Thoughts on recent Ninth Circuit and California appellate cases from Professor Shaun Martin at the University of San Diego School of Law.
Friday, January 03, 2025
Grimm v. City of Portland (9th Cir. - Jan. 3, 2025)
Thursday, January 02, 2025
Charlie L. v. Kangavari (Cal. Ct. App. - Jan. 2, 2025)
The 2/2 publishes this interesting opinion on 1/2, ringing in the New Year. It creates a split with the Fifth District on an issue that I suspect occurs reasonably often: Whether the pro-defendant medical malpractice provisions of Section 1799.110 apply to emergency room doctors who work outside the E.R. -- here, the radiologists who review x-ray and other medical records off site.
The Fifth District held that they did not, whereas the Court of Appeal here holds that they do.
I'm tentatively going with the Fifth District on this one, notwithstanding Justice Hoffstadt's very good arguments to the contrary.
Section 1799.110 generally makes it more difficult to sue doctors who work in the emergency room, on the theory that we need doctors in that area (so don't want to overly burden them with high malpractice premiums) and that the often frantic nature of work in the E.R. makes the "normal" malpractice rules somewhat inapplicable. That statute clearly applies to, for example, the doctor who's actually working on you in the emergency room.
But what about a consulting radiologist? Radiologists (as I understand their practice, anyway) generally are not actually in the emergency room, but are rather working at their homes or offices, and receive the x-rays or MRI images remotely, review them there, and then relay their results back to the relevant E.R. personnel. Are those doctors equally protected by Section 1799.110?
Today's opinion holds that they are. There's a textual argument for that result (of course), but the basic intent and policy arguments that support that result are that radiologists who support E.R. services, just like the doctors who are physically located there, "must make instantaneous decisions on the diagnosis and treatment of emergency patients without the benefit of time to review [the patient’s] past medical history, seek a consultation, study current medical literature, [or] reflect upon the proper diagnosis and course of treatment.”
That's true, I think. But only to a degree.
The radiologist here was asked for a "stat" consult regarding a three-year old child who was taken to the emergency room in Whittier by his mother. The child, Charlie, "had been in and out of hospitals for conditions related to a malrotated bowel he had at birth," and the question was whether he had a bowel obstruction. If he did, that's a serious issue, and requires treatment. So they took x-rays and an MRI and sent them to an offsite doctor (presumably working out of his home and/or in another time zone, since it was 3:00 a.m.), who read the images and confirmed that there was no bowel obstruction. So they sent the child home.
But the doctor was (allegedly) wrong, and "[s]oon after returning home, plaintiff vomited and turned blue. His parents brought him back to the emergency department at 8:18 a.m., nonresponsive with a faint pulse and not breathing. Plaintiff was transferred to Children’s Hospital Orange County later that morning, where he underwent multiple surgeries over the next three days to remove necrotic tissue and the majority of his small bowel due to a lack of blood flow caused by a bowel obstruction. Plaintiff now suffers “short gut syndrome,” has to be fed with a G-tube, wears diapers at all times, and struggles with speech and other mental and emotional capabilities."
Hence the lawsuit.
The doctor moves for summary judgment, and to keep things (somewhat) brief, the dispositive issue there is whether Section 1799.110 applies. As I said, the Court of Appeal holds here that it does.
I think it's right that the radiologist here was under some degree of time pressure, and didn't have the ability to consult a full medical history, "study current medical literature," and the like. But I'm not sure that this really matters, especially in a case like this. I strongly suspect that radiologists who receive and interpret remote x-ray and MRI images exceptionally rarely rely on a "full medical history" to interpret those images, much less "study current medical literature" in the midst of their interpretation. I imagine that, most of the time, they do precisely what I expect was done here: they get a basic medical history (here, that the patient had a malrotated bowel at birth), rely on their expertise, look at the pictures, and report what, if anything, they see.
And, critically, they do that exact same thing for both emergency room and non-emergency room images. They're trying to see if a bowel is obstructed, a bone in broken, a heart is swollen, etc. If it is, then that's important, and potentially life-critical. If not, great. It's the same basic task, and the doctor accomplishes it in the same fundamental fashion.
Are there some additional time pressures potentially associated with a "stat" radiology consult? Yes, I suspect. In a way. It definitely means that the doctor can't dilly dally. We need to know the answer fairly rapidly. So it's not like a "regular" x-ray where maybe the doctor can take a day or two to get around to it. Hence the 3:00 a.m. consult here, and why radiologists (like this one) are assigned to be "on call" at all hours of the day and evening.
But that doesn't necessarily mean that an immediate -- or even shortened -- review is required. Here, for example, the child's "X-ray was taken at 3:12 a.m. and Kangavari issued a report based on the images at 3:51 a.m." and the child's "ultrasound was taken at 3:24 a.m. and Kangavari issued another report based on those images at 4:35 a.m." So it took a half-hour to examine and report on the x-ray and over an hour to examine and report on the MRI. I strongly doubt that examining non-ER images takes any different time period; in other words, that the doctor did indeed examine these images as soon as possible ("stat"), but that they nonetheless simply went through the normal review process -- the exact same process applied to non-ER images.
So was there "time pressure" for the doctor's review? Sort of. But not the type of "time pressure" that led to the special provisions of Section 1799.110. What the Legislature was worried about there was that doctors who have to treat patients extremely expeditiously -- e.g., in "meatball surgery" (for those old enough to remember M*A*S*H) -- shouldn't be subjected to the same sort of "second guessing" than "normal" doctors. Hence the special rules.
But here, there's no shorthand. No different process at all -- or at least none that I can see.
Instead, to take an analogy from my own academic practice, there was indeed "time pressure" -- the same kind of "time pressure" that applies when the Dean instructs you to grade a set of final exams for a graduating senior -- but that doesn't at all mean a different level of review. Do you put those set of 3L exams on the top of the pile? Yes. Just like the radiologist here puts "stat" images at the top of her pile. But the substantive review is the same. There's no shorthand. It's just that one set of documents is more time-urgent than the other. You give them the same review, the same basic time, and the same basic result. If so, it seems unnecessary to give "special protection" to one type of image review over the other. Just like we give the same basic protection to law school grades given to graduating 3Ls and non-graduating 2Ls. One set of exams is more "urgent" than the other, but the same basic rules apply.
Ditto for "stat" car repairs, childhood chores, or the like. Yes, we ask them to fix that car, or take out that trash can, immediately, because we need that car (or the trash truck is coming) tomorrow, so it can't take the weekend. But the substantive standard is the same. So too here, I think.
So if I had to choose, my tentative thought it to go with the earlier Fifth District's opinion on this one. At least in this context.
I might at least hypothetically imagine different contexts in which I might go the other way. If, for example, there was a patient having an apparent heart attack, and there was a remote consult where the radiologist only had, say, 30 seconds to make a determination of whether it was a blockage as opposed to an aneurysm, okay, maybe that's the kind of time pressure that supports a different standard. We can't expect "normal" procedures and standards to apply in that particular context. Just like, in our world, we would not expect the ordinary standards of lawyerly skill to apply to emergency appellate briefs that we are ordered to prepare and file within 24 hours as opposed to those we have the freedom to prepare over several months.
But in the present case, I'm just not sure that Section 1799.110 rightfully applies.