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APPEAL FROM CIVIL DISTRICT COURT, ORLEANS PARISH. NO. 2008-11359, DIVISION " I-14" . Honorable Piper D. Griffin, Judge.
James D. " Buddy" Caldwell, Attorney General, Luke M. Lancaster, Assistant Attorney General, Louisiana Department of Justice, New Orleans, LA, COUNSEL FOR DEFENDANT/APPELLANT/STATE OF LOUISIANA, ET AL.
Henry Gaffney, Covington, LA, APPELLEE/IN PROPER PERSON.
(Court composed of Judge Terri F. Love, Judge Paul A. Bonin, Judge Daniel L. Dysart). BONIN, J., CONCURS AND JOINS THE REASONS ASSIGNED BY DYSART, J. DYSART, J., CONCURS WITH REASONS.
Terri F. Love, J.
[2014-0384 La.App. 4 Cir. 1] This is a medical malpractice case brought by Henry Gaffney (" Mr. Gaffney" ), against Dr. Thomas Giles (" Dr. Giles" ) and LSU Healthcare Network (" LSU" ). The State of Louisiana on behalf of Dr. Giles and LSU seeks reversal of the trial court's ruling finding Dr. Giles breached the standard of care when he failed to return Mr. Gaffney's phone calls. The State claims that there is insufficient evidence to prove causation and damages, and even if Dr. Giles breached the standard of care, as a state-employed physician, Dr. Giles should not be held liable under Detillier v. Kenner Regional Medical Center. Additionally, Mr. Gaffney seeks review of the trial court's finding that Dr. Giles did not breach the standard of care for managing his Coumadin therapy as well as an increase of the damages award.
We find no error in the trial court's judgment relative to the monitoring of Mr. Gaffney's Coumadin treatment or the unreturned phone calls and awarded damages. Sufficient medical expert testimony was introduced at trial upon which the trial court reasonably relied to find that the proper standard of care for [2014-0384 La.App. 4 Cir. 2] managing a patient on Coumadin in 2001 was based on a physician's medical training and experience. In that Dr. Giles relied on his medical training and over thirty years of experience when ordering Mr. Gaffney's next blood test, the trial court did not err in finding that Dr. Giles did not breach the standard of care relative to Mr. Gaffney's Coumadin treatment. Moreover, the trial court reasonably concluded that although Dr. Giles' failure to return Mr. Gaffney's calls were not the cause of Mr. Gaffney's alleged residual damages, the unreturned calls did in fact lead to the progressive deterioration of Mr. Gaffney's condition. Consequently, we find no manifest error in the trial court's finding that Dr. Giles' breach of the standard of care in this instance was the cause-in-fact of Mr. Gaffney's advanced deteriorating condition. Likewise, we find the trial court did not abuse its discretion in the amount awarded in Mr. Gaffney's favor.
Pursuant to Detillier, however, the trial court's judgment as to the unreturned phone calls in favor of Mr. Gaffney must be entered against the State alone. Therefore, we amend the trial court's judgment to remove Dr. Giles' name and as amended, we affirm.
PROCEDURAL HISTORY AND FACTUAL BACKGROUND
Mr. Gaffney was diagnosed with a sinus of valsalva aneurysm of the aortic valve in 1998. He began treatment in July 2000 with Dr. Giles, a board-certified cardiologist, who ordered an echocardiogram every six months to monitor Mr. Gaffney's aneurysm. Mr. Gaffney testified that when he began treating with Dr. [2014-0384 La.App. 4 Cir. 3] Giles, he
lived an active lifestyle, riding a bike, swimming, and exercising three times a week.
In the fall of 2000, diagnostic tests showed significant progression of Mr. Gaffney's aneurysm, requiring surgery. Mr. Gaffney expressed a desire to have his surgery performed at the University of Alabama at Birmingham School of Medicine (" UAB" ), and Dr. Giles recommended Dr. Albert D. Pacifico (" Dr. Pacifico" ). Mr. Gaffney testified that he waited for Dr. Giles to refer him to Dr. Pacifico for surgery, but in March 2001, Mr. Gaffney sent a letter with his medical records requesting Dr. Pacifico to perform his operation. In response, Dr. Pacifico agreed that Mr. Gaffney needed surgery to replace the aortic valve and asked Mr. Gaffney to arrange for a pre-operative exam. Mr. Gaffney testified that he reported to UAB on July 9, 2001, for his pre-surgical testing and underwent surgery the next day.
Dr. Pacifico performed a successful cardiac surgery removing Mr. Gaffney's aortic valve and root aneurysm and replacing it with a prosthetic valve. Dr. Pacifico explained to Mr. Gaffney that because of the prosthetic valve, he would require blood thinning medication, specifically Coumadin, for the remainder of his life to prevent blood clots that could cause a stroke. On July 14, 2001, Mr. Gaffney was discharged from UAB. Dr. Pacifico ordered Mr. Gaffney to follow [2014-0384 La.App. 4 Cir. 4] up with his cardiologist Dr. Giles, who would manage his cardiac condition and Coumadin anti-coagulation therapy.
Dr. Pacifico placed Mr. Gaffney on five milligrams of Coumadin daily, as well as Dicloxacillin, Lopressor, Digoxin, and Tylox. In his letter to Dr. Giles, Dr. Pacifico provided the list of medications Mr. Gaffney was taking, including Coumadin. The letter did not indicate a dosage level with respect to Mr. Gaffney's Coumadin therapy; however, Dr. Pacifico stated that Mr. Gaffney should be kept within an INR range of 3.0 and 3.5.
On July 16, 2001, Mr. Gaffney had his blood tested and results showed an INR of 3.7. At Mr. Gaffney's first post-operative visit on July 18, 2001, Dr. Giles received the letter from Dr. Pacifico along with Mr. Gaffney's July 16, 2001 INR results of 3.7.
Mr. Gaffney testified that during his follow-up visit, Dr. Giles explained to him that his INR level was " a little high." Similarly, Dr. Giles acknowledged at trial that Mr. Gaffney's INR reading was " outside the range" Dr. Pacifico documented in his letter. However, Dr. Giles did not change Mr. Gaffney's dosage, preferring to order his next PT/INR test for three weeks later. On cross-examination Dr. Giles was asked whether he knew at the time he saw Mr. Gaffney " what dosage of Coumadin [Dr.] Pacifico or UAB put Mr. Gaffney on," and Dr. Giles responded, " [n]o." Counsel for Mr. Gaffney also asked whether Dr. Giles knew " what [Mr. Gaffney's] prior INR or PT result might have been in Alabama." [2014-0384 La.App. 4 Cir. 5] Dr. Giles conceded that " [he] did not know the number." He also testified that he " never called UAB, nurse's staff, [Dr.] Pacifico or anyone to find out...what the dosage was, when [the] dosage was administered [or] what INR results might have existed." Dr. Giles testified that he " assumed [UAB]
followed the usual routine...[and] discharged him on a dose that is a common dose." He further stated that he relied on his " clinical judgment" to determine how long Mr. Gaffney was taking Coumadin and how much he was taking prior to his July 18, 2001 visit. Dr. Giles testified that based on his experience " when he saw Mr. Gaffney he had been on [five] milligrams of Coumadin for enough time, if he had exhibited an unusual sensitivity [he] would have seen it...and in [his] clinical judgment in [three] weeks, [he] would look at another INR and see if he stabilize[d]."
Following his first post-operative visit with Dr. Giles, Mr. Gaffney testified that he began experiencing problems. In the late afternoon on August 3, 2001, Mr. Gaffney was driving when he temporarily lost vision in one eye. He testified that he pulled over and waited ten to fifteen minutes when his vision restored, and he continued home. Arriving at home in his driveway, he lost vision in his other eye and again waited a few minutes until his vision returned.
Mr. Gaffney went inside and immediately called Dr. Giles' office. He testified at trial that he spoke with someone in the office who informed him that Dr. Giles had just left. Mr. Gaffney testified that he described his symptoms and [2014-0384 La.App. 4 Cir. 6] asked that Dr. Giles call him back. The person receiving the call then informed Mr. Gaffney that she would page Dr. Giles, and he would return Mr. Gaffney's call. Mr. Gaffney testified that he never received a call back from Dr. Giles or anyone at LSU. Concerned, Mr. Gaffney testified that around nine or ten o'clock that night he called Dr. Pacifico at UAB and left a message describing his symptoms. He did not hear from Dr. Giles/LSU or Dr. Pacifico/UAB that night.
The next morning, Mr. Gaffney left his house early, and around mid-day he stopped to use the restroom. He testified that he observed blood in his urine and immediately returned home. Once home, he learned Dr. Pacifico returned his call from the night before and left a message advising Mr. Gaffney to follow up with Dr. Giles. Mr. Gaffney called Dr. Giles again, but after not hearing from him, Mr. Gaffney called Dr. Pacifico/UAB. Mr. Gaffney explained that he noticed blood in his urine, and Dr. Pacifico/UAB then instructed Mr. Gaffney to have his INR tested. However, because it was a Saturday the clinic was closed. Mr. Gaffney called UAB back to report that the clinic was closed for the day. Dr. Pacifico/UAB advised Mr. Gaffney to hold his doses of Coumadin until he was able to have an INR test performed and to follow-up with his cardiologist " first thing Monday." Later that evening, Mr. Gaffney had a bowel movement and noticed blood in his stool. Mr. Gaffney called Dr. Pacifico/UAB and left a message. Dr. Pacifico/UAB promptly returned Mr. Gaffney's call and instructed him to go to the emergency room.
[2014-0384 La.App. 4 Cir. 7] There is competing evidence regarding when Mr. Gaffney arrived at the East Jefferson General Hospital (" EJGH" ) emergency room. Mr. Gaffney's emergency room medical records were not prepared until 10:40 p.m. Mr. Gaffney and Sean Gaffney, on the other hand, testified that they were fearful his " surgery was coming apart." For that reason, Mr. Gaffney reported to the emergency room shortly after he spoke with Dr. Pacifico/UAB that evening around 7:00 p.m. It
is undisputed that upon arrival Mr. Gaffney complained of " temporary episodes of foggy vision, blood in his urine, and blood in his stool." He also reported that he was on a daily Coumadin regimen, so a PT/INR test was conducted. The test indicated Mr. Gaffney's PT was over 130 and his INR level was 11.8. Expert witnesses on both sides stated an INR level of 11.8 was well outside the recommended levels. Mr. Gaffney was informed by hospital staff that he overdosed on Coumadin. The hospital immediately halted Mr. Gaffney's Coumadin and gave him two units of fresh frozen plasma. He was then admitted for further monitoring.
Dr. David Learned (" Dr. Learned" ), the cardiologist that monitored Mr. Gaffney's Coumadin management while in the hospital, testified that the two units of frozen plasma had the initial desired affects. By the next day, Mr. Gaffney's INR was at 5.3. During Mr. Gaffney's hospitalization, Dr. Learned ordered consults from cardiology for his Coumadin management, ophthalmology for his visual disturbances, urology for the blood in his urine, and neurosurgery for a subarachnoid bleed in his skull. The subsequent ophthalmologic work up included [2014-0384 La.App. 4 Cir. 8] a CT scan of Mr. Gaffney's head revealing a brain bleed. Mr. Gaffney remained hospitalized at EJGH through August 13, 2001.
The medical witnesses at trial, Dr. Robert Stark (" Dr. Stark" ), Dr. David Learned (" Dr. Learned" ), Dr. Giles, and defense expert Dr. Kenneth Kerut (" Dr. Kerut" ), all testified that Coumadin is a patient specific drug. Each acknowledged that patient dosages must be individualized based on each patient's response to a given dosage. Mr. Gaffney's expert Dr. Stark testified that the Physician's Desk Reference (PDR) provides the established standard of care for physicians prescribing and managing Coumadin. He stated that serial PT/INR testing is required and that a single INR test will not adequately indicate whether a patient's response to a particular dosage has stabilized. Dr. Stark testified that the standard of care requires repeat PT/INR testing every two to three days until the serial tests demonstrate a stable ...