Opinion ID: 2798735
Heading Depth: 2
Heading Rank: 1

Heading: Observe for a period of time, maybe a day, maybe

Text: several days, depending on the course. Very likely withdraw or try to alter drug therapy to alleviate the slow heartbeat. Moreover, the physician called by defendant, Dr. Freddy Michael AbiSamra, conceded, as suggested by the national guidelines, the implantation of a permanent pacemaker herein was not “emergent.” Significantly, a document was admitted into evidence entitled “Indications for a Permanent Cardiac Pacing,” listing the classifications for a permanent pacing as established by a joint task force 1 The testimony of the other two members were stipulated to as their testimony would have been identical to Dr. Brown’s. 3 formed by the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society. These guidelines set forth three classifications: Class I—Conditions in which permanent pacing is definitely beneficial, useful, and effective. In such conditions, implantation of a cardiac pacemaker is considered acceptable and necessary, provided that the condition is not due to a transient cause. Class II—Conditions in which permanent pacing may be indicated but there is conflicting evidence and/or divergence of opinion; class IIA refers to conditions in which the weight of the evidence/opinion is in favor of usefulness/efficacy, while class IIB refers to conditions in which the usefulness/efficacy is less well established by evidence/opinion. Class III—Conditions in which permanent pacing is not useful/effective and in some cases may be harmful. Symptoms—Patients frequently present for consideration of pacemaker placement because of symptoms that may be due to bradyarrhythmias (e.g. dizziness, lightheadedness, syncope, fatigue, and poor exercise tolerance.) These patients will often have evidence of mild or intermittent sinus node dysfunction or conduction abnormalities. It is critical to attempt to establish a direct correlation between symptoms and bradyarrhythmias. This is done via a careful history and ambulatory monitoring. A direct correlation between symptoms and bradyarrhythmias will increase the likelihood of recommending pacemaker placement. On the other hand, failure to document such a correlation or the presence of an alternative explanation for symptoms will make pacemaker placement less likely or even contraindicated. (Emphasis added). As the guidelines clearly provide, in non-emergent or non-life threatening situations, like the one herein, a cardiologist should “wait and see” before implanting a permanent pacemaker as a period of monitoring is necessary in order to ensure “the condition is not due to a transient cause.” These guidelines also caution failure to document a direct correlation between symptoms and bradycardia or the presence of an alternative explanation of the symptoms will make pacemaker placement less likely or even contraindicated. Here, the record undeniably shows Dr. Yue did not heed these warnings as he failed to do 4 ambulatory monitoring or even determine if Snider’s condition was due to a transient cause, like the beta blockers. Regarding the proper classification herein and the need for immediate action, Dr. Abi-Samra testified there was a clear indication this was a Class II implantation and as such would “benefit the patient, especially in the lifestyle, rather than the immediate survival or immediate prevention of immediate death.” It was not, according to him, an emergency surgery or anything of that sort, specifically “[i]t was not necessarily emergent.” Accordingly, the overall testimony and the objective medical evidence establish Snider’s presentation at the emergency room did not call for or require immediate surgery. The objective evidence clearly shows the jury’s factual error as it was not necessarily Dr. Yue’s performance of the procedure that breached the applicable standard, but rather his “rush,” or more appropriately his decision, to perform this particular procedure emergently based solely on the symptoms presented in the emergency room the very same day that constitutes malpractice. Though as the majority finds the evidence does reasonably show a young man at 26 years of age, facing a lifetime of beta blockers and drug therapy, may very well be a candidate for a Class II implantation of a permanent pacing device, that same evidence nevertheless conclusively and objectively establishes the implantation herein was not emergent because plaintiff was stable, not in heart failure, and with no ongoing angina. Thus, under the facts and circumstances of this case, the objective medical evidence clearly shows Dr. Yue breached the ordinary standard of care in his rush to treat the plaintiff’s symptoms through the implantation of a permanent pacemaker. Given the medical guidelines, the medical testimony, and the panel’s undisputed medical findings—all agreeing Dr. Yue rushed the decision for 5 implantation of a permanent pacemaker without first stopping the patient’s medication and monitoring for possible improvement in heart rate—a reasonable fact finder would not have found as this jury did on the issue of breach of the applicable standard of care. The Court of Appeal is an errors correcting court that properly reversed the jury’s verdict in its manifest error review. For these reasons, I would affirm the Court of Appeal. 6 05/05/15 SUPREME COURT OF LOUISIANA No. 2014-C-1964 CLIDE SNIDER, JR., ET UX. VERSUS LOUISIANA MEDICAL MUTUAL INSURANCE CO., ET AL. CRICHTON, J., additionally concurs and assigns reasons: I concur in the per curiam opinion reversing the court of appeal. I write separately to emphasize the substantial weight given to a jury’s finding of fact under Louisiana law. See Rosell v. ESCO, 549 So. 2d 840, 844 (La. 1989). As esteemed late Justice Albert Tate, Jr. observed, the rule of limited appellate review in the absence of manifest error “requires that the appellate court will not disturb the trial court’s express or implied factual findings if the evidence is reasonably open to any interpretation in accord therewith.” A. Tate, “Manifest Error” – Further observations on appellate review of facts in Louisiana civil cases, 22 La. L. Rev. 605, 611 (1962). The court of appeal disregarded this mandate in this case, despite the fact that the evidence presented at trial was “reasonably open to any interpretation” in accordance with the jury’s verdict. Indeed, as the per curiam explains, even plaintiffs’ own expert testified on cross-examination that the guidelines for pacemaker implantation were met in this case. As a result, I believe that, consistent with prior jurisprudence of this Court, the case is properly reversed.