Yorston v. Pennell

Dissenting Opinion by

Mb. Justice Benjamin R. Jones:

The majority of this Court would uphold the imposition of personal liability in damages upon a surgeon of a charitable hospital’s surgical staff for an injury to a person, not the surgeon’s private patient, caused by the alleged negligence of an intern and resident surgeon, neither of whom were employed by, compensated by, nor subject to discharge by the surgeon, the alleged negligent acts having been performed neither in the presence of the surgeon nor under his physical control.

The majority opinion acknowledges that “if the judgment of the court below can be supported only on the evidence of direct negligence of defendant then *45the judgment cannot stand since this issue was not submitted to the jury”, and it upholds liability on the part of the surgeon on the theory of respondeat superior. The majority opinion clearly poses the basic question: “whether the persons (the intern and resident surgeon) who administered to plaintiff may be properly said to be agents of Dr. Pennell or agents only of the hospital” and resolves that question by concluding that both the intern and the resident surgeon were agents of Dr. Pennell.

The negligence averred in the complaint was threefold: (1) Dr. Pennell “negligently ordered penicillin to be administered to the plaintiff”; (2) Dr. Pennell “negligently failed to give orders that penicillin should not be administered to plaintiff”; (3) Dr. Pennell failed “to supervise and control his servants or those of the hospital . . . acting at the time on his behalf ... so as to prevent penicillin from being used in plaintiff’s treatment.” Neither (1) nor (2) are supported by any evidence of record: there is not a scintilla of evidence that Dr. Pennell ordered the administration of penicillin or that he knew or should have known of plaintiff’s allergy to penicillin. The only justification for the imposition of liability advanced in the majority opinion is that the intern, Mr. Rex, knew or had reason to know of plaintiff’s allergy and such knowledge on the part of Mr. Rex was imputable to the resident surgeon, Dr. Hatemi, which knowledge was in turn imputable to Dr. Pennell, on the theory that Dr. Hatemi was his agent and Mr. Rex his sub-agent.

An examination of the relationship of Dr. Hatemi to the hospital and the circumstances disclosed by the record cast serious doubt on the integrity of the majority’s conclusion that plaintiff was Dr. Pennell’s patient so that he personally had the duty of performing, or of designating someone to perform, the operation *46on plaintiff and that, as a result of this duty, Dr. Hatemi became the agent of Dr. Pennell in the performance of the operation. Dr. Lucius Wilson, the Director of Episcopal Hospital, testified that the assignment of the plaintiff to Dr. Pennell did not of itself make him the latter’s private patient; that it was part of Dr. Pennell’s general duties to see that free patients and ward patients were provided with adequate care; and that Dr. Pennell never assumed any responsibility with respect to this patient other than the ordinary responsibility of an associate surgeon to a ward patient. The evidence further disclosed that the plaintiff was received into the hospital in the name of Dr. Rosemond, the then nominal chief surgeon of the hospital. Following the ordinary and customary hospital procedure, Dr. Hatemi, the resident surgeon, an employee of the hospital on duty at the time, was notified and examined the plaintiff.

Dr. Hatemi, the resident surgeon, was hired by the hospital, and only the hospital had the right to discharge him. A small monetary compensation was paid him by the hospital, and, in addition, the hospital agreed to further instruct the resident in surgery in return for his services to the hospital, which instructions included the performance of minor surgery such as that involved in the present case. Under the rules of the hospital, a resident surgeon was not permitted to perform any operation, except in an emergency, without the consent of the chief or one of the associate surgeons. He was not permitted to have private patients, nor to receive any remuneration from the hospital patients whom he treated. Compensation for his services consisted of the small monetary stipend, and the advancement of his education through the performance of his duties, including minor surgical operations, and the instruction and advice given to him by the as*47sociate surgeons. The associate surgeons received uo compensation from the hospital for the instruction and supervision rendered to the resident surgeons. It was the practice of the hospital, however, to permit the associate surgeon who consented to and generally supervised the action of the resident to receive any compensation from an insurance carrier or from the patient for the services rendered by the residents, and this practice was followed in the present case.

Patients admitted to the hospital could not be assigned to the resident, but were assigned to the associate surgeon who counseled the resident. Such assignments were not governed on the basis of the patient’s status as a paying or non-paying patient, but rather on a rotation basis, depending on which associate surgeons were on duty and available at the time when the request to operate was made by the resident.1

A.s the majority opinion correctly states, Dr. Hatemi could only have been the agent of Dr. Pennell if he were employed “(1) to perform services in aid of [Dr. *48Pennell’s] private business affairs and (2) [was] subject to Ms control:” Commonwealth to the use of Orris v. Roberts et al., 392 Pa. 572, 584, 141 A. 2d 393. Dr. Hatemi, however, was performing the duties for which he had been hired by the hospital, namely, the treatment of patients received by the hospital in the ordinary course of its business. Minor surgical operations were obviously included within these duties. Moreover, part of the compensation Dr. Hatemi received from the hospital was the right to improve his surgical sMll by the performance of these operations. The rules of the hospital, however, required that this be done under the supervision of an associate surgeon, and the latter was required by the hospital to furnish such supervision and instruction to a resident surgeon without compensation by the hospital for the performance of such function. It seems obvious that the right of the associate surgeon to charge a compensation carrier for the services of a resident surgeon was intended to serve as partial compensation for the fulfillment by the associate surgeon of the hospital’s obligation to instruct and advance the surgical education of the resident. It is clear that if the instant plaintiff was anyone’s patient, he was the patient of Dr. Hatemi, and that Dr. Pennell rendered only supervisory control over Dr. Hatemi, as he was required to do by the hospital rules. Under the circumstances, I believe that both the operation performed by Dr. Hatemi, and any supervisory control exercised by Dr. Pennell over Dr. Hatemi, were solely in furtherance of the hospital’s business, and that no agency relationship between Dr. Hatemi and Dr. Pennell existed.

Assuming arguendo, however, that Dr. Hatemi was the agent of Dr. Pennell, our next inquiry is to determine whether there was sufficient evidence of record to justify a finding of negligence on the part of either *49or both doctors. In pursuing this inquiry it must be borne in mind that the negligence, if any, which caused the injury to plaintiff arose not from the surgery performed, but rather from the failure to take a proper preoperative history which resulted in the post-operative injection of penicillin into the plaintiff who was allergic to the drug. It is undisputed that there was evidence that the intern was told of plaintiff’s allergy and failed to note such fact on the history of the patient which he took prior to the performance of surgery. On the other hand, there is no evidence that the resident surgeon either had actual knowledge or reason to know of the existence of such an allergy. There was evidence that while the operation was being performed, the intern “informed the nurse anesthetist of the fact that the history was incomplete.” The majority opinion frankly admits that “Exactly what followed is not known”, and then proceeds to substitute conjecture and speculation for proof of what happened. The majority opinion says, if the nurse noted the fact of the allergy on the record, and if it was so noted before Dr. Hatemi read the record, or if the nurse told Dr. Hatemi of it, the jury could have found Dr. Hatemi negligent. On the other hand, if the nurse did not correct the history or if she did not tell Dr. Hatemi, then the nurse would have been negligent. Our review of the record, and a fact tacitly admitted by the majority, shows no evidence whatsoever that Dr. Hatemi had either knowledge or reason to know that the plaintiff was allergic to penicillin at the time that he ordered the administration post-operatively of that drug. The majority’s imposition of liability on Dr. Pennell must therefore originate with the failure of Mr. Rex to properly record plaintiff’s medical history.

The testimony of Dr. Wilson unequivocally demonstrates that the recording of a medical history prior to *50an operation is clearly within the duties of an intern such as Mr. Rex. He specifically acknowledged the fact that “[I]t [was] the practice at that time in the Episcopal Hospital in Workmen’s Compensation cases to have the history of a surgical patient taken by an [in]tern;” and that it is customary in all hospitals for interns to take histories and for the operating surgeon to rely on such histories. He further testified that the recordation of the history of a surgical patient is part of the “patient care” prior to the actual commencement of the operation. The evidence also clearly demonstrated that Mr. Rex was hired by and considered as an employee of the hospital; that Dr. Pennell had no power to hire or fire him nor any control over his professional assignments; and that the hospital charged plaintiff’s employer’s compensation carrier for the care rendered plaintiff by its — the hospital’s — employees, including Mr. Rex. In view of this undisputed evidence, it is inconceivable how the recording of the medical history by Mr. Rex, admittedly an employee of the hospital whose duties encompassed the taking of such histories, could be considered as anything but standard pre-operative preparation entirely under the control and dominion of the hospital.2

*51The problem presented in the instant case is not a new problem in Pennsylvania. In McConnell v. Williams, 361 Pa. 355, 65 A. 2d 243, this Court upheld the imposition of liability upon a surgeon on the theory of respondeat superior for the negligent act of an intern committed in the operating room where the surgeon, under the evidence, assigned the intern to the task which he performed negligently, to wit, the insertion of a solution into an infant’s eyes. The Court noted that the defendant was himself performing the operation, and for this purpose, had complete control over those present and assisting in the operating room; that he had freely chosen the intern who was to assist him in the operation; and that the negligent action was committed pursuant to an express direction given by the defendant to the intern during the course of and as an integral part of the operation. The McConnell rule was again applied by this Court in Benedict v. *52Bondi, 384 Pa. 574, 122 A. 2d 209, where the operating surgeon was held liable for injuries resulting from the application of excessive heat to the feet of the child-patient. This Court again noted that the surgeon was physically present in the operating room and expressly directed the application of the heat to the child’s feet and “that such an application is not a routine matter in all operative procedure but is sometimes employed where the patient is in shock; that it is therefore a decision for the surgeon to make and for him to determine and direct if, when and how heat should be applied” and “that his legal responsibility did not begin merely at the exact moment when he started to make an incision in the child’s body but that the operative process started with, and included, the application to the child — in the operating room and under the eye of the surgeon — of the hot water bottles. . .” (Emphasis supplied). In both cases, however, liability was specifically discounted where it involved pre-operative or post-operative treatment, not directly related to the operation itself, and where the person sought to be held liable was not physically present when the negligent act occurred. In the McConnell case, the reason for this distinction was aptly set forth by Mr. Justice (later Chief Justice) Stern: “Defendant’s counsel cites several cases from other jurisdictions in an attempt to show that an operating surgeon is not generally held liable for the negligence of hospital internes and nurses. In those cases, however, the negligence on the part of the nurse or interne was in connection with the post-operative care of a patient, not administered in the presence or under the control of the surgeon. Plaintiffs do not contend that a surgeon’s liability should apply, after the operation is concluded, to treatment administered by floor nurses and internes in the regular course of the services ordinarly furnished by a hospital; as to all such care and attention they would clearly be acting *53exclusively on behalf of the hospital and not as assistants to the surgeon. But for the period of the operation itself the situation is entirely different, and if operating surgeons were not to be held liable for the negligent performance of the duties of those then working under them, the law would fail in large measure to afford a means of redress for preventable injuries sustained during the course of such operations.” (Emphasis supplied). In Benedict v. Bondi, 384 Pa. 574, 580, supra, this doctrine was again reiterated by this Court when Chief Justice Steen stated: “Dr. Bondi contends that such control does not exist in regard to either pre-operative preparation or post-operative care which is not administered in the operating room in the presence of the surgeon and under his direct charge, and such indeed is the law: McConnell v. Williams, supra, p. 364, A. p. 247; Shull v. Schwartz, 364 Pa. 554, 73 A. 2d 402; Scacchi, Administrator v. Montgomery, 365 Pa. 377, 75 A. 2d 535.” (Emphasis supplied).

In the present case, the majority was faced with two major problems: (1) the defendant was not present in the operating room at the time the alleged negligent act occurred; and (2) no negligent act was committed by anyone during the course of the operation in so far as it related to the conduct of the operation: on the contrary, the record is that the operation was performed with competency and successful in purpose. The majority surmounts the first obstacle by ignoring the reason assigned in McGonnell for requiring the presence of the surgeon-defendant in the operating room and by the application of the expanded surgeon-assistant agency relationship previously discussed. The majority attempts to supply the second deficiency in two steps: (1) because Dr. Hatemi had complete control over the persons assisting in the operation, Mr. Bex’s knowledge of the allergy, which he communicated to the *54nurse anesthetist while in the operating room, is imputed to Dr. Hatemi; (2) because Dr. Hatemi ordered certain post-operative treatment which by the imputation of this knowledge to Dr. Hatemi constituted negligent treatment. Under the majority’s view apparently this constitutes the negligence that was committed during the course of the operation.3

The majority opinion thus states: “While defendant’s chosen agent, Dr. Hatemi, was performing the operation and therefore in full command of all persons in the operating room to the exclusion of hospital control during that period (see McConnell v. Williams, supra), Bex informed the nurse anesthetist of the fact that the history was incomplete.” From this assumed control, the majority imputes to Dr. Hatemi that which Bex told the nurse who may or may not have recorded it. Assuming arguendo that the majority’s holding on agency is correct, undoubtedly defendant, through his agent Dr. Hatemi, had control of all persons in the operating room, but only for the purpose of the proper and successful conduct of the operation. See McConnell v. Williams, 361 Pa. 355, supra.

*55When Mr. Bex failed to inform Dr. Hatemi of the inaccurate history he was negligent, but such negligence was related only to the patient’s post-operative care. The subsequent attempt during the operation to rectify his initial negligence in failing to properly record plaintiff’s medical history, a routine pre-operative function performed by hospital employees, was irrelevant both to the operation and to the rationale of McConnell in holding that a surgeon has complete control of the actions of persons in the operating room, but only for the purpose of conducting the operation and “to afford a means of redress for preventable injuries sustained during the course of such operations If Bex had told or failed to tell the anesthetist one-hal f hour before or one-half hour after the operation, would either or both of them have been any more or less negligent in failing to communicate this fact to Dr. Hatemi during the operation? Would this negligence still be imputable to Dr. Hatemi because he had complete control of them while in the operating room, when the fact that the plaintiff was allergic to penicillin was completely irrelevant to the success or failure of the surgery? If a nurse had informed the anesthetist during the operation that certain rooms were not to be used because the previous occupants had a communicable disease, would this knowledge have been imputable to Dr. Hatemi and would Dr. Hatemi be held liable for complications resulting from his sending a patient to that room because “he was performing the operation and therefore in full command of all persons in the operating room?” If an ambulance driver negligently administers an overdose of morphine to a plaintiff en-route to the hospital, will a communication of this fact to a nurse in the operating room impute this knowledge to a surgeon performing the operation who orders additional morphine as post-operative treatment *56because he “was performing the operation and therefore in full command of all persons in the operating room?” In previous cases, the doctrine of absolute control by a surgeon over those assisting him during an operation was applied solely for the purpose of placing-responsibility on the person who was primarily and directly entrusted with the success or failure of the surgery. Under the majority view, however, this doctrine is now to be used for converting the operating room into a combat information center where information as to and liability for the previous negligent actions of hospital employees — unrelated to the success or failure of the operation — may be transmitted and transferred to the operating surgeon, and for insuring employees of a convenient receptacle where their negligent actions may be discarded whether or not they have any relation to the successful performance of the operation.

Nor does the majority’s second step, namely, that Dr. Hatemi was negligent because he gave instructions to administer penicillin as part of the post-operative treatment during the course of the operation have any more validity. In Shull v. Schwarts, 364 Pa. 554, 73 A. 2d 402, this Court affirmed a judgment for the defendant where a hospital intern after a successful operation and upon the direction of, but in the absence of the operative physician, negligently failed to remove two stitches as part of the post-operative treatment. See also: Powell v. Risser, 375 Pa. 60, 99 A. 2d 454; Scacchi v. Montgomery, 365 Pa. 377, 75 A. 2d 535. The majority distinguishes these cases on the ground that the nurse who administered the penicillin did not do so negligently, but “acted in strict accordance with the post-operative care prescribed by Dr. Hatemi.” No one contends that the nurse negligently administered the penicillin, nor can anyone contend that Dr. Hatemi *57negligently prescribed penicillin, nor that such a drug constitutes improper post-operative treatment, unless one imputes knowledge to Dr. Hatemi that the plaintiff was allergic to penicillin by the application of the “all inclusive control doctrine” previously discussed. The negligence in the present case consisted of the failure of Mr. Rex to properly record the plaintiff’s medical history, a pre-operative function, while in the Shull case, the negligence consisted of a failure to properly remove the stitches, a post-operative function. Neither McConnell, Shull nor any of the other Pennsylvania cases cited by the majority distinguish between preoperative or post-operative negligence of an intern or nurse. In neither situation has a physician-surgeon been held liable. If the pre-operative and post-operative exclusion from surgeon liability set forth in McConnell and recently reiterated in Benedict is to have any meaning, it must be applied to such a factual situation as herein presented where such negligence as exists can only be traced to the failure of a person or persons employed by the hospital and under its control to properly perform routine pre-operative functions.

An examination of the majority’s views and the instant record leads inescapably to an obvious conclusion. Faced with the absence of any evidence of negligence in the performance of the surgery or of any control, direct or indirect, by the surgeon-defendant (or his agent) in the operating room over the actions of the person whose negligence resulted in plaintiff’s injury, the majority of this Court, in an attempt to bring the instant case within the rules of McConnell and related eases, has had to rely on two bases, both weak and legally insupportable, namely, the imputation of knowledge completely unrelated to the conduct of the operation and the prescription of the administration of penicillin during post-operative care, the latter made *58improper only if the imputation of knowledge of plaintiff’s allergy be fallaciously applied. The result of the majority’s opinion finds justification neither in law nor in reason. I accordingly dissent.

Mr. Justice Bell joins in this dissenting opinion.

Dr. Hatemi, while being examined by plaintiff’s counsel as on cross-examination, stated that: “Q. . . . Alter you saw Mr. Yorston what il anything did you do? A. I checked the patient and took a history how did it happen, ask him, and the brief story of his past. Then I took the x-ray of his leg and I saw the x-ray which was a nail in the one of the bone of the leg, and I took the x-ray to Dr. Pennell’s office because at that time no any other doctor was available in this hospital in our Service. Q. You mean you went to Dr. Pennell because he was the only one available? A. Of our Service.” The evidence disclosed that at the time in question Dr. Pennell was assigned to the women’s and children’s side of the service, and in the ordinary course of events would not have been assigned or under a duty to supervise the treatment of the plaintiff. Although the supervision of Dr. Hatemi’s treatment of the plaintiff was not one of the specific duties of Dr. Pennell when assigned to this side of the service, it was one of his general duties under hospital rules to advise any resident surgeon when requested to do so. Compare with note 2 infra.

The majority opinion, however, states: “The evidence is clear that the general duties of Rex qualified him to take case histories. However, in the normal course of events, since the hospital had assigned him to the receiving ward, he would not have taken this history had he not been selected by Dr. Hatemi to do so. In this sense, therefore, Rex was ‘borrowed’ from the hospital. While remaining a general employee of the hospital he became a sub-agent of Dr. Pennell.” The only testimony to support this conclusion is the testimony of Mr. Rex himself. Dr. Wilson’s testimony directly contradicted Rex’s statement: “Q. Can you tell, please, who took the admission history? A. Mr. Rex. Q. You say Mr. Rex? A. Yes. Q. Who was he? A. Extern. Q. How did he come to take the admission history? A. He was on duty in the Emergency Room. Q. *51What were his duties? A. His duties were to take histories, consult with the Residents or members of the visiting staff on treatments. . . .” Even assuming, however, that Mr. Rex is correct in that having been assigned to the Receiving Ward, his specific duties at that time did not include the recording of a pre-operative medical history, the majority’s holding1 that he became the sub-agent of Dr. Pennell because “he would not have taken this history had he not been selected by Dr. Hatemi to do so,” is indeed strained. The majority in so holding completely ignore the evidence of record establishing that the taking of a medical history is part of the ordinary and customary pre-operative preparation for which the employees of the hospital are directly responsible; that any intern is qualified to take a medical history; that it involves no unique or unusual skill not possessed by any qualified intern; that it is not ¡he type of action which requires the “selection” of a particular individual; and that at that time Dr. Hatemi had the right to tell Rex to take the history. The evidence clearly discloses that as an intern and employee of the hospital, Rex had the duty of taking medical histories whenever he was reqirested to do so by a doctor, regardless of whether or not his specific duties at that particular moment encompassed such action.

While Dr. Hatemi was being examined by plaintiffs counsel as on cross-examination, he stated: “Q. Did you order penicillin as part of the post-operative orders, A. Yes ... Q. Was that before the operation was finished or after that you dictated these orders? A. After it finished. ... Q. Are the post-operative orders an essential part of the operation and post-operative care? A. That’s right. Q. Is it part of the operation itself? A. No. Q. Is it part of the entire procedure? A. This is not operation. This is order, post-operative care.” This was not contradicted by any of plaintiffs witnesses. Although it is true that the orders were given while Dr. Hatemi was completing the east on - plaintiff s leg, his testimony demonstrates that as far as any relevant medical evidence of record in the present case is concerned, it establishes that as a matter of medical opinion post-operative orders are not part of the operation.