Title: Diana Velazquez et al. V. Ronald Portadin, M.D., et al.
Citation: N/A
Docket Number: a-12-99
State: new-jersey
Issuer: new-jersey Supreme Court
Date: May 18, 2000

(This syllabus is not part of the opinion of the Court. It has been prepared by the Office of the Clerk for the convenience of the reader. It has been neither reviewed nor approved by the Supreme Court. Please note that, in the interests of brevity, portions of any opinion may not have been summarized). LONG, J., writing for a unanimous Court. This appeal addresses the propriety of the medical judgment charge. In addition, the Court addresses whether the way in which the trial court conducted jury voir dire was prejudicial. Barbara and Luis Velazquez instituted a medical malpractice action against Dr. Ronald Portadin, Vineland Obstetrical and Gynecological Professional Association, and Nurses Eileen Cinotti and Ann Spaltore (collectively defendants) alleging that defendants failed to adhere to the accepted standard of medical care in connection with the birth of their daughter, Diana, resulting in Diana's cerebral palsy. According to the Velazquezes, defendants deviated from accepted standards of care while administering the drug Pitocin to Barbara to hasten her contractions during labor, because they negligently monitored Diana's fetal heart rate and, as a result, failed to timely discontinue the use of Pitocin, causing Diana to be deprived of oxygen. Defendants denied the malpractice claims. At trial, the experts testifying on behalf of the Velazquez family (the Velazquez experts) opined that Diana's cerebral palsy was caused by birth asphyxia. The Velazquez experts concluded that the oxygen deprivation occurred within the last one and one-half hours of birth while Pitocin was being administered. All experts agreed at trial that it was appropriate for Dr. Portadin to give Pitocin to enhance the contractions and that fetal monitoring was necessary. However, the experts strongly disagreed about whether monitoring actually took place and whether the monitoring strips were sufficiently readable to determine Diana's reaction to Pitocin. According to the Velazquez experts, there is no evidence that the fetal monitor was ever read, that the strips were unreadable and that they showed fetal distress. According to these experts, when the strip became unreadable, the nurses should have discontinued the Pitocin and notified Dr. Portadin so that he could determine the appropriate course of action. In addition, Dr. Portadin deviated from accepted standards of care by continuing the Pitocin. Instead, he should have discontinued the drug until reassuring tracings resumed or applied an internal fetal monitor to Diana's scalp and reinstitute Pitocin when those reading were more reassuring. According to the Velazquez experts, either option would have avoided Diana's injury. Dr. Portadin testified on his own behalf. He stated that the decision to use an internal scalp monitor is a medical judgment that requires the weighing of the risk of infection with the benefits of the monitor readings. Dr. Portadin testified that the monitoring strips did not indicate that Diana was experiencing difficulty; that the options offered by the Velazquez experts would have taken longer than spontaneous delivery; and that other delivery options were foreclosed by the passage of time and the risk-benefit analysis. In addition, Dr. Portadin's obstetrical expert as well as the nurses' expert testified that the strips overall were readable, that any unreadable portions were followed by reassuring tracings, and that the strips did not reveal fetal distress. At the conclusion of trial, the trial court, over objection of the attorney representing the Velazquezes, gave a charge based on the Model Jury Charge on exercise of judgment. That charge basically states that a physician or nurse cannot be found negligent if exercising judgment so long as he or she bases his or her judgment on accepted standards of medical or nursing practice. After deliberating, the jury determined that the defendants had not deviated from accepted standards of medical care. The Velazquezes appealed to the Appellate Division, which affirmed the lower court decision. HELD: In a medical malpractice action, the court and counsel, on the record, should analyze the parties' testimony and theories in detail to determine whether the medical judgment charge is applicable and, if so, to which specific issues. The charge should then be tailored accordingly. Because the exercise of judgment charge was not tailored to the facts of this case, its coverage was overbroad and had the potential to improperly insulate defendants from liability. 1. The application of the medical judgment charge is generally limited to medical malpractice actions concerning misdiagnosis or the selection of one of two or more generally accepted courses of treatment. (Pp. 11-14) 2. Appropriate and proper charges are essential for a fair trial. Jury charges must outline the function of the jury, set forth the issues, correctly state the applicable law in understandable language, and plainly spell out how the jury should apply the legal principles to the facts as they may find them. Thus, a trial court must not only administer the exercise of judgment charge solely in cases where the charge is appropriate, but it must separate out those aspects of the medical care that involved judgment and those that did not. The failure to do so constitutes reversible error where the jury outcome might have been different had the jury been properly instructed. (Pp. 14-16) 3. The trial court failed to tailor the charge to the theories and facts presented. The court failed to explain that it was the jury's duty to determine whether the defendants monitored Mrs. Velazquez while she was on Pitocin. The issue should have been presented as one involving the deviation from the standard of care without reference to the medical judgment charge. In addition, the issue of whether the strips were readable was not a judgment call and the charge was inapplicable to this aspect of the case. Moreover, the issue of the propriety of discontinuing the Pitocin and whether there was or was not fetal distress were standard of care issues, not requiring a exercise of judgment charge. The only issue of judgment was whether to utilize an internal monitor because the decision to do so involved choosing between two equally acceptable approaches. (Pp. 16-19) 4. Although the grant or denial of extra peremptory challenges is a matter of discretion, it may not be an arbitrary exercise. The court is required to analyze the positions of the multiple parties for identity purposes to determine whether the adversary will be prejudiced unless more peremptory challenges are awarded. The trial court failed to address the substantial identity of interests of the defendants. Because this case must be retried, the Court need not decide the effect of the trial court's denial of additional challenges. Merely concluding that there is or is not an identity of interests is not enough, a statement of reasons is required. (Pp. 19-22) Judgment of the Appellate Division is REVERSED and the matter is REMANDED to the Law Division for a new trial consistent with the principles stated. CHIEF JUSTICE PORITZ and JUSTICES O'HERN, GARIBALDI, STEIN, COLEMAN, and VERNIERO join in JUSTICE LONG'S opinion. DIANA VELAZQUEZ, an infant by her guardian ad litem, BARBARA VELAZQUEZ and BARBARA and LUIS VELAZQUEZ, Individually, Plaintiffs-Appellants, v. RONALD PORTADIN, M.D., NEWCOMB MEDICAL CENTER, EILEEN CINOTTI-MAGEE, R.N., ANN SPOLTORE, R.N. and VINELAND OBSTETRICAL &amp; GYNECOLOGICAL PROFESSIONAL ASSOCIATES, Defendants-Respondents, and DR. MICHELLE TORCHIA, M.D., JOHN DOES, M.D.'s (fictitious names), PATRICIA KNECHT, R.N., JANE ROES, R.N.'s (fictitious names), ROBERT SMITHS (fictitiously named health care providers), Defendants. Argued January 19, 2000-- Decided May 18, 2000 On certification to the Superior Court, Appellate Division, whose opinion is reported at 321 N.J. Super. 558 (1999). Carol L. Forte argued the cause for appellants (Blume, Goldfaden, Berkowitz, Donnelly, Fried &amp; Forte, attorneys). Richard A. Grossman argued the cause for respondents Newcomb Medical Center and Eileen Cinotti-McGee, R.N. (Grossman, Kruttschnitt, Heavey &amp; Jacob, attorneys; Roberta DiBiase, on letter brief). Timothy M. Crammer argued the caused for respondent Ann Spoltore, R.N. (Paarz, Master, Koernig, Crammer, O'Brien, Bishop &amp; Horn, attorneys). The opinion of the court was delivered by LONG, J. This case presents another chapter in the continuing saga of the medical judgment charge. Plaintiffs, Barbara and Luis Velazquez, instituted a medical malpractice action against Dr. Ronald Portadin, Vineland Obstetrical &amp; Gynecological Professional Association, and Nurses Eileen Cinotti and Ann Spaltore (collectively defendants).See footnote 11 Plaintiffs alleged that defendants failed to adhere to the accepted standard of medical care in connection with their daughter Diana's birth, resulting in severe injury to her (cerebral palsy). More particularly, the complainants alleged that defendants had deviated from accepted standards while administering the drug Pitocin to Barbara Velasquez insofar as they negligently monitored Diana's fetal heart beat readings and, as a result, failed to timely discontinue the drug, causing Diana to be deprived of oxygen. Defendants answered, denying the allegations of the complaint. Discovery ensued and the case went to trial. I The facts established at trial were as follows: At about 2:00 a.m. on August 18, 1990, Mrs. Velazquez came to Newcomb Medical Center to deliver her first child after an uneventful pregnancy. When she first arrived at the hospital, she was cared for by Dr. Michelle Torchia, the physician covering for Vineland Obstetrical Associates. Shortly after admission, electronic monitoring of the fetal heart began. That monitoring is carried out by placing a belt containing a transducer around the mother's abdomen. The monitor produces a continuous paper strip. The baby's heartbeat is printed along the top of the strip, and the pattern of the mother's uterine contractions is printed simultaneously along the bottom. The information on the strip allows the reader to examine the fetal heart rate and how it responds to contractions. The relationship between the two may demonstrate problems that the baby may be having. Dr. Portadin relieved Dr. Torchia at 8:00 a.m. At that time, Eileen Cinotti, R.N., and Ann Spoltore, R.N., began to care for Mrs. Velazquez. Nurse Cinotti, as the primary nurse, was responsible for monitoring Mrs. Velazquez during labor. Nurse Spoltore was the nurse designated to care for the baby after delivery. At approximately 1:30 p.m., Dr. Portadin determined that a drug called Pitocin should be given to increase uterine contractions and to assist in the descent of the baby down the birth canal. Pitocin is a medication used to increase the intensity and frequency of uterine contractions in women whose contractions are insufficient to deliver the baby. If Pitocin causes the contractions to occur too frequently or last too long, the baby may be harmed because blood flow to the baby slows during contractions. That condition is called hyperstimulation of the uterus. When the uterus is hyperstimulated, the interval between contractions is shortened and there is not enough time for the baby to catch up on its oxygen needs before the start of another contraction. That is why constant monitoring is required. Shortly after 1:30 p.m., Cinotti, the nurse on duty in the hospital's labor room, began the intravenous infusion of Pitocin at the rate of two milliunits per minute. Soon the fetal monitor strip began to decrease in readability. At about 1:45 p.m., Cinotti increased the Pitocin rate to four milliunits per minute. At about 2:24 p.m., Cinotti was relieved by Spoltore as the nurse on duty in the labor room so that Cinotti could prepare the adjacent delivery room for Mrs. Velazquez. At that time, the Pitocin rate was increased to six milliunits per minute. At 2:45 p.m., Mrs. Velazquez was disconnected from the fetal monitoring belt and, at about 2:55 p.m., she was transferred to the delivery room. Although defendants claim Mrs. Velazquez was monitored again when she reached the delivery room, those monitor strips are missing. At 3:02 p.m., while still receiving Pitocin, Mrs. Velasquez vaginally delivered Diana. At birth, Diana had virtually no heartbeat and, following resuscitation, was diagnosed as having cerebral palsy. Plaintiffs presented experts who testified that Diana's problems were due to birth asphyxia. They found no other explanation for her condition. They based their conclusion upon a multitude of evidence, including Diana's blood acidity, her susceptibility to seizures, and her breathing problems. Subsequent health care providers also diagnosed birth asphyxia, and neuroimaging studies were consistent with that diagnosis. The plaintiffs' experts concluded that the oxygen deprivation had occurred within the last one and one-half hours before birth, which was the same time that the Pitocin was being administered. Defendants also presented experts who testified in detail that the genesis of cerebral palsy is unknown and that plaintiffs' contention that it is caused by asphyxia at birth is only a theory. 3. Did Nurse Eileen Cinotti deviate from accepted standards of nursing practice? [Model Jury Charge 5.36A (Civil), supra, at 5-6.] Given the relationship between medical judgment and the standard of care, our courts have often struggled in determining whether the facts of a particular case call for the application of the judgment charge. We have generally limited the application of the judgment charge to medical malpractice actions concerning misdiagnosis or the selection of one of two or more generally accepted courses of treatment. Aiello, supra, 159 N.J. at 628-29; see Patton v. Amblo, 314 N.J. Super. 1, 9 (App. Div. 1998)(finding that doctor was not entitled to "exercise of judgment" charge where alleged malpractice involved making scalpel incision too deep because alleged deviation was in manner doctor performed procedure); Adams v. Cooper Hosp., 295 N.J. Super. 5, 10-11 (App. Div. 1996)(holding that court did not err by refusing to charge jury with "exercise of judgment" instruction where issue was whether nurse had duty to constantly monitor patient because case did not involve selection between one of two courses of treatment or two schools of thought), certif. denied, 148 N.J. 463 (1997). Indeed, the Model Charge itself is facially limited to cases in which the physician exercised judgment in selecting among acceptable courses of action: If ... in the exercise of his/her judgment a doctor selects one of two or more courses of action, each of which in the circumstances has substantial support as a proper practice by the medical profession, the doctor cannot be found negligent if the course chosen produces a poor result. [Model Jury Charge 5.36A (Civil), supra, at 5.] It is fundamental that "[a]ppropriate and proper charges to a jury are essential for a fair trial." State v. Green, 86 N.J. 281, 287 (1981). Jury charges "must outline the function of the jury, set forth the issues, correctly state the applicable law in understandable language, and plainly spell out how the jury should apply the legal principles to the facts as it may find them . . . ." Jurman v. Samuel Braen, Inc., 47 N.J. 586, 591-92 (1966); Navarro v. George Koch &amp; Sons, Inc., 211 N.J. Super. 558, 570 (App. Div.), certif. denied, 107 N.J. 48 (1986). Pursuant to those principles, a trial court must not only administer the exercise of judgment charge solely in cases where the charge is appropriate, but it must also separate out those aspects of the medical care that involved judgment and those that did not. Patton, supra, 314 N.J. Super. at 8-9. The failure to do so constitutes reversible error where the jury outcome might have been different had the jury been instructed correctly. Id. at 10. It is often difficult to determine what evidence must be presented in order to entitle a defendant to the exercise of judgment charge. However, that is an important determination because [i]f the exercise of judgment rule is inappropriately or erroneously applied in a case that involves only the exercise of reasonable care, the aspect of the rule that excuses physicians for 'mistakes' would enable the physician to avoid responsibility for ordinary negligence. Aiello, supra, 159 N.J. at 632. In other words, [t]he mistake that inheres in negligence, that is, failure to exercise reasonable care, is not the kind of mistake that is excusable. If, therefore, the physician's professional conduct implicates only the exercise of reasonable care in the performance of a medical procedure and not the exercise of medical judgment in selecting among acceptable and medically reasonable courses of treatment, the medical judgment rule should not be invoked. [Ibid.] That point is driven home in a footnote to the most recent Model Charge: If a case does not involve a legitimate judgment call or two schools of thought, then the Trial Judge should omit this portion of the charge. See Adams v. Cooper Hospital, 295 N.J. Super. 5, 8 (App. Div. 1996). If a case involves judgment issues on some theories of liability, but not on others, the charge should be tailored to those facts. Patton v. Amblo, 314 N.J. Super. 1 (App. Div. 1998), (trial judge committed reversible error when he failed to separate out what aspects of care involved judgment and which did not) and see Campos v. Firestone Tire and Rubber Company, 98 N.J. 198, 210 (1984). Medical malpractice practitioners should assist the court in framing tailored, objective statements of those issues which do involve legitimate dispute issues of judgment or two schools of thought. To give one example among many, if a distinct issue in a case involved a doctor who ordered a test and never received the result, the jury would appropriately be charged that there was no exercise of judgment or two schools of thought defense to that claim. In contrast, what steps to take in response to a test result might involve one or more issues of judgment. [Model Jury Charge 5.36A(Civil), 2 Medical Malpractice, Duty and Negligence (April 1999).] Here, the trial court failed to tailor the charge to the theories and facts presented. First, he neglected to explain that it was the jury's duty to determine whether the defendants, in fact, monitored Mrs. Velazquez at all while she was on Pitocin. All experts agreed that monitoring was required and that if it was not done, it was a deviation from the standard of care. There was evidence from which the jury could have concluded that defendants failed to monitor Mrs. Velazquez and that the reason they did not take action when the strips became unreadable was that they were unaware of it. That issue had to be presented to the jury as involving a deviation from the standard of care without reference to the judgment charge. Second, the issue of whether the strips were readable was not a judgment call. Experts testified on both sides as to the standard for readability. It was for the jury to decide which standard was correct and to determine whether there was a deviation. The judgment charge was thus inapplicable to that aspect of the case. Third, if the jury found that the strips were not readable, and no other meaningful monitoring technique was in place, all experts agreed that the Pitocin should have been stopped. That was not a judgment issue. Fourth, if the jury found the strips were, in fact, readable, the issue was whether they revealed fetal distress. If there was no fetal distress, no action was required. If fetal distress was evident, the issue was whether continuing the Pitocin without remedying that distress comported with the standard of care. Again, no judgment was required. The defense experts emphasized the fact that by 2:30 to 2:45 it was too late to deliver Diana any other way but vaginally. Assuming that was correct, the judgment charge was inapplicable for that very reason -- defendants had no choice at that point. Moreover, that determination could not insulate defendants from liability because plaintiff's theory was that it was the failure to monitor from l:30 onward that violated the standard of care and caused the later predicament. The only issue of judgment was whether to utilize an internal monitor because that decision apparently involved choosing between two equally acceptable approaches. In short, the bulk of this case implicated the question of deviation from the standard of care, not judgment. The able defense lawyers, knowing the power of the judgment charge, took every opportunity to lead the court and jury into thinking that the entire case revolved around the exercise of judgment. It did not. Although one or possibly a few judgment issues may have been implicated, the heart of the case was about whether there was a deviation from the standard of care. The undifferentiated instruction on medical judgment misled the jury and thus improperly insulated defendants from liability. We engaged in a rather painstaking factual analysis here to reaffirm for trial judges the nature of the inquiry that is essential when a medical judgment charge is at issue. Court and counsel should analyze the parties' testimony and theories in detail, on the record, to determine whether the charge is applicable at all and, if so, to which specific issues. The charge should then be tailored accordingly. Only such an approach will avoid the error that occurred in this case. Because the judgment charge was not tailored to the facts of this case, its coverage was overbroad and had the potential to improperly insulate defendants from liability. Accordingly, a new trial is required. III Although the ordering of a new trial makes it unnecessary for us to grapple with plaintiffs' complaints about the voir dire, we take this opportunity to make several observations. The first is in connection with plaintiffs' application for additional peremptory challenges. Plaintiffs contend that under Rule 1:8-3(c) they were entitled to additional peremptory challenges beyond the six granted under normal circumstances because defendants had eighteen peremptory challenges between them and a substantial identity of interest in one or more issues. Rule 1:8-3(c) provides: In civil actions each party shall be entitled to 6 peremptory challenges. Parties represented by the same attorney shall be deemed 1 party for the purposes of this rule. Where, however, multiple parties having a substantial identity of interest in one or more issues are represented by different attorneys, the trial court in its discretion may, on application of counsel prior to the selection of the jury, accord the adverse party such additional number of peremptory challenges as it deems appropriate in order to avoid unfairness to the adverse party. NO. A-12 DIANA VELAZQUEZ, etc., et al., Plaintiffs-Appellants, v. RONALD PORTADIN, M.D., et al., Defendants-Respondents, and DR. MICHELLE TORCHIA, M.D., et al., Defendants. DECIDED May 18, 2000 Chief Justice Poritz