Lama v. Borras
16 F.3d 473 (1994)
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Rule of Law:
A jury verdict finding medical malpractice will be upheld on appeal if the plaintiff provides sufficient evidence, including expert testimony, for a reasonable jury to conclude that the medical provider breached the applicable standard of care and that this breach was the most probable cause of the patient's injury.
Facts:
- In 1985, Roberto Romero Lama experienced back pain and was referred to Dr. Pedro Borras, a neurosurgeon.
- Dr. Borras diagnosed Romero with a herniated disc and scheduled surgery without first prescribing or enforcing a regime of conservative treatment, such as absolute bed rest.
- On April 9, 1986, Dr. Borras performed an initial surgery, but Romero's symptoms returned shortly thereafter.
- Dr. Borras performed a second surgery on May 15, 1986, without ordering pre- or post-operative antibiotics.
- Beginning on May 17, 1986, nurses' notes indicated Romero's surgical bandage was "very bloody," a potential sign of infection.
- Asociación Hospital del Maestro (Hospital) utilized a "charting by exception" policy, meaning nurses did not record qualitative observations every shift.
- On the night of May 20, 1986, Romero began to experience severe pain.
- On May 21, 1986, Romero was diagnosed with discitis, a serious infection in the space between his spinal discs, and began receiving antibiotic treatment.
Procedural Posture:
- Roberto Romero Lama and his wife filed a diversity tort action against Dr. Borras and Asociación Hospital del Maestro, Inc. in the U.S. District Court for the District of Puerto Rico.
- At trial, the defendants moved for judgment as a matter of law at the close of the plaintiffs' case and at the close of all evidence, both of which the court denied.
- The jury returned a verdict in favor of the plaintiffs, awarding them $600,000 in compensatory damages.
- After the verdict, the defendants filed post-verdict motions for judgment as a matter of law and for a new trial, arguing the evidence was legally insufficient.
- The district court denied all of the defendants' post-verdict motions.
- Dr. Borras and the Hospital (appellants) appealed the district court's denial of their post-verdict motions to the U.S. Court of Appeals for the First Circuit.
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Issue:
Does sufficient evidence exist in the record to support a jury's finding that a physician's failure to provide conservative treatment before surgery and a hospital's deficient record-keeping policy were the proximate causes of a patient's post-surgical infection and resulting harm?
Opinions:
Majority - Stahl, J.
Yes, sufficient evidence exists to support the jury's findings of negligence against both Dr. Borras and the Hospital. For Dr. Borras, the court found that plaintiffs presented sufficient expert testimony to establish that the standard of care required a neurosurgeon to pursue conservative treatment before recommending surgery for a herniated disc, absent neurological impairment. A reasonable jury could conclude that Dr. Borras breached this standard and that this breach was the proximate cause of the injury, as the unnecessary surgery exposed Romero to the foreseeable risk of infection. For the Hospital, the court found that its "charting by exception" policy violated a state health regulation and that a reasonable jury could infer this substandard record-keeping failed to provide the continuous danger signals that would have spurred earlier intervention, thereby delaying the diagnosis and allowing the wound infection to develop into the more severe discitis.
Analysis:
This decision reaffirms the high degree of deference appellate courts grant to jury verdicts in fact-intensive medical malpractice cases. It underscores that a plaintiff can establish causation even when the chain of events is not direct, such as linking a failure to provide pre-operative conservative care to a post-operative infection. The case also serves as a warning to healthcare institutions that administrative policies, such as "charting by exception," can be a basis for liability if they violate regulations and contribute to patient harm by delaying diagnosis.
