Reyes Vs Sisters of Mercy Hospital
Reyes Vs Sisters of Mercy Hospital
Reyes Vs Sisters of Mercy Hospital
For their part, respondents offered the testimonies of Dr. Peter Gotiong III. THE HONORABLE COURT OF APPEALS GRAVELY ERRED
and Dr. Ibarra Panopio. Dr. Gotiong is a diplomate in internal medicine WHEN IT RULED FOR A LESSER STANDARD OF CARE AND
whose expertise is microbiology and infectious diseases. He is also a DEGREE OF DILIGENCE FOR MEDICAL PRACTICE IN
consultant at the Cebu City Medical Center and an associate professor of ILIGAN CITY WHEN IT APPRECIATE[D] NO DOCTORS
medicine at the South Western University College of Medicine in Cebu NEGLIGENCE IN THE TREATMENT OF JORGE REYES.
City. He had treated over a thousand cases of typhoid patients. According to Petitioners action is for medical malpractice. This is a particular form of
Dr. Gotiong, the patients history and positive Widal Test results ratio of negligence which consists in the failure of a physician or surgeon to apply to
1:320 would make him suspect that the patient had typhoid fever. As to Dr. his practice of medicine that degree of care and skill which is ordinarily
Vacalares observation regarding the absence of ulceration in Jorges gastro- employed by the profession generally, under similar conditions, and in like
intestinal tract, Dr. Gotiong said that such hyperplasia in the intestines of a surrounding circumstances.[12] In order to successfully pursue such a claim, a
typhoid victim may be microscopic. He noted that since the toxic effect of patient must prove that the physician or surgeon either failed to do something
typhoid fever may lead to meningitis, Dr. Vacalares autopsy should have which a reasonably prudent physician or surgeon would have done, or that
included an examination of the brain.[10] he or she did something that a reasonably prudent physician or surgeon
The other doctor presented was Dr. Ibarra Panopio, a member of the would not have done, and that the failure or action caused injury to the
American Board of Pathology, examiner of the Philippine Board of Pathology patient.[13] There are thus four elements involved in medical negligence
from 1978 to 1991, fellow of the Philippine Society of Pathologist, associate cases, namely: duty, breach, injury, and proximate causation.
professor of the Cebu Institute of Medicine, and chief pathologist of the In the present case, there is no doubt that a physician-patient
Andres Soriano Jr. Memorial Hospital in Toledo City. Dr. Panopio stated that relationship existed between respondent doctors and Jorge
although he was partial to the use of the culture test for its greater reliability Reyes. Respondents were thus duty-bound to use at least the same level of
in the diagnosis of typhoid fever, the Widal Test may also be used. Like Dr. care that any reasonably competent doctor would use to treat a condition
Gotiong, he agreed that the 1:320 ratio in Jorges case was already the under the same circumstances. It is breach of this duty which constitutes
maximum by which a conclusion of typhoid fever may be made. No additional actionable malpractice.[14]As to this aspect of medical malpractice, the
information may be deduced from a higher dilution. [11] He said that Dr. determination of the reasonable level of care and the breach thereof, expert
Vacalares autopsy on Jorge was incomplete and thus inconclusive. testimony is essential. Inasmuch as the causes of the injuries involved in
On September 12, 1991, the trial court rendered its decision absolving malpractice actions are determinable only in the light of scientific knowledge,
respondents from the charges of negligence and dismissing petitioners it has been recognized that expert testimony is usually necessary to support
action for damages. The trial court likewise dismissed respondents the conclusion as to causation.[15]
counterclaim, holding that, in seeking damages from respondents, petitioners
were impelled by the honest belief that Jorges death was due to the latters
negligence. Res Ipsa Loquitur
We turn to the question whether petitioners have established specific A I had only seen three cases.
acts of negligence allegedly committed by respondent doctors. Q And that was way back in 1964?
Petitioners contend that: (1) Dr. Marlyn Rico hastily and erroneously A Way back after my training in UP.
relied upon the Widal test, diagnosed Jorges illness as typhoid fever, and
immediately prescribed the administration of the antibiotic Q Clinically?
chloromycetin;[21] and (2) Dr. Marvie Blanes erred in ordering the
administration of the second dose of 500 milligrams of chloromycetin barely A Way back before my training.
three hours after the first was given.[22] Petitioners presented the testimony of He is thus not qualified to prove that Dr. Marlyn Rico erred in her
Dr. Apolinar Vacalares, Chief Pathologist of the Northern Mindanao Training diagnosis. Both lower courts were therefore correct in discarding his
Hospital, Cagayan de Oro City, who performed an autopsy on the body of testimony, which is really inadmissible.
Jorge Reyes. Dr. Vacalares testified that, based on his findings during the
autopsy, Jorge Reyes did not die of typhoid fever but of shock undetermined, In Ramos, the defendants presented the testimony of a pulmonologist to
which could be due to allergic reaction or chloromycetin overdose. We are prove that brain injury was due to oxygen deprivation after the patient had
not persuaded. bronchospasms[24] triggered by her allergic response to a drug,[25] and not
due to faulty intubation by the anesthesiologist. As the issue was whether the
First. While petitioners presented Dr. Apolinar Vacalares as an expert intubation was properly performed by an anesthesiologist, we rejected the
witness, we do not find him to be so as he is not a specialist on infectious opinion of the pulmonologist on the ground that he was not: (1) an
diseases like typhoid fever.Furthermore, although he may have had anesthesiologist who could enlighten the court about anesthesia practice,
extensive experience in performing autopsies, he admitted that he had yet to procedure, and their complications; nor (2) an allergologist who could
do one on the body of a typhoid victim at the time he conducted the properly advance expert opinion on allergic mediated processes; nor (3) a
postmortem on Jorge Reyes. It is also plain from his testimony that he has pharmacologist who could explain the pharmacologic and toxic effects of the
treated only about three cases of typhoid fever. Thus, he testified that: [23] drug allegedly responsible for the bronchospasms.
ATTY. PASCUAL:
Q Why? Have you not testified earlier that you have never seen a patient Second. On the other hand, the two doctors presented by respondents
who died of typhoid fever? clearly were experts on the subject. They vouched for the correctness of Dr.
A In autopsy. But, that was when I was a resident physician yet. Marlyn Ricos diagnosis. Dr. Peter Gotiong, a diplomate whose specialization
is infectious diseases and microbiology and an associate professor at the
Q But you have not performed an autopsy of a patient who died of typhoid Southwestern University College of Medicine and the Gullas College of
fever? Medicine, testified that he has already treated over a thousand cases of
typhoid fever.[26] According to him, when a case of typhoid fever is suspected,
A I have not seen one. the Widal test is normally used,[27]and if the 1:320 results of the Widal test on
Q And you testified that you have never seen a patient who died of Jorge Reyes had been presented to him along with the patients history, his
typhoid fever within five days? impression would also be that the patient was suffering from typhoid
fever.[28] As to the treatment of the disease, he stated that chloromycetin was
A I have not seen one. the drug of choice.[29] He also explained that despite the measures taken by
respondent doctors and the intravenous administration of two doses of
Q How many typhoid fever cases had you seen while you were in the
chloromycetin, complications of the disease could not be discounted. His
general practice of medicine?
testimony is as follows:[30]
A In our case we had no widal test that time so we cannot consider that
ATTY. PASCUAL:
the typhoid fever is like this and like that. And the widal test does not
specify the time of the typhoid fever. Q If with that count with the test of positive for 1 is to 320, what treatment
if any would be given?
A If those are the findings that would be presented to me, the first thing I hyperplasia[31] in the payers patches or layers of the small intestines is
would consider would be typhoid fever. present in typhoid fever, the same may not always be grossly visible and a
microscope was needed to see the texture of the cells.[32]
Q And presently what are the treatments commonly used?
Respondents also presented the testimony of Dr. Ibarra T. Panopio who
A Drug of choice of chloramphenical. is a member of the Philippine and American Board of Pathology, an examiner
Q Doctor, if given the same patient and after you have administered of the Philippine Board of Pathology, and chief pathologist at the MetroCebu
chloramphenical about 3 1/2 hours later, the patient associated with Community Hospital, Perpetual Succor Hospital, and the Andres Soriano Jr.
chills, temperature - 41oC, what could possibly come to your mind? Memorial Medical Center. He stated that, as a clinical pathologist, he
recognized that the Widal test is used for typhoid patients, although he did
A Well, when it is change in the clinical finding, you have to think of not encourage its use because a single test would only give a presumption
complication. necessitating that the test be repeated, becoming more conclusive at the
second and third weeks of the disease.[33] He corroborated Dr. Gotiongs
Q And what will you consider on the complication of typhoid?
testimony that the danger with typhoid fever is really the possible
A One must first understand that typhoid fever is toximia. The problem is complications which could develop like perforation, hemorrhage, as well as
complications are caused by toxins produced by the bacteria . . . liver and cerebral complications.[34] As regards the 1:320 results of the Widal
whether you have suffered complications to think of -- heart toxic test on Jorge Reyes, Dr. Panopio stated that no additional information
myocardities; then you can consider a toxic meningitis and other could be obtained from a higher ratio.[35] He also agreed with Dr. Gotiong that
complications and perforations and bleeding in the ilium. hyperplasia in the payers patches may be microscopic.[36]
Q Even that 40-year old married patient who received medication of Indeed, the standard contemplated is not what is actually the average
chloromycetin of 500 milligrams intravenous, after the skin test, and merit among all known practitioners from the best to the worst and from the
received a second dose of chloromycetin of 500 miligrams, 3 hours most to the least experienced, but the reasonable average merit among the
later, the patient developed chills . . . rise in temperature to 41 oC, ordinarily good physicians.[37] Here, Dr. Marlyn Rico did not depart from the
and then about 40 minutes later the temperature rose to 100oF, reasonable standard recommended by the experts as she in fact observed
cardiac rate of 150 per minute who appeared to be coherent, the due care required under the circumstances. Though the Widal test is not
restless, nauseating, with seizures: what significance could you conclusive, it remains a standard diagnostic test for typhoid fever and, in the
attach to these clinical changes? present case, greater accuracy through repeated testing was rendered
unobtainable by the early death of the patient. The results of the Widal test
A I would then think of toxemia, which was toxic meningitis and probably and the patients history of fever with chills for five days, taken with the fact
a toxic meningitis because of the high cardiac rate. that typhoid fever was then prevalent as indicated by the fact that the clinic
Q Even if the same patient who, after having given intramuscular valium, had been getting about 15 to 20 typhoid cases a month, were sufficient to
became conscious and coherent about 20 minutes later, have give upon any doctor of reasonable skill the impression that Jorge Reyes had
seizure and cyanosis and rolling of eyeballs and vomitting . . . and typhoid fever.
death: what significance would you attach to this development? Dr. Rico was also justified in recommending the administration of the
A We are probably dealing with typhoid to meningitis. drug chloromycetin, the drug of choice for typhoid fever. The burden of
proving that Jorge Reyes was suffering from any other illness rested with the
Q In such case, Doctor, what finding if any could you expect on the post- petitioners. As they failed to present expert opinion on this, preponderant
mortem examination? evidence to support their contention is clearly absent.
A No, the finding would be more on the meninges or covering of the brain. Third. Petitioners contend that respondent Dr. Marvie Blanes, who took
over from Dr. Rico, was negligent in ordering the intravenous administration
Q And in order to see those changes would it require opening the skull? of two doses of 500 milligrams of chloromycetin at an interval of less than
A Yes. three hours. Petitioners claim that Jorge Reyes died of anaphylactic
shock[38] or possibly from overdose as the second dose should have been
As regards Dr. Vacalares finding during the autopsy that the deceaseds administered five to six hours after the first, per instruction of Dr. Marlyn Rico.
gastro-intestinal tract was normal, Dr. Rico explained that, while As held by the Court of Appeals, however:
That chloromycetin was likewise a proper prescription is best established by medical The standard of extraordinary diligence is peculiar to common
authority. Wilson, et. al., in Harrisons Principle of Internal Medicine, 12th ed. write carriers. The Civil Code provides:
that chlorampenicol (which is the generic of chloromycetin) is the drug of choice for
typhoid fever and that no drug has yet proven better in promoting a favorable clinical Art. 1733. Common carriers, from the nature of their business and for reasons of
response. Chlorampenicol (Chloromycetin) is specifically indicated for bacterial public policy, are bound to observe extraordinary diligence in the vigilance over the
meningitis, typhoid fever, rickettsial infections, bacteriodes infections, etc. (PIMS goods and for the safety of the passengers transported by them, according to the
Annual, 1994, p. 211) The dosage likewise including the first administration of five circumstances of each case. . . .
hundred milligrams (500 mg.) at around nine oclock in the evening and the second
dose at around 11:30 the same night was still within medically acceptable limits,
The practice of medicine is a profession engaged in only by qualified
since the recommended dose of chloromycetin is one (1) gram every six (6)
individuals. It is a right earned through years of education, training, and by
hours. (cf. Pediatric Drug Handbook, 1st Ed., Philippine Pediatric Society,
first obtaining a license from the state through professional board
Committee on Therapeutics and Toxicology, 1996). The intravenous route is
examinations. Such license may, at any time and for cause, be revoked by
likewise correct. (Mansser, ONick, Pharmacology and Therapeutics) Even if the test
the government. In addition to state regulation, the conduct of doctors is also
was not administered by the physician-on-duty, the evidence introduced that it was
strictly governed by the Hippocratic Oath, an ancient code of discipline and
Dra. Blanes who interpreted the results remain uncontroverted. (Decision, pp. 16-
ethical rules which doctors have imposed upon themselves in recognition
17) Once more, this Court rejects any claim of professional negligence in this regard.
and acceptance of their great responsibility to society. Given these
safeguards, there is no need to expressly require of doctors the observance
.... of extraordinary diligence. As it is now, the practice of medicine is already
conditioned upon the highest degree of diligence. And, as we have already
As regards anaphylactic shock, the usual way of guarding against it prior to the noted, the standard contemplated for doctors is simply the reasonable
administration of a drug, is the skin test of which, however, it has been observed: average merit among ordinarily good physicians. That is reasonable
Skin testing with haptenic drugs is generally not reliable. Certain drugs cause diligence for doctors or, as the Court of Appeals called it, the reasonable skill
nonspecific histamine release, producing a weal-and-flare reaction in normal and competence . . . that a physician in the same or similar locality . . .
individuals. Immunologic activation of mast cells requires a polyvalent allergen, so a should apply.
negative skin test to a univalent haptenic drug does not rule out anaphylactic
sensitivity to that drug. (Terr, Anaphylaxis and Urticaria in Basic and Clinical WHEREFORE, the instant petition is DENIED and the decision of the
Immunology, p. 349) What all this means legally is that even if the deceased suffered Court of Appeals is AFFIRMED.
from an anaphylactic shock, this, of itself, would not yet establish the negligence of SO ORDERED.
the appellee-physicians for all that the law requires of them is that they perform the
standard tests and perform standard procedures. The law cannot require them to Bellosillo, (Chairman), Quisumbing, Buena, and De Leon, Jr.,
predict every possible reaction to all drugs administered. The onus probandi was on JJ., concur.
the appellants to establish, before the trial court, that the appellee-physicians ignored
standard medical procedure, prescribed and administered medication with
recklessness and exhibited an absence of the competence and skills expected of
general practitioners similarly situated.[39]
Home medication afforded him no relief so he went to Mercy Issue: WON there was medical malpractice. NO
Community Clinic. He was then attended by Dr. Marlyn Rico.
Held:
Since typhoid fever was common at that time, the Widal test was
performed and he was found positive for typhoid. Dr. Apolinar Vacalares is not a specialist of typhoid fever and he is thus
not qualified to prove that Dr. Marlyn Rico erred in her diagnosis.
Thereafter, Dr. Marlyn Rico indorse Jorge Reyes to Dr. Marvie Blanes. While petitioners presented Dr. Apolinar Vacalares as an expert witness, we
do not find him to be so as he is not a specialist on infectious diseases like
Suspecting that that Jorge had typhoid fever, Dr. Marvie Blanes ordered typhoid fever. Furthermore, although he may have had extensive experience
that Jorge be tested for compatibility with chloromycetin, an antibiotic. in performing autopsies, he admitted that he had yet to do one on the body of
Such test was conducted by Nurse Pagente. a typhoid victim at the time he conducted the postmortem on Jorge Reyes. It
is also plain from his testimony that he has treated only about three cases of
As there was no adverse reaction, Dr. Blanes administered 500 mg of typhoid fever.
the antibiotic. Another dose was given 3 hours later.
The two doctors presented by respondents clearly were experts on the
Subsequently, Jorge Reyes developed high fever and experienced subject
vomiting and convulsions. He then turned blue due to deficiency in They vouched for the correctness of Dr. Marlyn Ricos diagnosis. Dr. Peter
oxygen cyanosis and died. The cause of death was stated to be Gotiong, a diplomate whose specialization is infectious diseases and
ventricular arrhythmia secondary to hyperpyrexia and typhoid fever. microbiology and an associate professor at the Southwestern University
College of Medicine and the Gullas College of Medicine, testified that he has
The heirs of Reyes filed with the RTC a complaint for damages against already treated over a thousand cases of typhoid fever.
Sisters of Mercy, Sister Rose Palacio, Dr. Blanes, Dr. Rico and Mercy
Community Clinic contending that the death of Jorge was due to the According to him, when a case of typhoid fever is suspected, the Widal test is
wrongful administration of chloromycetin. (NOTE: Petitioners action is normally used, and if the 1:320 results of the Widal test on Jorge Reyes had
for medical malpractice.) been presented to him along with the patients history, his impression would
also be that the patient was suffering from typhoid fever. As to the treatment
RTC ruled in favor of the respondents. The CA affirmed in toto the RTC of the disease, he stated that chloromycetin was the drug of choice. He also
decision. Hence, this appeal. explained that despite the measures taken by respondent doctors and the
intravenous administration of two doses of chloromycetin, complications of
Petitioners contend that: the disease could not be discounted.
Dr. Marlyn Rico hastily and erroneously relied upon the Widal test,
diagnosed Jorges illness as typhoid fever, and immediately Respondents also presented the testimony of Dr. Ibarra T. Panopio who is a
prescribed the administration of the antibiotic chloromycetin member of the Philippine and American Board of Pathology, an examiner of
Dr. Marvie Blanes erred in ordering the administration of the the Philippine Board of Pathology, and chief pathologist at the MetroCebu
second dose of 500 milligrams of chloromycetin barely 3 hours Community Hospital, Perpetual Succor Hospital, and the Andres Soriano Jr.
after the first was given. Memorial Medical Center.
Testimony presented: That of Dr. Apolinar Vacalares, (Chief Pathologist He stated that, as a clinical pathologist, he recognized that the Widal test is
of the Northern Mindanao Training Hospital) who performed an autopsy used for typhoid patients, although he did not encourage its use because a
on the body Dr. Vacalares testified that Reyes did not die of typhoid single test would only give a presumption necessitating that the test be
repeated, becoming more conclusive at the second and third weeks of the something that a reasonably prudent physician or surgeon would not have
disease. done, and that the failure or action caused injury to the patient.
He corroborated Dr. Gotiongs testimony that the danger with typhoid fever is
really the possible complications which could develop like perforation,
hemorrhage, as well as liver and cerebral complications.
In order to successfully pursue such a claim, a patient must prove that the When the doctrine is appropriate, all that the patient must do is prove a
physician or surgeon either failed to do something which a reasonably nexus between the particular act or omission complained of and the injury
prudent physician or surgeon would have done, or that he or she did
sustained while under the custody and management of the defendant without
need to produce expert medical testimony to establish the standard of care.
Prior to his admission, the patient already had recurring fevers and chills for
five days unrelieved by the analgesic, antipyretic, and antibiotics given him
by his wife. This shows that he had been suffering from a serious illness and
professional medical help came too late for him.
It must be conceded that the doctrine of res ipsa loquitur can have no
application in a suit against a physician or a surgeon which involves the
merits of a diagnosis or of a scientific treatment. The physician or surgeon is
not required at his peril to explain why any particular diagnosis was not
correct, or why any particular scientific treatment did not produce the desired
result.