Armour v. Bader

316 A.3d 1164

John ARMOUR, Individually and as Personal Representative of the Estate of Judith Armour

v.David BADER, M.D., et al.

No. 2023-5-Appeal.

(WC 18-344)

Supreme Court of Rhode Island.

June 28, 2024

Washington County Superior Court, Associate Justice Sarah Taft-Carter

Mark S. Mandell, Esq., for Plaintiff.

Judah H. Rome, Esq., Christine Anne Stowell, Esq., for Defendants.

Present: Suttell, C.J., Goldberg, Robinson, Lynch Prata, and Long, JJ.

OPINION

Justice Lynch Prata, for the Court.

In this appeal, the plaintiff, John Armour, individually and as personal representative of the Estate of Judith Armour (plaintiff or Mr. Armour), appeals from the denial of his motion for a new trial following a verdict for the defendants, David Bader, M.D. (Dr. Bader), Neil Brandon, M.D. (Dr. Brandon), and South County Hospital Healthcare System d.b.a. South County Cardiology (South County Cardiology) in a medical negligence case.

The plaintiff challenges the trial justice’s refusal to issue a jury instruction based on this Court’s holding in Oliveira v. Jacobson, 846 A.2d 822 (R.I. 2004). The plaintiff further claims that the trial justice erred in permitting defendants’ standard-of-care expert to utilize the referring doctor’s records and in limiting cross-examination of that expert regarding a particular study. The defendants maintain that the trial justice did not err by refusing to issue a jury instruction based on Oliveira and that the trial justice properly permitted defendants’ standard-of-care expert to reference the patient’s medical records and, further, that it was proper to limit the cross-examination of that expert regarding the study at issue. For the reasons set forth herein, we vacate the judgment of the Superior Court.

Facts and Travel

On November 8, 2016, Judith Armour (Mrs. Armour or the decedent) arrived at South County Cardiology for a stress echocardiogram¹ (stress test) after she was referred by her primary-care physician, Dariusz Kostrzewa, M.D. (Dr. Kostrzewa). The defendants, Dr. Brandon and Dr. Bader, are the cardiologists at South County Hospital who supervised and interpreted the decedent’s stress test. The results of Mrs. Armour’s echocardiogram were "markedly abnormal" and indicated that she "may have significant coronary [artery] disease."² However, Mrs. Armour was sent home after South County Cardiology staff determined that she was medically stable. Tragically, the next day, Mrs. Armour died from a heart attack.

On the morning of the stress test, South County Cardiology nurses Joy Greene (Nurse Greene) and Margaret Cunnie (Nurse Cunnie) conducted a physical assessment of Mrs. Armour. The nurses determined that she was stable to undergo the stress echocardiogram; but they did not have access to her primary-care doctor’s records when making this assessment. Nurse Greene testified that Mrs. Armour’s stress test "only went a couple of minutes" before she became short of breath. She remained on the treadmill "for two minutes and ten seconds at 1.7 miles per hour at an incline of [ten] percent." In fact, the test was cut short before Mrs. Armour could complete the first stage of the Bruce protocol,³ which would have been three minutes long. Nurse Greene and Nurse Cunnie agreed that Mrs. Armour’s test was abnormal, which was relayed to the physician. Nurse Cunnie gave Mrs. Armour a dose of nitroglycerin,⁴ and Nurse Greene noted that she had no chest pains or difficulty breathing. Mrs. Armour’s peak heart rate was 136 compared to the baseline of 78. The nurses asked Dr. Brandon, the on-site cardiologist, to evaluate Mrs. Armour. After conferring with the physician, the decision was made to administer a second dose of nitroglycerin to Mrs. Armour. It took about seventeen minutes for her EKG levels to return to baseline.

That evening, Mrs. Armour returned home without any apparent difficulty. However, she drove the short distance to her neighbor’s house that night because she was unable to physically walk across the yard, approximately 150 feet. Likewise, her husband testified that Mrs. Armour attempted to unload the dishwasher but could not do so because she did not have the strength to lift the dishes. The following morning, Mrs. Armour went for routine blood work. Later that day while on the phone with her husband, who was in Hawaii at the time, Mrs. Armour had difficulty speaking and collapsed. Mr. Armour contacted a neighbor to check on his wife, who was found unresponsive on the floor. Mrs. Armour was transported to South County Hospital, where she was pronounced dead.

The plaintiff filed a ten-count complaint in Washington County Superior Court, alleging medical negligence against defendants, Dr. Bader, Dr. Brandon, and South County Cardiology. In the complaint, plaintiff alleged that defendant cardiologists "negligently failed to perform and recommend timely, adequate, necessary and required follow up and treatment to * * * [the] decedent following the stress test," and that defendants were otherwise negligent in their treatment and care of Mrs. Armour, which ultimately caused her death. A six-day jury trial was held in Washington County Superior Court. Over the course of the trial, the jurors heard testimony from various witnesses, including the nurses, the defendant-doctors, Mrs. Armour’s family, and expert testimony from both sides regarding the applicable standard of care and causation.

At trial, Dr. Joseph Bouchard, a cardiologist affiliated with UMass Memorial and Marlborough Hospital, testified as plaintiff's expert. Doctor Bouchard is a board-certified cardiologist with over thirteen years of experience treating patients and interpreting stress echocardiograms as an attending physician. On a yearly basis, Dr. Bouchard estimated, he reviews anywhere between 150 and 200 stress tests. Doctor Bouchard reviewed Mrs. Armour’s medical records, including the stress test, the nursing notes, the EKG and echocardiograph images, her primary-care physician’s notes, and the autopsy report.

Based on his review of the records, Dr. Bouchard testified that Mrs. Armour was referred for a stress test by her primarycare physician because "she was having issues with shortness of breath and * * * [her doctor] wanted to see if * * * [a] coronary blockage could potentially be a factor." Doctor Bouchard agreed that the decedent’s escalating shortness of breath was a reason to suspect coronary disease. The expert opined that Mrs. Armour had angina and other coronary risk factors, such as hypertension, hypercholesteremia, and high cholesterol. A patient with multiple coronary risk factors, the doctor explained, is at risk of coronary disease. Likewise, "her EKG findings * * * raise[d] a suspicion for significant coronary disease." Doctor Bouchard testified that the changes in Mrs. Armour’s EKG levels were concerning and the fact that it took over seventeen minutes for these changes to resolve was another "red-flag thing[ ] that we look for[,]" particularly when the patient had been administered two doses of nitroglycerin. The doctor further explained that "if [he] was looking at this EKG * * * [he] would be very concerned that the patient in front of [him] may have significant coronary disease." In addition, "the sizes of the ST depressions" were "markedly abnormal."

Doctor Bouchard opined that the procedure was "a very high-risk stress test" meaning that "the patient is at high risk for having significant coronary disease," and "that’s the moment in time where [the doctors] had a chance to potentially intervene * * *." The plaintiff's expert explained that the standard of care in "a patient with a high-risk stress test that’s unstable" required Dr. Brandon, the supervising physician on the date of Mrs. Armour’s stress test, to send her to the emergency room. Thus, he opined that it was a breach of the standard of care to send her home after the test. The expert also explained that Dr. Bader, who was responsible for interpreting the results of the stress echocardiogram, had another chance to intervene and breached the standard of care by "not having the patient go to the emergency room." Doctor Bouchard opined that the failure of both Drs. Brandon and Bader was the cause of Mrs. Armour’s death and that "if Mrs. Armour went to the emergency room * * * she wouldn’t have had that cardiac arrest the following day."

Doctors Brandon and Bader also gave testimony regarding the events on the date of Mrs. Armour’s stress test. Doctor Brandon testified that, on the day in question, he remembered the decedent telling him that she had been experiencing shortness of breath for six months. He clarified that it would not have been his response to "have done a test on someone who had a significant change in her symptoms over a short period of time * * *." The doctor explained that Mrs. Armour had stable coronary artery disease for six months up until the date of her stress test and that she likely became unstable that evening. Doctor Brandon indicated that the fact that the decedent was unable to walk the short distance to her neighbor’s house signaled that her stability had changed. He agreed that Mrs. Armour should have gone to the emergency room that evening, after her stress echocardiogram.

Despite her coronary risk factors, Dr. Brandon stated that his decision to send Mrs. Armour home that day "was based on her * * * having stable symptoms prior to the test and returning entirely to baseline in every way and being completely stable at the end of the test." He further explained that the decedent "did not meet any indications for being admitted to the hospital on an urgent basis * * *." Doctor Brandon stated that his "clinical impression was that she did have blocked arteries, she had stable coronary artery disease," which is a diagnosis made daily in their office. Moreover, with other patients who have heart blockages, they are hospitalized only when their symptoms become unstable or they have a sudden cardiac arrest.

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