RAMOS v CA

[ G.R. No. 124354 April 11, 2002]

 KAPUNAN, J.:
 June 17, 1985 afternoon: Erlinda Ramos, 47-year old robust woman underwent on an operation
to the stone at her gall bladder removed after being tested that she was fit for
"cholecystectomy" operation performed by Dr. Orlino Hozaka.  
 Dr. Hosaka charged a fee of P16,000.00, which was to include the anesthesiologist's fee and
which was to be paid after the operation.  He assured Rogelio E. Ramos, husband that he will get
a good anesthesiologist who was Dra. Perfecta Gutierrez.  
 Erlinda's hand was held by Herminda Cruz, her sister -in-law who was the Dean of the College of
Nursing at the Capitol Medical Center together with her husband went down with her to the
operating room. 
 Instead of 9:30 am, Dr. Hosaka arrived at about 12:15 P.M.
 Herminda noticing what Dra. Perfecta Gutierrez was doing, saw the nailbed of Erlinda becoming
bluish and Dr. Hosaka called for another anesthesiologist  Dr. Calderon.  
 She went out of the operating room to tell Rogelio that something is wrong. 
 When she went back she saw Erlinda in a trendelenburg position and at 3 p.m. she was taken to
the Intensive Care Unit (ICU) where she stayed for a month due to bronchospasm
incurring P93,542.25 and she was since then comatosed. 
o She suffered brain damage as a result of the absence of oxygen in her brain for four to
five minutes. 
o She was also diagnosed to be suffering from "diffuse cerebral parenchymal damage" 
  Monthly expenses ranged from P8,000 to P10,000
 Spouses Ramos and their minors filed against Dr. Hosaka and Dra. Perfecta Gutierrez 

 Since the ill-fated operation, Erlinda remained in comatose condition until she died on August 3,
1999.

 Petitioners filed with the Regional Trial Court of Quezon City a civil case for damages against
private respondents. After due trial, the court a quo rendered judgment in favor of petitioners.
Essentially, the trial court found that private respondents were negligent in the performance of
their duties to Erlinda. On appeal by private respondents, the Court of Appeals reversed the trial
court’s decision and directed petitioners to pay their "unpaid medical bills" to private
respondents.

 Petitioners filed with this Court a petition for review on certiorari. The private respondents were
then required to submit their respective comments thereon. On December 29, 1999, this Court
promulgated the decision which private respondents now seek to be reconsidered. The
dispositive portion of said Decision states:

WHEREFORE, the decision and resolution of the appellate court appealed from are
hereby modified so as to award in favor of petitioners, and solidarily against private
respondents the following: 1) P1,352,000.00 as actual damages computed as of the
date of promulgation of this decision plus a monthly payment of P8,000.00 up to the
time that petitioner Erlinda Ramos expires or miraculously survives; 2) P2,000,000.00
as moral damages, 3) P1,500,000.00 as temperate damages; 4) P100,000.00 each
exemplary damages and attorney’s fees; and 5) the costs of the suit. 2

 In his Motion for Reconsideration, private respondents submit the following as grounds therefor:
DR. HOSAKA: Dr. Hosaka mainly contends that the Court erred in finding him negligent as a surgeon by
applying the Captain-of-the-Ship doctrine.30 Dr. Hosaka argues that the trend in United States
jurisprudence has been to reject said doctrine in light of the developments in medical practice. He points
out that anesthesiology and surgery are two distinct and specialized fields in medicine and as a surgeon,
he is not deemed to have control over the acts of Dr. Gutierrez.

DR. GUTIERREZ: maintains that the Court erred in finding her negligent and in holding that it was the
faulty intubation which was the proximate cause of Erlinda’s comatose condition.

DELOS SANTOS MEDICAL CENTER: contends that applying the four-fold test in determining whether
such a relationship exists between it and the respondent doctors, the inescapable conclusion is that
DLSMC cannot be considered an employer of the respondent doctors.

ISSUES:
1. Whether or not Dr. Orlino hosaka (surgeon) is liable for negligence;
2. Whether or not Dr. Perfecta gutierrez (anesthesiologist) is liable for negligence; and
3. Whether or not the hospital (Delos Santos Medical Center) is liable for any act of negligence committed
by their visiting consultant surgeon and anesthesiologist.

SC:
1. That there is a trend in American jurisprudence to do away with the Captain-of-the-Ship doctrine does
not mean that this Court will ipso facto follow said trend. Due regard for the peculiar factual
circumstances obtaining in this case justify the application of the Captain-of-the-Ship doctrine. From the
facts on record it can be logically inferred that Dr. Hosaka exercised a certain degree of, at the very least,
supervision over the procedure then being performed on Erlinda.

First, it was Dr. Hosaka who recommended to petitioners the services of Dr. Gutierrez. In effect, he
represented to petitioners that Dr. Gutierrez possessed the necessary competence and skills. Drs. Hosaka
and Gutierrez had worked together since 1977. Whenever Dr. Hosaka performed a surgery, he would
always engage the services of Dr. Gutierrez to administer the anesthesia on his patient. 36
Second, Dr. Hosaka himself admitted that he was the attending physician of Erlinda. Thus, when Erlinda
showed signs of cyanosis, it was Dr. Hosaka who gave instructions to call for another anesthesiologist
and cardiologist to help resuscitate Erlinda.37

Third, it is conceded that in performing their responsibilities to the patient, Drs. Hosaka and Gutierrez
worked as a team. Their work cannot be placed in separate watertight compartments because their
duties intersect with each other.38

While the professional services of Dr. Hosaka and Dr. Gutierrez were secured primarily for their
performance of acts within their respective fields of expertise for the treatment of petitioner Erlinda, and
that one does not exercise control over the other, they were certainly not completely independent of
each other so as to absolve one from the negligent acts of the other physician.

That they were working as a medical team is evident from the fact that Dr. Hosaka was keeping an eye
on the intubation of the patient by Dr. Gutierrez, and while doing so, he observed that the patient’s nails
had become dusky and had to call Dr. Gutierrez’s attention thereto. The Court also notes that the counsel
for Dr. Hosaka admitted that in practice, the anesthesiologist would also have to observe the surgeon’s
acts during the surgical process and calls the attention of the surgeon whenever necessary 39 in the course
of the treatment. The duties of Dr. Hosaka and those of Dr. Gutierrez in the treatment of petitioner
Erlinda are therefore not as clear-cut as respondents claim them to be. On the contrary, it is quite
apparent that they have a common responsibility to treat the patient, which responsibility necessitates
that they call each other’s attention to the condition of the patient while the other physician is performing
the necessary medical procedures.

It is equally important to point out that Dr. Hosaka was remiss in his duty of attending to petitioner
Erlinda promptly, for he arrived more than three (3) hours late for the scheduled operation.
The cholecystectomy was set for June 17, 1985 at 9:00 a.m., but he arrived at DLSMC only at around
12:10 p.m. In reckless disregard for his patient’s well being, Dr. Hosaka scheduled two procedures on the
same day, just thirty minutes apart from each other, at different hospitals. Thus, when the first
procedure (protoscopy) at the Sta. Teresita Hospital did not proceed on time, Erlinda was kept in a state
of uncertainty at the DLSMC.

The unreasonable delay in petitioner Erlinda’s scheduled operation subjected her to continued starvation
and consequently, to the risk of acidosis, or the condition of decreased alkalinity of the blood and tissues,
marked by sickly sweet breath, headache, nausea and vomiting, and visual disturbances.  The long period
that Dr. Hosaka made Erlinda wait for him certainly aggravated the anxiety that she must have been
feeling at the time. It could be safely said that her anxiety adversely affected the administration of
anesthesia on her. As explained by Dr. Camagay, the patient’s anxiety usually causes the outpouring of
adrenaline which in turn results in high blood pressure or disturbances in the heart rhythm:

2. The cyanosis (bluish discoloration of the skin or mucous membranes caused by lack of oxygen or
abnormal hemoglobin in the blood) and enlargement of the stomach of Erlinda indicate that the
endotracheal tube was improperly inserted into the esophagus instead of the trachea. Consequently,
oxygen was delivered not to the lungs but to the gastrointestinal tract. This conclusion is supported by
the fact that Erlinda was placed in trendelenburg position. This indicates that there was a decrease of
blood supply to the patient’s brain. The brain was thus temporarily deprived of oxygen supply causing
Erlinda to go into coma.

The injury incurred by petitioner Erlinda does not normally happen absent any negligence in the
administration of anesthesia and in the use of an endotracheal tube. As was noted in our Decision, the
instruments used in the administration of anesthesia, including the endotracheal tube, were all under the
exclusive control of private respondents Dr. Gutierrez and Dr. Hosaka. 27 In Voss vs. Bridwell,28 which
involved a patient who suffered brain damage due to the wrongful administration of anesthesia, and even
before the scheduled mastoid operation could be performed, the Kansas Supreme Court applied the
doctrine of res ipsa loquitur, reasoning that the injury to the patient therein was one which does not
ordinarily take place in the absence of negligence in the administration of an anesthetic, and in the use
and employment of an endotracheal tube. The court went on to say that "[o]rdinarily a person being put
under anesthesia is not rendered decerebrate as a consequence of administering such anesthesia in the
absence of negligence. Upon these facts and under these circumstances, a layman would be able to say,
as a matter of common knowledge and observation, that the consequences of professional treatment
were not as such as would ordinarily have followed if due care had been exercised." 29 Considering the
application of the doctrine of res ipsa loquitur, the testimony of Cruz was properly given credence in the
case at bar.

3. The Court finds that respondent hospital’s position on this issue is meritorious. There is no
employer-employee relationship between DLSMC and Drs. Gutierrez and Hosaka which would hold
DLSMC solidarily liable for the injury suffered by petitioner Erlinda under Article 2180 of the Civil Code.
As explained by respondent hospital, that the admission of a physician to membership in DLSMC’s
medical staff as active or visiting consultant is first decided upon by the Credentials Committee thereof,
which is composed of the heads of the various specialty departments such as the Department of
Obstetrics and Gynecology, Pediatrics, Surgery with the department head of the particular specialty
applied for as chairman. The Credentials Committee then recommends to DLSMC's Medical Director or
Hospital Administrator the acceptance or rejection of the applicant physician, and said director or
administrator validates the committee's recommendation. 52 Similarly, in cases where a disciplinary action
is lodged against a consultant, the same is initiated by the department to whom the consultant concerned
belongs and filed with the Ethics Committee consisting of the department specialty heads. The medical
director/hospital administrator merely acts as ex-officio member of said committee.

Neither is there any showing that it is DLSMC which pays any of its consultants for medical
services rendered by the latter to their respective patients.

Moreover, the contract between the consultant in respondent hospital and his patient is separate and
distinct from the contract between respondent hospital and said patient. The first has for its object the
rendition of medical services by the consultant to the patient, while the second concerns the provision by
the hospital of facilities and services by its staff such as nurses and laboratory personnel necessary for
the proper treatment of the patient.

Further, no evidence was adduced to show that the injury suffered by petitioner Erlinda was
due to a failure on the part of respondent DLSMC to provide for hospital facilities and staff
necessary for her treatment.
For these reasons, we reverse the finding of liability on the part of DLSMC for the injury suffered by
petitioner Erlinda.