

employees to the government. This is not the independent 

contractor nexus that the FTCA contemplates, although the 

government's argument tends to confuse the two. The pertinent 

issue is whether nurse Bullen, himself, was an independent 

contractor. 

The hospital's power to control and supervise, which cannot 

be gainsaid here, was not diminished by any generality or laxness 

of that control at particular times. If this were otherwise, 

added to the recognized difficulty of decision concerning the 

power of control would be superimposed the day-to-day and perhaps 

minute-to-minute evaluation of vagaries pertaining to the manner 

that control was actually exercised, the diligence or inattention 

of supervising personnel, and other variables which if held to be 

governing factors would render the application of the control rule 

almost impossible. 

The fact that a nurse has special training certification and 

skills does not change the situation in light of the circumstances 

uncontested here that nurse Bullen necessarily worked by virtue of 

the license and under the supervision and control of a physician 

employed by the government hospital. 

We agree with the government that this is not a case for 

application of the loaned servant doctrine, nor does that of 

estoppel apply. Appellant to the contrary cites the loaned 

employee cases of United States v. N. A. Degerstrom, Inc., 408 

F.2d 1130 (10th Cir. 1969), and Martarano v. United States, 231 

F.Supp. 805 (D. Nev. 1964). These cases do have tangential 

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bearing not because they demonstrate that Bullon was a borrowed 

employee, but because the principles they explicate support the 

conclusion that Bullon was a direct employee under analogous 

circumstances. Denton v. Yazoo & M.V.R. Co., 284 U.S. 305 (1931), 

also applying the loaned servant doctrine in different context, 

emphasizes the "power to control" as the crucial element 

characterizing the employer-employee relationship. Here there was 

no employer from whom Bullon was borrowed, nor any competing 

control. By no stretch of advocatory creativity could Grinovich 

reasonably be thought to have any control over Bullen as he 

performed his duties at the government hospital. If Bullon were 

an employee at all, it would have to be that of the government 

hospital. The role of employer, or that of independent contractor 

of Bullon's work, ill suits Grinovich, and the role of independent 

contractor suits Bullen not at all. 

Disregard of these basic considerations would not only 

misapply the rules laid down by the Supreme Court for 

differentiation between employees and independent contractors in 

general and application of the FTCA in particular, but would 

distort the essential relationships between nurses and physicians 

in related contexts -- relationships that have developed from 

centuries of experience, that are ingrained in the statutory law, 

and have become vital to the medical profession in systematically 

accommodating and utilizing all levels of training, accreditation, 

skills, responsibilities and power in the public interest. We 

reject the government's final argument that the same rules of 

independence should apply to physicians and CRNAs alike. 

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f 

Some concepts and relationships are inherently implausible 

a two-year old yearling, a white blackbird, a plural single, an 

independent dependent, a certified registered nurse anesthetist 

serving in a hospital in the circumstances of this case under the 

license, supervision and control of a surgeon or physician 

anesthesiologist as an integral part of a government operating 

team, but at the same time as an independent contractor. 

VI. 

In our judgment, CRNA Bullon at the time in question was an 

employee of the government and not an independent contractor 

within the contemplation of the FTCA. 

With jurisdiction thus founded upon that act, and coverage so 

established, we REVERSE and REMAND for further proceedings 

consistent with this opinion. 

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