Case Name: Marion L. CANGELOSI, Sr., et ux., v. OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER, et al.
Court: Louisiana Supreme Court
Jurisdiction: Louisiana
Decision Date: 1989-10-23
Citations: 564 So. 2d 654
Docket Number: No. 89-C-1093
Parties: Marion L. CANGELOSI, Sr., et ux., v. OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER, et al.
Judges: CALOGERO, J., concurs and assigns reasons.
Reporter: Southern Reporter, Second Series
Volume: 564
Pages: 654–671

Head Matter:
Marion L. CANGELOSI, Sr., et ux., v. OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER, et al.
No. 89-C-1093.
Supreme Court of Louisiana.
Oct. 23, 1989.
Dissenting Opinion of Justice Dennis Nov. 20, 1989.
Rehearing Granted Dec. 7, 1989.
Opinion on Rehearing April 20, 1990.
Malcolm Dugas, Jr., George M. Papale, Stumpf, Dugas, LeBlanc, Papale & Ripp, Gretha, for plaintiffs-appellants.
Roger Fritchie, T. MacDougall Womack, Durrett, Hardin, Hunter, Dameron & Frit-chie, Herbert J. Mang, Jr., Glen Scott Love, Mathews, Atkinson, Guglielmo, Marks & Day, F.W. Middleton, Jr., Vicki M. Crochet, Taylor, Porter, Brooks & Phillips, William N. Faller, Bell, Faller & West, Baton Rouge, Robert Kleinpeter, for defendants-appellees.

Opinion:
MARCUS, Justice.
Marion A. Cangelosi, Sr. and his wife brought this medical malpractice action to recover damages for injuries sustained by Mr. Cangelosi. Defendants were Our Lady of the Lake Hospital, Inc., Dr. Ronald A. Radzikowski, Dr. James S. Osterberger, Jr., Dr. William Booth, Dr. Donald Cowick, Dr. Marshall Sommers, Dr. Martin Peuler, Anesthesiology Group Associates, and Ms. A.L. Ashbaugh. Plaintiffs alleged that, at and/or between the intubation and extubation accompanying gallbladder surgery, negligence caused a fracture of two tracheal rings leading to a permanent tracheotomy and subsequent medical procedures.
A medical review panel ruled unanimously in favor of all defendants. Mr. and Mrs. Cangelosi then filed this suit. Plaintiffs voluntarily dismissed Drs. Cowick, Booth, and Sommers. The remaining defendants moved for a directed verdict at the close of the plaintiffs' case. The trial judge took the motions under advisement. At the close of all the evidence, he granted directed verdicts in favor of Drs. Radzikowski and Osterberger, but denied the motions made by Our Lady of the Lake, Ms. Ash-baugh, Dr. Peuler, and Anesthesiology Group Associates. Next, finding that the doctrine of res ipsa loquitur did not apply to any of the defendants because no evidence showed that the injury would not have occurred in the absence of negligence, the trial judge refused to instruct the jury on the doctrine. The remaining defendants then made new motions for a directed verdict which the trial judge granted. Plaintiffs appealed. The court of appeal affirmed. Upon plaintiffs' application to this court, we granted certiorari to determine the correctness of that decision.
The issues presented are whether the trial judge was correct (1) in determining that the doctrine of res ipsa loquitur did not apply to this ease and (2) in granting defendants' motions for a directed verdict at the close of all the evidence.
FACTS
Mr. Cangelosi entered Our Lady of the Lake Regional Medical Center in Baton Rouge on November 26, 1982 to undergo gallbladder surgery. He was 68 years old. Dr. Radzikowski, Mr. Cangelosi's treating physician, had recommended the gallbladder surgery. He testified to Mr. Cangelo-si's history of health problems which included mild adult onset diabetes, a silent heart attack, pacemaker surgery, hiatal hernia, congestive heart failure, chronic pulmonary disease, and orthopnea, or breathlessness while lying flat. On admission, Mr. Cangelosi showed signs of congestive heart failure including breathlessness, swelling, and an irregular heart rhythm. As a result, the attending physicians postponed the surgery. By December 2, his condition was maximally compensated, meaning it was as good as it would be given his medical problems. Although he remained a high risk, surgery was performed on December 3. Ms. Ashbaugh, a certified registered nurse anesthetist employed by Anesthesiology Group Assoc., anesthetized and intubated Mr. Cangelosi. She testified that she did not use a stylet to intubate Mr. Cangelosi and that, in fact, she never uses a stylet. Dr. Peuler, an anesthesiologist and a co-worker, observed the intubation at Ms. Ashbaugh's request because of the high risk factor of Mr. Can-gelosi's health. Several witnesses testified that Mr. Cangelosi's intubation and surgery were uneventful. He remained in intensive care until December 5. Testimony and the hospital records showed that, during this time, the cuff pressure was routinely checked and the endotracheal tube routinely suctioned. Dr. Osterberger, who practices with Dr. Radzikowski, testified that he removed the endotracheal tube without difficulty on December 5. He also explained the steps that he followed for proper extubation. Mr. Cangelosi had been intubated for a total of 53 hours.
On December 7, Dr. Radzikowski examined Mr. Cangelosi and noted labored breathing and congestion. His condition worsened and he was moved back to intensive care. Dr. Charles Mitchell, an ear- nose-throat (ENT) physician, diagnosed laryngeal swelling secondary to the intubation. He prescribed medication, and the symptoms disappeared two days later. Dr. Mitchell released Mr. Cangelosi from his care, and he was transferred out of intensive care. On December 14, he was discharged from the hospital.
On December 29, Mr. Cangelosi saw Dr. Radzikowski for a post-operative visit. The doctor testified that he had not observed any breathing difficulties at that time. However, on January 4, Mr. Cange-losi saw Dr. Osterberger with complaints of hoarseness and shortness of breath. Dr. Osterberger testified that it sounded as though he was breathing through a straw. He made an appointment for Mr. Cangelosi with Dr. Mitchell who, after examination, admitted him to Our Lady of the Lake. The next day, Mr. Cangelosi was transferred to New Orleans to be examined by Dr. Daniel Mouney, an ENT specialist. The transfer summary indicated tracheal steno-sis (narrowing of the trachea due to swelling or scar tissue) and stridor (a sound on respiration caused by constriction of the airway). Dr. Mouney performed a tracheotomy, which is an opening into the trachea through the neck, to maintain an airway for Mr. Cangelosi and to do a direct laryn-goscopy. On direct observation, he saw scar tissue which had reduced the interior diameter of the trachea. In his opinion, the scar tissue covered collapsed and apparently fractured tracheal cartilaginous rings. Subsequently, Mr. Cangelosi underwent sixteen surgical procedures to reduce the continual growth of tissue and to maintain the airway. No procedures were performed after July 1986 because of his deteriorated general health. At the time of trial, Mr. Cangelosi resided in a nursing home following an unrelated stroke.
Dr. Mouney, testifying for the plaintiffs, said that his first impression was that Mr. Cangelosi had suffered an injury of the trachea. In his opinion, the event causing the damage to the trachea occurred sometime during the 53 hours of intubation. However, Dr. Mouney also testified that tracheal stenosis is seen in the absence of substandard care. He further stated that perichondritis, the condition asserted by defendants as the cause of Mr. Cangelosi's tracheal stenosis, was a credible explanation and that an aging patient with heart and pulmonary disease is at a higher risk for developing tracheal stenosis. Moreover, he testified that a skilled and experienced person doing the intubation would know that the rings had fractured because of the force a fracture would require. Finally, if a fracture had occurred, blood would be seen on suctioning which is routinely done immediately after intubation.
Plaintiffs called Dr. Joseph Stirt, an anesthesiologist, as an expert witness. Dr. Stirt testified that, based on his review of the medical records, Mr. Cangelosi's injury would not have occurred in the absence of substandard care by some health care provider. He opined that some external force on the trachea caused the injury rather than an internal inflammation or infection. However, Dr. Stirt could not say with any certainty which event or defendants) might have caused the injury. Further, he testified that perichondritis is not within his area of expertise, and he deferred to Dr. Mouney's opinion whether it was a possible cause of Mr. Cangelosi's injury. Dr. Stirt also testified that he found no cases in the medical literature of fractured tracheal rings from intubation when a styl-et was not used. Moreover, he estimated that his program does 10,000 to 15,000 intu-bations annually. He never saw or heard of a patient with a tracheal fracture caused by intubation during his four years with that institution.
Additionally, the defense presented Drs. Mouney and Stirt with the following hy-pothet. An experienced and capable an-esthesist intubated Mr. Cangelosi without using a stylet. The intubation was not difficult and the tracheal rings were not manipulated externally. No tracheal bleeding occurred, and an experienced anesthesiologist observed the intubation and felt that it was a-traumatic. Assuming these facts, both doctors conceded the unlikelihood that the intubation process caused Mr. Cangelosi's injury. Defendants established by direct testimony all the factors in the hypothet.
Dr. Booth, testifying for the defendants, stated that a fracture of two tracheal rings on intubation was almost "inconceivable." He testified that an air leak would have occurred immediately with accompanying swelling. This condition is known as subcutaneous emphysema and is part of the diagnosis of a fractured trachea. Its appearance is dramatic and is also heard and felt. In addition, free air from an air leak is detected on x-rays. Mr. Cangelosi's x-ray reports did not indicate the presence of free air. Also, Dr. Cowick testified that the effect of fractured tracheal rings is immediately visible and palpable. Based on his review of the surgical records, he felt that fractured tracheal rings absolutely did not occur during intubation.
Similarly, Dr. Osterberger testified that the signs of a tracheal fracture are dramatic and immediate. Based on his opinion and a review of the medical records, the process of perichondritis leading to collapse of the tracheal rings was exactly what happened in this case. Dr. Radzikowski testified that, in his opinion, no fracture occurred at or during intubation or extubation. He stated that perichondritis was the cause of the injury, particularly given the length of time that intubation was required and Mr. Cangelosi's overall physical condition. Further, he noted that Mr. Cangelosi's complaints of hoarseness and breathing difficulty on December 7 abated with the prescribed medications. If the rings had been fractured, the problems would not have cleared with these medications.
Dr. James LaNasa, an ENT physician, testified for the defendants that, with most patients, some abnormality of the tracheal lining occurs within two hours of being intubated. This is a normal event without any negligence on the part of any health care provider. In fact, he would have been surprised if no swelling or inflammation had occurred here. In his opinion, the cause of Mr. Cangelosi's injury was peri-chondritis aggravated by the patient's general health. Further, he testified that the endotracheal tube itself is too soft to exert sufficient force to break cartilaginous rings, particularly rings that have partially ossified due to aging as was the case with Mr. Cangelosi.
Ms. Ashbaugh stated that she has been practicing as an anesthetist since 1951. She estimated that she has done 40,000 to 50,000 intubations in her career. She testified that she remembered Mr. Cangelosi because of his high risk status and that the intubation was uneventful. Again, Ms. Ashbaugh testified that she did not use a stylet to intubate Mr. Cangelosi and that she never uses a stylet. She also described, as had Dr. Stirt, the procedure to follow if resistance is encountered during the first intubation attempt. Dr. Peuler stated that he has known Ms. Ashbaugh professionally for seven years and that, in his opinion, she was as fine an anesthetist as he had ever seen. He testified that he observed the intubation and saw nothing abnormal. Dr. Peuler estimated that, in his former career as an instructor, he supervised 7,000 to 10,000 intubations done by inexperienced personnel using stylets. He never saw a fracture on intubation. In his opinion, the fracture of two tracheal rings is physically impossible to do without the use of a stylet.
RES IPSA LOQUITUR
This court recently addressed the doctrine of res ipsa loquitur:
The principle of res ipsa loquitur is a rule of circumstantial evidence that infers negligence on the part of defendants because the facts of the case indicate that the negligence of the defendant is the probable cause of the accident, in the absence of other equally probable explanations offered by credible witnesses. The doctrine allows an inference of negligence to arise from the common experience of the factfinder that such accidents normally do not occur in the absence of negligence.
Additionally, the doctrine does not dispense with the rule that negligence must be proved. It simply gives the plaintiff the right to place on the scales, "along with proof of the accident and enough of the attending circumstances to invoke the rule, an inference of negligence" sufficient to shift the burden of proof.
The doctrine applies only when the facts of the controversy "suggest negligence of the defendant, rather than some other factor, as the most plausible explanation of the accident. Application of the principle is defeated if an inference that the accident was due to a cause other than defendant's negligence could be drawn as reasonably as one that it was due to his negligence." The doctrine does not apply if direct evidence sufficiently explains the injury.
Montgomery v. Opelousas Gen. Hosp., 540 So.2d 312 (La.1989) (citations omitted).
As provided by La.R.S. 9:2794(C), the court determines the applicability of res ipsa loquitur in medical malpractice actions. See Green v. Dupre, 520 So.2d 761 (La. App. 3d Cir.1987), cert. denied, 522 So.2d 568 (La.1988); Oswald v. Rapides Iberia Management Enter., 452 So.2d 1258 (La. App. 2d Cir.), cert. denied, 457 So.2d 14 (La.1984); Rogers v. Brown, 416 So.2d 624 (La.App. 2d Cir.), cert. denied, 422 So.2d 153 (La.1982).
Defendants argued that perichondritis caused Mr. Cangelosi's tracheal stenosis. All the physicians who testified addressed the issue • of perichondritis. Drs. Booth, Cowick, Osterberger, Radzikowski, and La-Nasa stated that, in their opinions, peri-chondritis was the only possible explanation. Even the plaintiffs' witness, Dr. Mouney, testified that perichondritis was a credible explanation. While Dr. Stirt testified that, in his opinion, the stenosis would not have resulted without the negligence of a health care provider, he deferred to Dr. Mouney's opinion on perichondritis. Additionally, he stated that the medical literature was devoid of examples of tracheal ring fracture on intubation when a stylet was not used. Further, Drs. Stirt and Peu-ler never saw a tracheal puncture caused by intubation during their extensive experience as anesthesiologists. Ms. Ashbaugh, an experienced anesthetist, testified that she did not use a stylet to intubate Mr. Cangelosi, no resistance was encountered, and the entire procedure was very uneventful. Moreover, Drs. Mouney and Stirt, testifying for the plaintiffs, admitted that a tracheal ring fracture during intubation was highly unlikely based on the given facts of Mr. Cangelosi's intubation. Hence, perichondritis is a reasonable explanation for Mr. Cangelosi's tracheal steno-sis. The facts of the case do not suggest negligence by any of the defendants as the most plausible explanation. To the contrary, the facts of the case indicate that perichondritis is the most probable cause of the tracheal stenosis. Therefore, the trial judge was correct in finding that res ipsa loquitur did not apply.
DIRECTED VERDICT
Because res ipsa loquitor does not apply to this case, the plaintiffs have the burden of proving defendants' negligence by a preponderance of the evidence as provided in La. R.S. 9:2794(C). In a medical malpractice action against a physician, the plaintiff must establish the doctor's deviation from the standard of care exercised by others in the same field. The plaintiff must also show a causal relationship between the doctor's alleged negligence and the resulting injury. La.R.S. 9:2794(A); Smith v. State, 523 So.2d 815 (La.1988). Nurses who perform medical services are subject to the same standards of care and liability as are physicians. Belmon v. St. Frances Cabrini Hosp., 427 So.2d 541 (La. App. 3d Cir.1983); Butler v. Louisiana State Bd. of Educ., 331 So.2d 192 (La.App. 3d Cir.), cert. denied, 334 So.2d 230 (La. 1976). Likewise, in a medical malpractice action against a hospital, the plaintiff must prove that a hospital caused the injury when it breached its duty. A hospital must exercise that amount of care required by a particular patient, and must protect that patient from external circumstances peculiarly within the hospital's control. Hunt v. Bogalusa Community Medical Center, 303 So.2d 745 (La.1974).
This court set forth the standard for granting a motion for a directed verdict in Hastings v. Baton Rouge Gen. Hosp., 498 So.2d 713 (La. 1986):
A directed verdict should only be granted when the facts and inferences point so strongly in favor of one party that the court believes reasonable people could not reach a contrary verdict. It is appropriate, not when there is a preponderance of evidence, but only when the evidence overwhelmingly points to one conclusion.
The testimony and medical records support an uneventful intubation. Ms. Ashbaugh testified that she encountered no resistance during the intubation, and Dr. Peuler stated that the intubation was a-traumatic. Also, no air leak and accompanying swelling occurred. The surgeons testified that the dramatic signs of an air leak would have been seen immediately as well as heard and felt. Testimony showed that suctioning of the tube and checks of the cuff pressure were routinely documented in the medical records between the time of intubation and extubation with normal results. Dr. Stirt could not point to any specific act by any defendant which was substandard. Moreover, plaintiffs' witnesses testified that no injury occurred during extubation. Plaintiffs offered no evidence to refute the testimony which supports a normal intubation and extubation procedure. None of the evidence demonstrates a deviation from the standards of care required of physicians, nurses, and hospitals. The facts and inferences point so strongly in favor of defendants that reasonable minds could not reach a contrary verdict. Thus, the trial judge was correct in granting the directed verdicts.
DECREE
For the reasons assigned, judgment of the court of appeal is affirmed.
CALOGERO, J., concurs and assigns reasons.
DIXON, C.J., and DENNIS, J., dissent with reasons.
LEMMON, J., dissents and will assign reasons.
. Intubation is the placement of a flexible, soft plastic endotracheal tube into the patient's mouth which is passed through the larynx, between the vocal cords, and into the trachea. The fundamental purpose of intubation is to maintain an open airway. Oxygen and anes thetic gases are administered through the tube. A cuff at the end of the tube is inflated to seal the trachea. The seal stops the backflow of aspiration into the lungs and prevents the escape of gases and oxygen thus providing control over the pressures within the lungs. The tube can be inserted with or without a stylet. A stylet is a flexible aluminum rod which is placed inside the tube to help shape it to the patient's anatomy. Extubation is the removal of the tube.
. Drs. Cowick and Booth performed the gallbladder surgery. Dr. Sommers, an anesthesiologist, was present in the recovery room.
. 542 So.2d 90 (La.App. 1st Cir.1989).
. 546 So.2d 1201 (La.1989).
. Several witnesses described perichondritis. The endotracheal tube is not immobile after insertion. It moves as the patient swallows, moves their head, etc. Thus the tube rubs on the mucousal lining, or perichondrium, of the trachea denuding and abrading the tissue. This can lead to perichondritis, or inflammation of the cartilage. The inflammation softens the cartilage. Scar tissue forms and contracts pulling the cartilage inward narrowing the trachea. Eventually, the cartilaginous ring fractures into two pieces. This condition is commonly aggravated when the tube and/or cuff presses against the lining of the trachea cutting off the blood supply to the tissue.
. Testimony during the plaintiffs' case-in-chief proved that no injury occurred during the removal of the tube.
. None of the testifying physicians felt that the length of time of intubation was excessive for this case.
. La.R.S. 9:2794(C) provides:
In medical malpractice actions the jury shall be instructed that the plaintiff has the burden of proving, by a preponderance of the evidence, the negligence of the physician, dentist or chiropractic physician. The jury shall be further instructed that injury alone does not raise a presumption of the physician's, dentist's or chiropractic physician's negligence. The provisions of this Section shall not apply to situations where the doctrine of res ipsa loquitur is found by the court to be applicable. [Emphasis added.]