Opinion ID: 1597354
Heading Depth: 1
Heading Rank: 5

Heading: Sufficiency of Evidence on Alleged Breach of Standard of Care

Text: We first note that the Foundation's liability in this case is based on the doctrine of respondeat superior, or vicarious liability. However, the Foundation's liability cannot be founded on the alleged negligence of Dr. Didea, who Reagan claimed was an agent of the Foundation. The jury found that Dr. Didea was not negligent in his treatment of Reagan. Under the doctrine of respondeat superior, the master cannot be liable unless one of the master's servants has been found to be negligent. Otwell v. Bryant, 497 So.2d 111 (Ala.1986). However, we have ruled: Where the liability of the master may be rested on ... the negligence of employees other than the employee who was made a defendant, a verdict against the master, but exonerating the employee who was made a defendant, is not inconsistent. Atlantic Coast Line R.R. v. Kines, 276 Ala. 253, 258, 160 So.2d 869, 873 (1963). Thus, in this case, the Foundation's liability must rest, if at all, on the negligence of an employee who was not named as a defendant. To support her claim of medical malpractice against the Foundation, Reagan offered the expert testimony of Dr. Lloyd Olson, a pediatrician specializing in pediatric infectious diseases, and offered information from several medical treatises. In addition to his testimony relating to Dr. Didea, Dr. Olson offered testimony regarding the actions of Dr. Zeiger, an employee of the Foundation who was not named as a defendant. Dr. Olson was generally not critical of Dr. Zeiger's action's taken until the time of Reagan's spinal tap. His testimony focused on Dr. Zeiger's decision to treat Reagan's meningitis, which, when the decision was made, was still unidentified as to the exact type of infection, with the antibiotic Mefoxin rather than with a combination of ampicillin and chloramphenicol, which was the recognized standard treatment for childhood meningitis. On direct examination, Dr. Olson testified: [DR. OLSON]: Yes. I mean, they they appreciated the fact that her neck was stiff; that this indicated an infection or possibility of an infection of the central nervous system. A shunt infection, again, would certainly be at the top of the list. They took this fluid off for analysis. That proved to be normal. So then they proceeded with the next step, which would be on the list, meningitis; and they did the lumbar puncture and found that she, indeed, had meningitis. [ATTORNEY FOR REAGAN]: All right, doctor. And what treatment was instituted? [DR. OLSON]: Well, an antibiotic was ordered, which is called Mefoxin and although that was not administered until, I think, three o'clock the next morning. [ATTORNEY FOR REAGAN]: All right, sir. Was that appropriate treatment in your opinion? [DR. OLSON]: No, it was not. In a child this age, there are three main different kinds of bacteria which might cause this kind of infection, and there's a standard antibiotic regimen, at least there was at that time, that would be used empirically to cover all those three possibilities and actually most of the others that would occur also, which are two antibiotics called ampicillin and chloramphenicol. That's a regimen that's been in place since probably the late 1960's for this clinical situation.  Mefoxin is an antibiotic which is not indicated for any central nervous system infection and would not have the spectrum nor tissue level required to treat these kinds of infections. .... [ATTORNEY FOR REAGAN]: In your opinion, what antibiotic should have been given? [DR. OLSON]: Well, the standard regimen which in 1982, I think, virtually all pediatric infectious disease [physicians] or all pediatricians would adhere to would have been the combination of ampicillin and chloramphenicol because it directly was effective against those most common bacteria that cause meningitis in children. .... [ATTORNEY FOR REAGAN]: Doctor, based on the facts that you've stated that the doctors at the University Hospital failed to administerI better ask you this.  Was the failure to administer chloramphenicol and ampicillin from 10:30 at night until nine the next morning, was that a deviation from the standard of care ordinarily exercised in the national medical community in 1982, in your opinion? [DR. OLSON]: In my opinion the standard of care was to administer effective antibiotics as soon as possible after the diagnosis was made.  (Emphasis added.) Reagan's counsel also offered medical treatises as evidence of the proper standard of care for the treatment of meningitis. In sum, those treatises tended to show that it is critical to begin treating meningitis with an effective antibiotic as soon as possible and that the family of drugs to which Mefoxin belongs was not effective in the treatment of meningitis. The counterpoint to Dr. Olson's expert testimony and the information from medical treatises admitted into evidence is the testimony of Dr. Zeiger, Reagan's attending neurosurgeon at UAB Hospital, who, upon finding that Reagan had an infection in her spinal fluid, ordered that she be treated with Mefoxin rather than a combination of ampicillin and chloramphenicol. In defense of his choice of the antibiotic Mefoxin, Dr. Zeiger testified as follows: [ATTORNEY FOR FOUNDATION]: Now, what antibiotic did you start with Reagan there after the spinal tap? [DR. ZEIGER]: We had a long discussion about what would be the very best treatment for Reagan. Again, we've got a rare situation. We've got a situation that we've never seen or heard of. We had evidence of infection that was compartmentalized in one area and not present in the brain. And based on experience and what we had been taught in the presence of a shunt ninety-six to ninety-nine percent of infections are due to Staphylococcus. Virtually, all infections in the presence of a shunt are due to Staphylococcus. [ATTORNEY FOR FOUNDATION]: Now, tell us what staphylococcus is. [DR. ZEIGER]: That's a bug that is present on everybody's skin. And in the presence of a shunt, which is a foreign body, without a shunt it's usually not a pathogen, meaning it usually can't cause an infection. But when you have a shunt, which is a foreign body, inside the body invading the body, it lowers the body's resistance to infection, and that's why these children are more prone to infection. In the presence of a shunt, the Staphylococcus which is on the skin can either get through the skin or could have gotten on the shunt when it's put through the skin and can cause infection. And so that's why ninety-six to ninety-nine percent of them are due to Staphylococcus. [ATTORNEY FOR FOUNDATION]: Now, you knew you had already tapped the shunt, and you knew that you didn't have infection there in the fluid in the shunt. [DR. ZEIGER]: Yes, sir. [ATTORNEY FOR FOUNDATION]: Did you still suspect that it might be a staph infection even though you didn't find infection there in the shunt? [DR. ZEIGER]: Yes, sir. [ATTORNEY FOR FOUNDATION]: And why would that be? [DR. ZEIGER]: Well, it could be that the infection had just not gotten that far yet or could have been in another part of the shuntyou see the fluid we got was out of the ventricle, but remember I showed you on the surface of the brain there was some more fluid, and we thought that there could have been Staphylococcus there. So even in that situation the most likely bug was Staphylococcus because there [were] other places that the shunt could have been touching that could be infected. And sometimes the infection is on the outside of the shunt and not the inside. These staphylococcal infections are fairly slow growing things, and it takes them some time to crawl along and get to different areas of the shunt. [ATTORNEY FOR FOUNDATION]: Why did you choose Mefoxin as an antibiotic to use in treating this? [DR. ZEIGER]: Mefoxin is what's called a third generation cephalosporin, meaning it was one ofat that time it was fairly new. It's a very safe drug, very little allergic reaction to it. It also has a broad spectrum of coverage. In other words, it covers a lot of different bacteria. It's very good for Staphylococcus.... It covers Hemophilus influenza and many other gram negative bugs. And the most commoneven though the chance of her having another kind of meningitis like Hemophilus influenza were only one or two percent, it would still cover that. ... It would cover a lot more bugs than ampicillin. Ampicillin does not cover Staphylococcus, which is what this was ninety-six percent of the time. And so it seemed like an excellent choice of drug at the time. (Emphasis added.) Dr. Zeiger further explained his decision to treat Reagan with Mefoxin rather than ampicillin and chloramphenicol: [ATTORNEY FOR FOUNDATION]: Now, Dr. Zeiger, would you agree with Dr. Olson if he testified that Reagan should have been placed on ampicillin and chloramphenicol immediately upon obtaining the shunt tap rather thanI mean, the spinal taprather than Mefoxin? [DR. ZEIGER]: No, sir. That would have been a stupid thing to do. .... [ATTORNEY FOR FOUNDATION]: Okay, are there any risks involvedwell, would it have been good medical practice to administer ampicillin and chloramphenicol to treat a child that comes in with an infection that has a shunt? [DR. ZEIGER]: No, sir. [ATTORNEY FOR FOUNDATION]: And why would that be? [DR. ZEIGER]: Because ninety-six percent of the timewhat we're talking about is the initial treatment. See, the problem is you don't know what's causing the infection when they come in.... And so you have to go with the odds until you get the final results from the test[s] that show what's causing the infection. So it makes sense to use an antibacterial, an antimicrobial, an antibiotic that covers both staph and Hemophilus influenza, not just one that covers Hemophilus influenza. Ampicillin is no good for staph. Staph would grow like crazy and then you've got trouble.  (Emphasis added.) After hearing all of this conflicting testimony, the jury found that the Foundation was liable for negligent treatment of Reagan's meningitis. As noted previously, the only physician on which the Foundation's vicarious liability could be based would be Dr. Zeiger or Dr. Kendrick. Thus, the first issue we must face is whether Dr. Olson's expert testimony and the information from medical treatises also offered by Reagan, taken as a whole, represented a scintilla of evidence that either Dr. Zeiger or Dr. Kendrick was negligent in diagnosing and treating Reagan's Hemophilus influenza meningitis, which would make that issue a proper question for the jury. A scintilla of evidence has been defined by this Court as a mere spark, gleam, glimmer, i.e., the smallest trace, of evidence in support of a plaintiff's claim. Ricwil, Inc. v. S.L. Pappas & Co., 599 So.2d 1126 (Ala.1992); Howard v. Crowder, 496 So.2d 31 (Ala.1986). After thoroughly reviewing the record, we conclude that the evidence presented by Reagan met this test. In sum, the medical treatises and Dr. Olson's testimony presented at least a scintilla of evidence that Dr. Zeiger's treatment of Reagan fell below the applicable standard of care for treating a case of pediatric meningitis, once Dr. Zeiger's treatment continued to be based on the assumption that the meningitis was caused by a shunt-related Staphylococcus infection even though the shunt tap had revealed that the shunt fluid was not infected. Dr. Olson testified that once Dr. Zeiger realized that Reagan was suffering from meningitis even though her shunt fluid was not infected, the medical standard of care required that one treatment regimen be followedadministration of the antibiotics ampicillin and chloramphenicol. Dr. Olson testified that Dr. Zeiger's treatment of Reagan breached this standard of care. Accordingly, the trial court properly denied the Foundation's motion for a JNOV on this issue.