RAYMOND SEELS, ADMINISTRATOR OF THE ESTATE OF TERRI SEELS-DAVILA, DECEASED, AND RAYMOND SEELS, IN HIS OWN RIGHT, Appellant
TENET HEALTH SYSTEM HAHNEMANN, LLC, D/B/A HAHNEMANN UNIVERSITY HOSPITAL AND PHILADELPHIA HEALTH & EDUCATION CORPORATION AND DREXEL UNIVERSITY COLLEGE OF MEDICINE, Appellees
from the Judgment Entered July 22, 2015 In the Court of
Common Pleas of Philadelphia County Civil Division at No(s):
00560 September Term, 2012
BEFORE: PANELLA, SHOGAN, and SOLANO, JJ.
Raymond Seels, administrator of the estate of Terri
Seels-Davila ("Seels-Davila"), deceased, and
Raymond Seels,  in his own right, appeal from the judgment
entered on July 22, 2015, in favor of Tenet Health System
Hahnemann, LLC, d/b/a Hahnemann University Hospital and
Philadelphia Health & Education Corporation and Drexel
University College of Medicine (collectively
"Appellees") in this medical malpractice action. We
trial court provided a thorough recitation of the relevant
facts of this case, which is set forth below:
In early 2010, 38-year-old Terri Seels-Davila
("Seels-Davila") and her husband Levi Davila were
working in Managua, Nicaragua as Jehovah's Witnesses
missionaries. During this time, Seels-Davila became pregnant
and received prenatal care in Nicaragua for the first seven
months of her pregnancy. N.T. 4/24/15 at 11. In
early September 2010 she returned to her hometown of
Philadelphia to ensure that "she was seen by the best
health care in a first world country." Id. at
11, 16, 39-40, 61-63; N.T. 4/21/15 at 33. Adherents
of the Jehovah's Witness faith refuse to accept blood
transfusions and so, with the help of Appellant, who was her
father and a retired licensed nurse and also a devout
Jehovah's Witness, Seels-Davila chose Hahnemann
University Hospital as the hospital where she would deliver
her baby. N.T. 4/24/15 at 12-16.
Hahnemann was one of the few regional medical facilities that
engage in outreach to "Bloodless Medicine"
patients, the term used for patients who, for various
reasons, refuse blood transfusions. In order to assist these
patients, Hahnemann had a "Bloodless Medicine
Program" with three clerical staff who were
Jehovah's Witnesses. See N.T. 4/23/15 at 154.
These clerks were responsible for explaining the risks
inherent in not receiving blood transfusions and alternative
treatment methods if transfusions are refused, ensuring the
bloodless patients' wishes were memorialized on blood
transfusion refusal consent forms, and that this information
was transmitted to and prominently displayed on the
patient's medical chart and hospital wristbands upon
On November 19, 2010, Seels-Davila and her father met with
Iris Jiminez, one of the clerks at Hahnemann's Center for
Bloodless Medicine. N.T. 4/24/15 at 12-13, 41. After
talking with Ms. Jiminez, Seels-Davila signed a form entitled
"Hahnemann University Hospital Center for Bloodless
Medicine and Surgery Medical Directive/Release" where
she indicated the following:
I, Terri Elaine Seels-Davila ... request that no blood (whole
blood, red cells, white cells, platelets and plasma) be
administered to me during this hospitalization. I will accept
the use of nonblood [sic] volume expanders (such as dextran,
saline, or Ringer's solution or hetastarch) and other
Appellant's Motion in Limine to Preclude Appellees
from Offering Testimony and/or Evidence of Informed Consent
and/or Any Medical Release, Ex. A at 1 ("Consent
MIL"). In addition to these restrictions, Seels-Davila
further stated that she did not consent to the use of
hemodilution (i.e. blood storage, even of her own blood).
Id. This administrative process took approximately
fifteen minutes and did not involve any of Hahnemann's
doctors, nurses, or other employees besides Ms. Jiminez.
N.T. 4/24/15 at 13-14.
On Wednesday November 24, 2010, Seels-Davila went into labor
and was admitted to Hahnemann at approximately 4:30 PM.
Id. at 16, 44. She arrived with her cervix dilated
to "approximately four centimeters, " but quickly
began to experience difficulties with her labor. N.T.
4/23/15 at 13. Dr. Minda Green, who was the attending
obstetrician/gynecologist at the time of Seels-Davila's
admission, insisted that Seels-Davila talk with the
Center's staff to again review her treatment choices.
N.T. 4/21/15 at 65-66, 69-72. After a conversation
with these advocates and Dr. Brandi Musselman, another
Hahnemann obstetrician, Seels-Davila signed a form at 6:25 PM
entitled "Consent for Refusal for Transfusion of Blood
and/or Human Source Products, " ("Consent for
Refusal") in which she again expressly indicated that
she refused to accept blood transfusions as part of her
treatment at Hahnemann, stating that:
I [Seels-Davila] understand from Dr. Musselman that it may be
advisable for me to receive a transfusion of blood, blood
components or other human source products. I understand the
circumstances that might make a transfusion necessary and the
benefits of such a transfusion to my health. I have been
given the attached information sheet, which describes the
risks, benefits, and alternatives to the transfusion of blood
and/or human source products ... I refuse all blood
components and human source products.
Consent MIL, Ex. D at 1; N.T. 4/21/15 at
69-70; N.T. 4/24/15 at 44; see N.T. 4/27/15
at 93-97 (Dr. Musselman testifying regarding her pre-cesarean
section discussions with Seels-Davila, as well as
Seels-Davila signing the Consent for Refusal). Seels-Davila
also indicated on this form that she consented to the use of
a cell saver machine, if necessary, for intra-operative blood
salvage and, below the signature line,
handwrote "I am one of Jehovah's
Witnesses. No blood."
Consent MIL, Ex.Eat 1. According to Dr. Musselman,
Seels-Davila specifically told her that she "would
rather die than receive blood products." N.T.
4/27/15 at 97. At 6:31 PM, Seels-Davila also signed a form
entitled "Consent for Delivery, " checking off
boxes indicating that she consented to giving birth via
"vaginal delivery" or "cesarean section."
Consent MIL, Ex. C at 1.
After over 12 hours of labor, Seels-Davila developed a fever
and her unborn child's heart rate spiked. N.T.
4/21/15 at 83-84; N.T. 4/23/15 at 13-14.
Accordingly, Dr. Green decided to perform a cesarean section
at approximately 7:00 AM on Thursday, November 25, 2010.
N.T. 4/21/15 at 84-85; N.T. 4/23/15 at 13-14.
Seels-Davila's child was successfully delivered at 7:16
AM, and her uterus was then exteriorized. N.T. 4/21/15 at
103. Dr. Green and Dr. Asata Mehta, a third-year resident,
"tagged" the corners of Seels-Davila's uterine
incision, cleaned the sides of her abdomen and pelvis with
sponges to remove excess blood, and inspected the incision
multiple times to ensure that it was not bleeding.
Id. at 104-106. Drs. Green and Mehta then cut these
"tags, " and proceeded to suture close each of the
abdominal wall layers that had been cut during the cesarean
section, checking for bleeding throughout the whole process.
Id. at 105-106.
Following surgery, Seels-Davila was transferred to the
Post-Anesthesia Care Unit ("PACU") at approximately
8:20 AM. N.T. 4/23/15 at 16. Her vital signs were
checked, including her blood pressure which was recorded as
100/48. Id. At 8:30 AM, Seels-Davila's blood
pressure was taken again, this time registering as 97/50.
Id.; N.T. 4/21/15 at 136. Additional
readings were taken at 8:40 AM and 8:45 AM, at which points
Seels-Davila's blood pressure was respectively 102/55 and
108/53. N.T. 4/21/15 at 136. At 9:00 AM, her blood
pressure was measured as being 89/62. N.T. 4/21/15
at 136-37; N.T. 4/23/15 at 16-18. At 9:15 AM,
Seels-Davila's blood pressure fell significantly to
67/32, at which point the anesthesia unit was notified.
N.T. 4/23/15 at 18-19. At 9:20 AM, PACU staffers and
Dr. Saninuj Malayaman, an anesthesiologist, arrived at her
bedside. N.T. 4/22/15 at 6; N.T. 4/23/15 at
At 9:30 AM, Dr. Yusef Morant-Wade, a third-year resident,
called Dr. Kelli Daniels, who had taken over for Dr. Green as
attending obstetrician at around 8:30 AM that morning.
N.T. 4/21/15 at 129-131; N.T. 4/23/15 at 95. Dr.
Morant-Wade advised Dr. Daniels that Seels-Davila's blood
pressure had precipitously dropped, but that she was not
exhibiting any other telltale signs of internal bleeding such
as shortness of breath, palpitations, pain, or a distended
stomach. N.T. 4/22/15 at 18, 21; N.T.
4/23/15 at 31-32. Dr. Daniels responded by ordering a
complete blood count ("CBC") test, in order to see
if Seels-Davila's hemoglobin levels were dropping, and to
determine whether she was anemic or had low levels of
oxygen-carrying red blood cells. N.T. 4/21/15 at
131, 158-59. Based on the information provided by Dr.
Morant-Wade, Dr. Daniels surmised that the likely cause of
Seels-Davila's abnormally low blood pressure was either
blood loss during the C-section, the anesthesia given during
her cesarean section, or by Pitocin, a medication that was
given to Seels-Davila to help her uterus contract after her
cesarean section. N.T. 4/21/15 at 138; N.T. 4/22/15
at 12, 22. At 9:35 AM, Dr. Malayaman administered 10
milligrams of Ephedrine to Seels-Davila, and confirmed that
Seels-Davila was a Jehovah's Witness who would not
consent to the use of blood products as part of her
treatment. N.T. 4/23/15 at 29. Within minutes, the
Ephedrine boosted Seels-Davila's blood pressure, which
registered 91/48 at 9:40 AM. Id. Despite this
improvement, PACU staffers began to suspect that Seels-Davila
was suffering from internal bleeding, documenting their
collective concerns at 9:42 AM through a note on her medical
records. N.T. 4/23/15 at 35. At 10:00 AM,
Seels-Davila's blood pressure had fallen to a
"dangerously low" level of 64/39, with a subsequent
reading five minutes later that showed her blood pressure as
67/25. N.T. 4/23/15 at 31, 32. At 10:05 AM, a nurse
attempted to draw blood from Seels-Davila for use in the CBC
test, but was unable to do so and had to call for assistance.
Id. at 96-97; see Appellant's Trial Exhibit
P-7 at 5 ("1005 Unable to obtain blood for CBC-CL
Robbin RN called for assist."). Seels-Davila was still
alert and oriented at 10:10 AM, and asked for ice chips, but
shortly thereafter she began to slur her speech. N.T.
4/23/15 at 33; Appellant's Trial Exhibit
P-7 at 5. At 10:15 AM, a nurse successfully took
Seels-Davila's blood for the CBC test. N.T.
4/23/15 at 96; see Appellant's Exhibit P-7
at 5 ("1015 ... CL Robbins drawing CBC.").
Dr. Daniels was then called to Seels-Davila's bedside
and, along with PACU staffers, began to administer large
volumes of intravenous fluids to Seels-Davila. N.T.
4/23/15 at 34-35; Appellant's Trial Exhibit
P-7 at 5. This seemed to improve Seels-Davila's
condition, as her speech pattern returned to normal, and her
blood-oxygen saturation levels reached 100%. N.T.
4/23/15 at 35. Dr. Daniels performed a "head to
toe" bedside examination of Seels-Davila, determining
that there were still no obvious signs of internal bleeding.
N.T. 4/22/15 at 22-24. By 10:46 AM, Dr. Daniels was
joined at Seels-Davila's bedside by Dr. Asemato (the
chief resident) and Dr. Malayaman, to observe and monitor
their patient. N.T. 4/23/15 at 36. At 10:59 AM, the
results of the CBC test came back and showed that
Seels-Davila's condition was deteriorating, as her
hemoglobin count had dropped precipitously from 14.1 at
admission, to 7.8 at the time that the test had been
administered. N.T. 4/21/15 at 146-47; N.T.
4/23/15 at 36. In addition, during this time frame (i.e.
between 10:00 AM and 11:00 AM), Dr. Daniels performed a
bedside sonogram that revealed the presence of extraneous
fluid in Seels-Davila's abdomen, which Dr. Daniels
suspected was blood. N.T. 4/21/15 at 140; N.T.
4/22/15 at 23; N.T. 4/23/15 at 37. Accordingly,
Dr. Daniels made the decision to bring Seels-Davila back to
the operating room for an exploratory laparotomy, in order to
determine the exact cause of Seels-Davila's distress.
N.T. 4/23/15 at 38.
Dr. Daniels reviewed Seels-Davila's admission paperwork
prior to surgery, noting that, as mentioned supra,
Seels-Davila had authorized the use of a cell saver machine.
Dr. Daniels discussed this with her patient while trying,
unsuccessfully, to convince Seels-Davila that she should
consent to a blood transfusion. However, according to Dr.
Daniels, Seels-Davila "was adamant about not receiving
blood and was instead given one liter of albumin" before
her transfer to surgery. N.T. 4/21/15 at 159-61;
see also N.T. 4/22/15 at 30 (Dr. Daniels testified
that Seels-Davila "said that she was a minister in the
faith i.e. Jehovah's Witnesses and that she was okay with
whatever happened."); N.T. 4/27/15 at 7-10 (Nurse
Flanagan testifying that, while enroute to the operating
room, she unsuccessfully attempted to get Seels-Davila to
authorize the use of blood transfusions if such treatment was
deemed necessary). At approximately 11:00 AM, Dr. Daniels
called the operating room and informed the staff that she
would need a cell saver machine for use during the
laparotomy. N.T. 4/21/15 at 159-60. This was an
essential step, as cell savers are normally not used in
emergency surgical procedures and require additional time to
set-up. Id. at 73-75. These machines can only be
fully operated by a perfusionist, who is called in from
offsite and usually takes around 30 minutes to arrive at the
hospital. Id.; cf. Amron Deposition at 66
(stating that Hahnemann contracts with "an outside
service that just about every hospital in the city uses as
their source for perfusionists ... Probably 80 percent of the
hospitals in the city are using the same company so--it may
be 70 percent but it's largely one company.")
Nurse Wayne Rivers brought the cell saver to the operating
room, connected a suction catheter to the machine, put in
anticoagulants, "and did whatever else was necessary to
set the cell saver up." N.T. 4/21/15 at 148-49.
The emergency laparotomy procedure began at 11:33 AM and the
cell saver machine was switched on and began collecting
Seels-Davila's blood. At approximately 12:00 PM, the
perfusionist joined Dr. Daniels in the operating room and
began essentially cleaning the blood for re-infusion into the
patient. N.T. 4/21/15 at 148-51, 156-57, 161.
During the exploratory laparotomy surgery, Dr. Daniels
discovered that Seels-Davila was bleeding internally, and
used the cell saver in an attempt to salvage the
approximately 2, 500 to 3, 000 CCs of blood [that] had pooled
in her abdomen. This effort was complicated by the fact that
a good portion had already become clotted. N.T.
4/21/15 at 145; N.T. 4/22/15 at 36-37; N.T.
4/23/15 at 38. According to Dr. Daniels, Dr. Morant-Wade
was "continuously trying to break up the clots to
suction the blood to put it into the cell saver filtration
canister, " which was "a difficult thing to do
because it's almost like suctioning Jell-0 through ... a
suction tube." N.T. 4/22/15 at 36. As a result
of these efforts, the cell-saver machine was able to process
approximately 1800 CCs of this pooled blood and, after being
filtered and processed, 626 CCs were ultimately transfused to
Seels-Davila in the form of packed red blood cells. N.T.
4/23/15 at 118, 126-27.
While it was clear that Seels-Davila was bleeding internally,
the source of the bleeding was not readily apparent. Dr.
Daniels had no choice but to extend the incision by cutting
upward, in an "upside-down T fashion, " to get a
better visual of the uterus. N.T. 4/21/15 at 144.
After properly doing so, Dr. Daniels discovered that
Seels-Davila had an extremely rare uterine anomaly, in which
her uterus had a small extra horn or "nub" on its
side, outside of where her child had been gestating.
Id. This additional horn exhibited a two
centimeter-long cut, which was apparently the source of
Seels-Davila's internal bleeding. Id. at 144-45,
161. The manner in which this cut had occurred was never
fully resolved by the physicians or the evidence offered at
trial. Whether Dr. Green was negligent in the performance of
the C-section by cutting this uterine horn was one of the key
issues before the jury.
Dr. Daniels repaired the cut of Seels-Davila's anomalous
horn, put a compression stitch on the right uterine artery
(i.e. the artery which provides the bulk of the uterine blood
supply), and tied off the uterine ovarian ligament (the other
major source of blood for the uterus) to slow down the
bleeding. N.T. 4/21/15 at 144-45. Dr. Daniels also
used a B-lynch compression suture, wrapping it around
Seels-Davila's uterus in an effort "to kind of
shrink the uterus down because it wasn't contracting on
its own." N.T. 4/21/15 at 145; see N.T.
4/22/15 at 40-41 (Dr. Daniels:
"Because her uterus wasn't contracting down, we gave
her medications. We gave her Hemabate and Methergine, which
both, again, make the muscles contract, and that didn't
work, so we did a compression suture called a B-lynch
suture."). During this surgery, Dr. Daniels also
installed a "JP drain" in Seels-Davila's
abdominal cavity, in order to permit blood and other fluids
to evacuate, and to allow for monitoring of activity within
the cavity without additional exploratory surgery. N.T.
4/21/15 at 165.
After the surgery, Seels-Davila was taken down to the
surgical intensive care unit. N.T. 4/21/15 at 165;
N.T. 4/27/15 at 54. At some point between 2:00 p.m.
and 4:00 p.m., Dr. Daniels noticed that more blood was
emptying from Seels-Davila's JP drain, and decided to
take her back into the operating room for the purpose of
removing her uterus. N.T. 4/21/15 at 165. Dr. Daniels
believed that the loss of so much blood had, in effect,
caused Seels-Davila's remaining blood to be depleted of
its clotting factors, and that this additional surgery was
necessary under the circumstances, given that Dr. Daniels was
prohibited from halting the internal bleeding through the
transfusion of fresh blood. N.T. 4/22/15 at 43-44,
49-50. Accordingly, Dr. Daniels performed a supracervical
hysterectomy, a procedure through which the uterus is removed
while the cervix is left intact and in place within the
patient's body. N.T. 4/21/15 at 166.
Seels-Davila lost roughly 300 CCs of blood during this
surgery and, all told, lost an estimated five liters of blood
during the three surgeries. Id. at 167-68. The blood
that was processed through the cell saver and returned to her
did not help with her clotting issues, however, as the
filtration process strips away any platelets or other
components that would assist with coagulation. See N.T.
4/23/15 at 127.
Certain that Seels-Davila's very survival hinged on the
ability to give her blood transfusions, Hahnemann doctors
then sought in vain to get authorization from her family
members to do such a procedure, despite Seels-Davila's
firm and repeated opposition to blood transfusions because of
her faith. Dr. Daniels repeatedly asked Seels-Davila's
parents over the following two days to override their
daughter's advance directive but, each time the topic was
broached, they rebuffed Dr. Daniels' entreaties. N.T.
4/22/15 at 43-49; N.T. 4/28/15 at 26. Out of
desperation, Dr. Owen Montgomery, chairman of Hahnemann's
OB/GYN department, called [Seels] at 4:00 AM on Saturday,
November 27, 2010, telling him that: "I know and I
respect your daughter's wishes. And I understand the
family's wishes. And I'm calling you not as her
doctor, but as a father. I have three daughters ... I'm
calling you father to father. And ... I respect your wishes.
But. .. if there is ever going to be a time that your family
changes their minds, it has to be now." N.T.
4/28/15 at 25. Though Dr. Montgomery "wasn't
even sure at that point whether just giving the ...
transfusion would actually reverse the damage ... he was
pretty sure it would still save Seels-Davila's life ...
and very sure that if Hahnemann doctors didn't give her
blood, that she would die." Id. at 25-26. This
plea did not change the resolve of Seels-Davila's
parents, who, according to Dr. Daniels, told her "that
it was God's will, they stood strong in their faith i.e.
that of the Jehovah's Witnesses, and on behalf of their
daughter declined any blood products." N.T. 4/22/15 at
48. Later that day, Dr. Daniels and Dr. Montgomery contacted
Levi Davila-Rios, Seels-Davila's husband, who was still
involved in missionary work in Nicaragua, to see if he would
authorize a blood transfusion for his wife. Id. at
52. In addition they attempted to secure an emergency visa
for him, so that he could be with Seels-Davila. Id.
at 53. Despite these efforts, Mr. Davila-Rios also declined
to assent to the transfusion, saying that he did not want to
go against his wife's wishes or submit her to medical
treatment that violated her religious beliefs. Id.;
N.T. 4/24/15 at 73, 77-78.
Seels-Davila's condition continued to deteriorate and, on
the morning of November 28, 2010, she passed away, in spite
of her doctors' uniform belief that a blood transfusion
would have almost certainly saved her life. Id. at
45, 53-56 (testimony from Dr. Daniels; N.T. 4/24/15
at 21-24 (Appellant stating that Hahnemann personnel told him
that Seels-Davila needed a blood transfusion); id.
at 30-31 (noting date of death); N.T. 4/28/15 at 26
(testimony from Dr. Montgomery). Critically important in this
case is that even Appellant's own expert, Dr.
Prince testified that that a blood transfusion would have
likely saved Seels-Davila from her ultimate fate. See
N.T. 4/23/15 at 117 (Drexel's Attorney: "If Ms.
Seels-Davila received a blood transfusion, do you believe she
would have survived?" Dr. Prince: "More likely than
not, yes, she probably would have survived.").
Trial Court Opinion, 6/14/16, at 2-14 (footnotes and internal
brackets omitted) (emphases in original).
September 6, 2012, Appellant filed a medical malpractice suit
against Appellees and included claims of vicarious liability,
corporate negligence, negligent infliction of emotional
distress, wrongful death, and survival. Appellant filed an
Amended Complaint on October 19, 2012, and Appellees
responded by filing preliminary objections. On December 20,
2012, the trial court sustained in part and overruled in part
Appellees' Preliminary objections. The trial court
struck, without prejudice, Appellant's claims of
negligence against unnamed agents, servants, employees,
contractors, workmen, and apparent or ostensible agents and
other language deemed overly broad in Appellant's Amended
Complaint at paragraphs 8, 24, 34, 62, 63, 66, 75, 79, 80,
82, 93, and 95. Order (Drexel), 12/20/12; Order (Hahnemann),
12/20/12. Despite the trial court striking these claims
without prejudice, Appellant did not file a second amended
trial began on April 21, 2015, and on April 30, 2015, the
jury returned a verdict in favor of Appellees. The jury found
that the conduct of Dr. Green and Dr. Daniels did not fall
below the applicable standard of care. N.T. 4/30/15 at 5-6.
Thus, there was no negligence which could stand as the basis
for Appellant's ancillary claims, including vicarious
liability. Accordingly, the trial court entered a verdict in
favor of Appellees. Appellant filed post-trial motions, and
the trial court denied the motions on May 13, 2015. Appellant
filed a notice of appeal on June 5, 2015.
26, 2015, Appellant filed a twenty-two-page Pa.R.A.P. 1925(b)
statement containing nineteen issues with
subparts. Appellees filed a motion to dismiss this
appeal due to the length, format, bad faith, and the sheer
number of issues Appellant purported to raise in his
Pa.R.A.P. 1925(b) statement. Motion, 7/12/16. This Court
denied that motion on August 16, 2016. Despite
Appellant's verbose and repetitive Pa.R.A.P. 1925(b)
statement, we conclude that each of the questions presented
in Appellant's brief was preserved in the issues set
forth in the Pa.R.A.P. 1925(b) statement or were fairly
suggested thereby. Thus, we also decline the ...