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March 28, 1966

George A. HONEYWELL, Jr., and Judith Honeywell, natural parents and next of friend of Deborah Honeywell, a minor, and George A. Honeywell, Jr., individually, Plaintiffs,
Dr. George E. ROGERS and Conemaugh Valley Memorial Hospital, Defendants

The opinion of the court was delivered by: WEBER

 This is a diversity negligence malpractice action based on an allegation that minor plaintiff suffered permanent injuries from the result of a hypodermic intramuscular injection administered by a nurse in defendant hospital while minor plaintiff was a patient there under the care of defendant physician. Subsequent to the filing of this action and before it came to trial the Pennsylvania Supreme Court abolished the charitable immunity doctrine which had insulated hospitals from liability on such claims. Flagiello v. Pennsylvania Hospital, 417 Pa. 486, 208 A.2d 193 (1965). The case proceeded to trial against both defendants, and the jury returned a verdict in favor of the plaintiffs against the defendant Conemaugh Valley Memorial Hospital and for the defendant Dr. George E. Rogers. The defendant Conemaugh Valley Memorial Hospital has moved for a new trial.

 The minor plaintiff, Deborah Honeywell, then eleven months old, was admitted to defendant Conemaugh Valley Memorial Hospital in Johnstown, Pennsylvania, as a private patient of defendant, Dr. George E. Rogers, for medical treatment for an acute attack of bronchitis and anemia. She was confined in said hospital from February 7, 1962 to February 17, 1962, and during that period was administered approximately eighteen intramuscular injections of various drugs, including penicillin and Imferon *fn1" alternately in the left and right buttocks. These injections were given by the members of the nursing staff of the hospital in accordance with the hospital procedure and in accordance with medication orders given by defendant Dr. Rogers in writing on the patient's order sheet of the hospital record. There is no dispute in this case that the nurses and student nurses were agents of the hospital. There was also no evidence introduced in this case of any negligence on the part of defendant Dr. George E. Rogers personally; his liability, if any, would have to be based on the doctrine of respondeat superior.

 Around noon of February 17, 1962, Dr. Rogers visited the patient and signed the order for her discharge from the hospital.At that time he signed an order on the order sheet that an injection of 2 cc of Imferon should be administered to the patient at the time of discharge. The mother of the minor plaintiff testified that at the time of making this order the Doctor talked to a registered nurse explaining that the Imferon injection should be given with a "Z-track" technique and in so explaining drew a sketch illustrating this technique on a piece of paper. At the trial such a sketch was shown on the backside of one of the sheets of the hospital record which had been introduced into the evidence. The doctor was not present when this injection was administered, nor was he present at the administration of any of the other injections during plaintiff's stay in the hospital.

 It is the injection of 2 cc of Imferon into the left buttock of plaintiff at about 2 p.m., February 17, 1962, that forms the basis for this action. The mother of the minor plaintiff testified that the injection was given by a student nurse, later identified as Ruby Saylor Poole, who was assisted by an unidentified registered nurse who held the child's legs while the mother held the head and arms of the child. The mother testified that it appeared to her that the injection was given toward the center of the buttock and not where prior injections had been given. The mother also testified that the other nurse made a remark to Nurse Poole to the effect that the injection had not been given in the right place but that she felt that it would be effective anyway. The mother further testified that the child screamed more violently than she had on previous injections, that the site of the injection became red and inflamed, and that when the child was taken home from the hospital she continued to complain, that she favored her left leg and hip and that the leg was cold to the touch and painful to the child when touched.

 The only other witness to this injection who was produced was Ruby Saylor Poole. She had no independent recollection of the event, having had no notice of any subsequent development until almost two years later. Mrs. Poole's testimony as to the incident was entirely based on entries in the hospital records and her memory of hospital training and practice.

 The child developed symptoms involving the sciatic and peroneal nerve and has been examined and treated by a number of doctors. There is no dispute at this time that she suffers a permanent impairment of paralysis of the lower left leg and foot, a condition commonly known as "foot-drop."

 The plaintiff has introduced evidence of the causal connection between the injection in question and the injury suffered by the minor plaintiff through the testimony of Drs. Swain and Silenskey. It, therefore, becomes our problem to determine whether or not the plaintiffs have established that the injection was given in an improper manner or in an improper area or under improper circumstances. This cannot be established from the mere occurrence of the injury and would require the production of expert medical testimony to establish negligence by a procedure which was not in accord with the standards of medical or hospital practice. Demchuk v. Bralow, 404 Pa. 100, 170 A.2d 868, 88 A.L.R.2d 285 (1961); Robinson v. Wirts, 387 Pa. 291, 127 A.2d 706 (1956).

 A great number of witnesses and a large body of medical testimony was produced on this point. The plaintiffs produced testimony both from their own witnesses and by the admissions of parties, or cross-examination of defendants' witnesses that it is improper and contrary to accepted medical practice to make an injection in the sciatic nerve area of the buttock. The sciatic nerve bundle, which at this point contains several subsidiary nerves, is located in the approximate center of the buttock although somewhat upward and outward from the center of the cheek of the buttock. These two areas are not concentric as was shown by an anatomical illustration at the trial. The location of the upper outer quadrant is not capable of exact definition. The exact location of the sciatic nerve in this area varies in individuals. Testimony that it was accepted and recognized by all doctors and nurses that no injection of any kind should be made in the sciatic nerve area and that such injection if done would be in violation of recognized standard medical, nursing and hospital procedures, was elicited from the defendant, Dr. Rogers; from Mrs. Cook, the chief nurse of the pediatric section of defendant hospital, and from Dr. Wiley, the director of defendant hospital's department of physical medicine, in addition to testimony of plaintiffs' witnesses.

 The defendant's expert medical testimony was that the proper area for intramuscular injections was the upper outer quadrant of the buttock. If we were to superimpose the face of a clock upon the face of the left buttock this would be the area between the hands at nine o'clock and twelve o'clock. The upper outer quadrant guide was used for two reasons: to stay away from the sciatic nerve as much as possible and to place the medication into the large muscle at the outer periphery of this quadrant so that it would be absorbed more readily. However, the medical witnesses admit that in using the standard of the upper outer quadrant there should be no injection into the medial portion of this quadrant. It was shown by anatomical charts that the lower corner, or the apex of the lines which form the angle of the quadrant, was the area where the sciatic nerve would be found. The medical witnesses admitted that an injection given in this area could damage the sciatic nerve and that no injection should be given in this medial area according to standard medical practice.

 Plaintiffs' evidence to establish the location of the injection was the eye-witness testimony of Mrs. Honeywell, the mother of the minor plaintiff. Dr. Silenskey testified with reference to an anatomical diagram that the area described by the mother as the location of the injection would be over the sciatic nerve area. In addition to this eye-witness testimony there was circumstantial evidence supporting the contention that the injection was not given in the medically accepted proper area. Other medical witnesses found that brown stains such as are sometimes left by an Imferon shot were present on the child in the sciatic nerve area. While other medical witnesses testified that they found evidence of intramuscular injection punctures in the upper outer quadrant of the minor's buttock away from the sciatic nerve area, they could not establish when these injections had been made. The child had received many such injections.

 There was evidence that the sciatic nerve in this minor plaintiff of eleven months of age would be located approximately one inch below the skin surface in the center of the buttock. While the instructions issued with Imferon by the manufacturer calls for the use of a two inch needle the defendant hospital in its pediatric ward adopted a one and one-half inch needle as a "pediatric adaptation" for this purpose. Medical testimony was produced to the effect that an injection at or pointed toward the center of the buttock with a needle this size would come into the sciatic nerve area. That the injection in question did come into the sciatic nerve area is further supported by the symptoms which the minor plaintiff developed in a short period of time after the injection, the evidence of unusual pain shown by the child, the cold and sensitive condition of the leg, and the child's other reactions in connection with the leg.

 The defendant hospital produced an extensive body of testimony as to the training and supervision of student nurses in its School of Nursing, particularly with reference to the technique of administering intramuscular hypodermic injections. The nurses were trained in anatomy and in the use of anatomical landmarks to determine the site of such injections. They had extensive practice in the use of the hypodermic needle, first on anatomical models or dummies and then on actual patients under direct supervision. There is no question that the student nurse involved in this case had received proper and adequate training in the technique of insertion of the hypodermic needle. It was further shown that they were instructed that the location of intra-muscular injections to be administered in the buttock area was the upper outer quadrant of the buttock. This is in accord with standard medical and nursing practice and technique as substantiated by the testimony of physicians, instructors in nursing and standard text books on the subject. However, it was equally as well established by the plaintiff that it was not proper medical or nursing technique to give such an injection in the buttock in the area of the sciatic nerve.

 Finally the evidence, illustrated by the use of anatomical models and charts, showed that the sole reliance on the criteria of upper outer quadrant did not prevent an injection even in that area from ...

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