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Seels v. Tenet Health System Hahnemann, LLC

Superior Court of Pennsylvania

July 18, 2017


         Appeal 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



          SHOGAN, J.

         Appellant, Raymond Seels, administrator of the estate of Terri Seels-Davila ("Seels-Davila"), deceased, and Raymond Seels, [1] 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 affirm.

         The 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 admission.
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 nonblood management.
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 29.
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).

         On 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 complaint.

         A jury 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.

         On June 26, 2015, Appellant filed a twenty-two-page Pa.R.A.P. 1925(b) statement containing nineteen issues with subparts.[2] 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 ...

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