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04/20/95 BRYON J. HOLSTON ET AL. v. SISTERS THIRD

April 20, 1995

BRYON J. HOLSTON ET AL., APPELLEES,
v.
THE SISTERS OF THE THIRD ORDER OF ST. FRANCIS, OWNER AND OPERATOR OF ST. ANTHONY MEDICAL CENTER, APPELLANT.



The Honorable Justice McMORROW delivered the opinion of the court: Justice Heiple, dissenting

The opinion of the court was delivered by: Heiple

JUSTICE McMORROW delivered the opinion of the court:

Defendant, The Sisters of the Third Order of St. Francis, as owner and operator of St. Anthony Medical Center (St. Anthony), appeals from a $7.3 million verdict entered against it in the circuit court of Cook County for the wrongful death of a patient, Theodora Holston (Holston). Plaintiffs are decedent's children, Byron J. Holston and Heather L. Holston, who are co-administrators of her estate. All defendants other than St. Anthony settled with plaintiffs during trial. The jury awarded damages upon the wrongful death claims of Holston's husband and two children, and also compensated Holston's estate for her pain and suffering and disability and disfigurement. The appellate court affirmed. (247 Ill. App. 3d 985.) We allowed the defendant's petition for leave to appeal (145 Ill. 2d R. 315).

Defendant challenges certain of the trial court's rulings and also contends that the verdict was excessive. Specifically, defendant claims: (1) plaintiffs' expert witness should have been precluded at trial from rendering an opinion that differed from or supplemented his deposition opinion regarding the hospital's care; (2) defendant's employee, a treating nurse, was wrongly precluded from giving an opinion as to the nursing standard of care; (3) defendant's motion to transfer venue, which occurred during the trial and after plaintiff dismissed the sole Cook County defendant, should have been granted; (4) the decedent's pain and suffering and disability and disfigurement were improper elements of damages in light of her failure to regain consciousness; (5) on the issue of loss of consortium, the court should have admitted evidence that the decedent had been separated from her husband for a period of four months, although the separation had ended approximately 1 1/2 years before her death.

We affirm the appellate court.

BACKGROUND

During the morning of January 12, 1978, Theodora Holston, aged 29, underwent gastric bypass surgery at St. Anthony's Medical Center in an attempt to reduce her weight. Dr. George Arends, the anesthesiologist, placed a central venous pressure (CVP) catheter into Holston's right internal jugular vein, which was threaded down to rest in a blood vessel above her heart. The purpose of the catheter was to monitor Holston's fluids and central venous pressure. At 1 p.m., following her surgery, Holston was brought to the special care unit for post-operative care.

Unknown to anyone, the CVP catheter at some point punctured Holston's heart and became embedded in a portion of her heart muscle. The nine-inch long catheter ran down the internal jugular vein into the heart and through the heart wall with the tip just beyond the heart wall into the pericardial sac. This caused the fluid from the IV to pass into the pericardial sac rather than into the intended blood vessel. The continuing accumulation of fluid in the pericardial sac created an increasing pressure on Holston's heart, which eventually caused her to go into cardiac arrest. The medical term for the accumulation of fluid in the pericardial sac is cardiac tamponade, which is a life-threatening condition characterized by increased CVP readings, increased pulse rate, a condition known as pulsus paradoxus, and decreased blood pressure.

One of the primary issues at trial was whether St. Anthony, through its nursing staff, should have detected the patient's deteriorating condition and notified doctors of her condition at an earlier time. According to evidence in the record, cardiac tamponade is a reversible condition if corrected early enough. Treatment for an early tamponade is a relatively simple matter of inserting a hypodermic needle into the pericardial sac and withdrawing the fluid. At trial, plaintiffs presented evidence that Holston's tamponade had begun by 4 p.m. on January 12, 1978, and, although her treating nurse made several attempts to persuade the charge nurse to summon the doctors, it was not until 6:50 that Holston was brought into emergency surgery in an unsuccessful attempt to save her life.

Christine Carlson was the staff nurse who undertook the care of Holston during the critical hours before her death. According to her videotaped evidence deposition, which was shown to the jury at trial, the following chronology of events occurred while Carlson attended Holston. Shortly after Carlson came on duty, at 4 p.m., she observed from the patient's medical chart that Holston's pulse had risen to 120 beats per minute from a post-surgery baseline in the seventies. Carlson asked the nurse who had been attending Holston before 4 p.m. about the increase and was told only that the patient was "agitated." Carlson then asked her supervisor, charge nurse Pam Markin, to examine the patient. However, Markin did not examine the patient at 4 p.m. or at 4:20 p.m., when Carlson repeated her request. Carl son testified that she believed that the patient might have been in the early stages of cardiac tamponade, based on her observations of several indicators, including the CVP reading, the elevated pulse, and the marginal urinary output of the patient. By 4:45, a warning buzzer had sounded on Holston's pulse monitor three times, and her pulse had risen to 140. Carlson again asked Markin to check the patient, urging her to contact Dr. Sharp, the treating physician. Carl son conveyed her belief that Holston was tamponading, but Markin did not agree that it was necessary to notify Dr. Sharp. Markin instructed Carlson to simply monitor the patient for indications of a dropping blood pressure, which would indicate the presence of cardiac tamponade. Markin told Carlson that the elevated pulse rate could be explained by the "restlessness" of the patient.

Carlson testified that Holston appeared to be resting comfortably at 4 p.m. but that she later expressed concern over the number of times Carlson left her bedside to talk to Markin. Although Carlson was unaware of it at the time, Holston was a nurse herself.

Carlson was concerned about Holston's low urinary output, which indicated to her that something was definitely wrong and that Holston's heart was not functioning properly. In addition, Holston's pulse rate was continuing to climb and her CVP was significantly high. By 5 p.m., Carlson considered Holston's condition to be so serious that she attempted to obtain Dr. Sharp's telephone number and call him herself. Markin stopped her, instructed her to return to her station and advised Carlson that she, Markin, would make the judgment as to when it was necessary to summon a physician.

During the trial, Dr. Sharp, Holston's surgeon and treating physician, stated that at 5 p.m., the individual readings of Holston's vital signs as reflected in the medical chart could be considered normal. However, he acknowledged that the nurse at the bedside would be in the best position to interpret the patient's condition, based on the trend of increasing pulse rate and CVP. Dr. Sharp testified that he should have been notified of Holston's condition no later than 5 p.m., and if he had been notified then, he would have had sufficient time to properly diagnose and treat the tamponade before the condition became irreversible.

By 6 p.m., Holston's pulse had reached 150 and her blood pressure was starting to fall. Carlson testified that she told Markin at that time that if she did not summon assistance immediately she would have a dead patient on her hands. Markin then called an intern or resident, who arrived within approximately 15 minutes.

Carlson testified that at 6:20 p.m., Holston was slow to respond to directions and could barely open her eyes and squeeze Carlson's hand. She could speak in a whisper, and asked what was happening to her. She looked extremely anxious. Carlson tried to calm her but related that there was a problem with her blood pressure.

A cardiologist, Dr. Paul Maxwell, also was summoned to Holston's room at approximately 6:20 p.m. Dr. Sharp, Holston's treating physician, arrived at 6:43. By this time, Holston apparently had lost her blood pressure. Dr. Sharp ordered emergency surgery for Holston, at approximately 6:50 p.m. As Holston was being wheeled out to surgery in her hospital bed, Carlson spoke to her patient about the upcoming surgery and mentioned that there was fluid in her chest. According to Carlson, Holton "said 'okay' basically."

In the operating room, a slash was made to Holston's chest and, because of the extreme emergency, anesthetic was not used. However, Dr. Sharp testified regarding his belief that she was unconscious during the surgery and would not have been able to respond to pain at that time.

The operation lasted approximately two hours. Initially, Dr. Sharp believed that Holston was suffering from internal bleeding related to the earlier gastric bypass procedure. During an exploratory laparotomy, Holston's heart stopped beating for several minutes. Dr. Sharp immediately performed an emergency left thoracotomy, during which he discovered that Holston was suffering from cardiac tamponade and that her pericardial sac was filled with fluid. Dr. Sharp nicked Holston's pericardial sac to release the fluid. Holston suffered brain damage as a result of the tamponade and never regained consciousness following the surgery.

When Carlson next saw Holston at 9 p.m., the patient was in a coma. She died approximately one week later.

Dr. Alden, an expert in gastric bypass surgery, testified that the cause of Holston's death and brain damage was pericardial tamponade resulting from a perforation of the right atrium of the heart by an improperly positioned catheter. In Dr. Alden's opinion, the perforation had occurred by 4 p.m. or earlier because the patient's vital signs began to change at that time. According to Dr. Alden, the hospital deviated from the standard of care for diagnosing and treating cardiac tamponade in the case at bar.

Dr. Frank Edward Robbins, Jr., an anesthesiologist, testified that the catheter placement was not within the standard of practice because a chest X ray was not obtained to check and correct the placement. Proper procedure would have been to place the tip of the catheter into the superior vena cava, above the pericardial sac, and then to confirm the placement by an X ray of the patient's chest.

Dr. Alden testified that a doctor should have been called to Holston's bedside at 5 p.m. because of the changes in the patient's condition. In Dr. Alden's opinion, the diagnosis of cardiac tamponade could have been made at that time. Dr. Maxwell, the cardiologist who had been called in at 6:20 p.m., agreed that plaintiff's surgeon should have been called at 5 p.m., under the facts of the case. Another of plaintiff's expert witnesses, Jeff Beicher, who was a nurse with extensive training and experience, testified that St. Anthony's deviated from accepted standards of medical practice by failing to notify a doctor of Holston's condition at 5 p.m., by which time the pattern of increasing heart rate and drop in urinary output signalled a serious problem.

By 6 p.m., the seriousness of Holston's condition was clear. According to Dr. Alden, when physicians began arriving, at 6:15 or 6:20 p.m., the correct diagnosis should have been made because the most likely diagnosis was pericardial tamponade, based on the symptoms. However, neither the surgeon nor the cardiologist made the correct diagnosis. According to Dr. Alden, their failure to make the diagnosis was a deviation from standard practice. Dr. Alden testified that available tests to assist in diagnosing cardiac tamponade include taking a chest X ray and, if there were sufficient time, an echocardiogram, which would reveal whether there was fluid around the heart. In addition, a procedure called pericardiocentesis would have assisted in both the diagnosis and treatment of the tamponade. Pericardiocentesis consists of inserting a needle into the patient's chest to determine if fluid in the pericardial sac is present. If so, the needle would be used to continue withdrawing fluid, thereby relieving the cardiac tamponade.

Dr. Alden, as well as Holston's surgeon, Dr. Sharp, and the cardiologist, Dr. Maxwell, agreed that early detection of a tamponade is important ...


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