Opinion

Seels v. Tenet Health System Hahnemann, LLC

2017 Pa. Super. 227
167 A.3d 190
2017 Pa. Super. LEXIS 532
2017 WL 3033949

Court: Superior Court of Pennsylvania
Filed: Jul 18, 2017
Status: Published
Author: Shogan
On the bench: Panella, Shogan, Solano
Cited by: 17 cases
Authority: More cited than 75.1%

noting courts address jury instructions and wording of verdict slip together, using same standard

How later courts described this case

noting courts address jury instructions and wording of verdict slip together, using same standard

Written by the judges who cited it.

The opinion

J-A06045-17

2017 PA Super 227

RAYMOND SEELS, ADMINISTRATOR OF IN THE SUPERIOR COURT OF

THE ESTATE OF TERRI SEELS-DAVILA, PENNSYLVANIA

DECEASED, AND RAYMOND SEELS, IN

HIS OWN RIGHT,

Appellant

TENET HEALTH SYSTEM HAHNEMANN,

LLC, D/B/A HAHNEMANN UNIVERSITY

HOSPITAL AND PHILADELPHIA HEALTH &

EDUCATION CORPORATION AND DREXEL

UNIVERSITY COLLEGE OF MEDICINE,

Appellees No. 1838 EDA 2015

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

BEFORE: PANELLA, SHOGAN, and SOLANO, JJ.

OPINION BY SHOGAN, J.: FILED JULY 18, 2017

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

____________________________________________

Appellant is Seels-Davila’s father.

J-A06045-17

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:

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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.[]

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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

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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

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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

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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.

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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

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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

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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

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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

____________________________________________

On July 20, 2015, this Court informed Appellant that he had improperly

appealed from the order denying his post-trial motions, and that an appeal

lies only from judgment entered subsequent to the trial court’s disposition of

post-trial motions. Order, 7/20/15 (citing Pa.R.A.P. 301; Vance v. 46 And

2, Inc., 920 A.2d 202 (Pa. Super. 2006); and Melani v. Northwest

Engineering, Inc., 909 A.2d 404 (Pa. Super. 2006)). This Court directed

Appellant to praecipe the trial court Prothonotary to enter judgment on the

verdict in favor Appellees and file with the Prothonotary of this Court a

certified copy of the trial court docket reflecting the entry of the judgment.

Id. On July 28, 2015, Appellant complied with this Court’s directive and

certified that on July 22, 2015, judgment was entered on the verdict.

(Footnote Continued Next Page)

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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 trial court’s suggestion that this Court quash the appeal due to the

Pa.R.A.P. 1925(b) statement being “incomprehensible.” Trial Court Opinion,

6/14/16, at 22.3

In his brief on appeal, Appellant reduced the number of issues as

follows:

I. Whether the trial court wrongfully precluded an expert witness

from testifying?

II. Whether the trial court erred as a matter of law and abused

its discretion and committed reversible error in excluding

Appellant’s claims of corporate negligence against Appellees.

III. Whether the trial court erred in permitting the admission of

the consents for treatment into evidence in a medical

malpractice trial at the time of trial which was an error of law.

_______________________

(Footnote Continued)

Response to Order, 7/28/15. Thus, this appeal is now properly before this

Court.

We note also that the trial court diligently analyzed Appellant’s garrulous

Pa.R.A.P. 1925(b) statement in an effort to address the myriad issues

presented.

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IV. Whether the trial court erred and abused its discretion and

committed reversible error in the jury slip?

Appellant’s Brief at 6 (full capitalization omitted).4

In Appellant’s first issue on appeal, he alleges that the trial court erred

in precluding the testimony of a proffered expert witness. “Whether a

witness has been properly qualified to give expert witness testimony is

vested in the discretion of the trial court.” Kovalev v. Sowell, 839 A.2d

359, 362-363 (Pa. Super. 2003) (citation omitted). “It is well settled in

Pennsylvania that the standard for qualification of an expert witness is a

liberal one. When determining whether a witness is qualified as an expert

the court is to examine whether the witness has any reasonable pretension

to specialized knowledge on the subject under investigation.” Id. (citations

omitted).

The determination of whether a witness is a qualified expert

involves two inquiries:

When a witness is offered as an expert, the first

question the trial court should ask is whether the

subject on which the witness will express an opinion

is so distinctly related to some science, profession,

business or occupation as to be beyond the ken of

the average layman. ... If the subject is of this sort,

the next question the court should ask is whether

the witness has sufficient skill, knowledge, or

experience in that field or calling as to make it

appear that his opinion or inference will probably aid

the trier in his search for truth.

____________________________________________

For purposes of our discussion, we have renumbered Appellant’s issues.

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Sowell, 839 A.2d at 363 (citations and quotation marks omitted).

The trial court denied Appellant’s attempt to have Dr. Ronald Paynter,

M.D., testify as an expert to support the claim that Hahnemann had

committed corporate negligence by failing to properly operate, staff, and

maintain its bloodless medicine program. N.T., 4/20/15, at 68-90. The trial

court concluded that Dr. Paynter’s expert report was misleading because the

bloodless medicine program was an administrative program, and there was

no evidence that Dr. Paynter was an expert or had any experience in

bloodless medicine. Trial Court Opinion, 6/14/16, at 15. Thus, there was no

evidence that Dr. Paynter had any specialized knowledge on the subject of

this type of administrative program, and his testimony would only confuse

the jury. Id. The trial court stated:

this [c]ourt disqualified Dr. Paynter because his report

mischaracterized the nature of bloodless medicine, as well as the

role of the bloodless medicine program itself in handling

Hahnemann patients, and because Dr. Paynter had provided

nothing whatsoever to show that he had any experience or

specific knowledge as to how such “programs” are supposed to

be run. As was borne out throughout the trial, from physician

witnesses, and experts on both sides, there is no specialized

medical training that doctors ever receive in “bloodless

medicine.” Dr. Paynter completely mischaracterized the

function of the clerks who staffed the Bloodless Medicine

Program at Hahnemann.

Id.

The trial court further explained its decision as follows:

In the instant matter, it was abundantly clear that Dr.

Paynter had no specialized knowledge regarding bloodless

medicine programs, or even an accurate grasp of what

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“bloodless medicine” actually entailed. Consequently, allowing

him to testify would have misled the jury and had an unfairly

prejudicial impact on Hahnemann’s defense. In his report, Dr.

Paynter identified himself as “an expert in the administrative

standards applicable to hospitals in the United States, including

Hahnemann,” and stated that it was his opinion that Hahnemann

had not “provided a bloodless medicine program despite holding

itself out as a hospital that offered such a program” by failing to

provide “specific training in the methods required to deal with

bloodless medicine patients.” Paynter Expert Report at 1, 3. He

then followed this by listing twenty-one separate “hospital

accreditation standards,” each of which were accompanied by a

vague, single-sentence description, opining “that Hahnemann

failed to comply with the above standards,” without ever

explaining specifically how they were violated. Id. at 5. Dr.

Paynter then closed with a general, catchall paragraph in which

he stated that he believed, “with a reasonable degree of medical

certainty,” that Hahnemann

willfully and negligently failed to provide executive

and management oversight, supervision, education,

competency-based training, planning sufficient staff,

resources, policies and an effective performance

improvement/quality assurance program to its

patients and staff. The hospital administration and/or

governing boards knew or should have known that

failure to ensure the provision of executive and

management oversight, supervision, education,

competency based training, sufficient staff,

resources, policies, and ·an effective quality

assurance program to the Center would endanger

patients and likely result in injuries and death to

patients such as Ms. Seels-Davila. These deviations

did result in her injuries and death.

Id. at 6-12. Distinctly absent from these materials was anything

suggesting that Dr. Paytner had any specific experience in

creating, operating, or supervising a bloodless medicine program

at an administrative level, that he had specific knowledge

about cell saver machines or autologous blood transfusions, or

that he knew or understood what specific types of bloodless

medicine “training” would have satisfied the applicable standard

of care under the circumstances. Id. at 1-12; see N.T. 4/20/15

at 70,52 80-92 (discussing this [c]ourt’s reasoning).

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This [c]ourt: “Dr. Paynter basically just recites

the history as he reads the records, and just says,

‘this is clear that they violated all kinds of standards.’

But he doesn’t ever say specifically what standards

should be in this practice, this discreet and

specialized practice, of bloodless medicine, whether

it’s transfusion or cell savers or perfusionists. He

never says that. He just said Seels-Davila died and

therefore, the Hahnemann staff ... did everything

wrong.”

Moreover, Dr. Paynter’s depiction of “bloodless medicine”

grossly mischaracterized the nature of the concept itself, and

would have given the jury a starkly inaccurate understanding of

what it actually entails. As described by Dr. Paynter in his report,

“bloodless medicine” is purportedly a distinct field, for which

medical personnel need to receive specialized training in order to

provide competent, effective care. See Paynter Expert Report at

2-3. In reality, however, “bloodless medicine” requires nothing

of the sort. Rather, as the testimony at trial clearly revealed,

even by [Appellant’s] own expert, all doctors always try to

minimize surgical blood loss and can, and do, capably treat

patients who refuse, for one reason or another, to allow the use

of various blood products during the course of their treatment,

without needing to have some sort of formalized expertise.

There are no specific medical courses or training in “bloodless

medicine” as such knowledge in this area is part and parcel to,

and integrated, into the overall general medical training. See

N.T. 4/21/15 at 66, 94-95 (testimony from Dr. Green);54 N.T.

4/22/15 at 8-9 (testimony from Dr. Daniels);55 Appellant’s

Motion in Limine to Exclude in Part the Appellees’ Expert

Testimony of Arnold W. Cohen, M.D., Ex.Cat 4-6 (“Cohen MIL”)

(Frank expert report). 56 Indeed, even Dr. Prince, Appellant’s

own expert, admitted that not only had he himself never been

specially trained in bloodless medicine, and that such training did

not actually exist. N.T. 4/23/15 at 56-57.

Appellant’s Attorney: “Is it fair to say, ma’am,

that during your medical education, you had no

specific education in bloodless medicine?” Dr.

Green: “The education is on the job education, as

[with] many aspects of our training.” ... Appellant’s

Attorney: “Now, the bloodless medicine program as

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you understood it, is it fair to say that if you knew a

patient was in the bloodless program, that the

doctors and the medical team had to be careful to

prevent the loss of blood?” Dr. Green: “We are

careful with the prevention of loss of blood with

every patient.” Appellant’s Attorney: “And that’s

fair to say.” Dr. Green: “With every patient, yes.”

Appellant’s Attorney: “But for a person who has

sought out bloodless medicine, would there have

been a heightened recognition of blood loss by you?”

Dr. Green: “I treat every surgery as a heightened.

Blood loss is important and I’m a surgeon, so every

case I treat the same. Blood loss is at the top of the

list particularly for delivery, for any form of delivery.”

Appellant’s Attorney: “Is it also fair to say that

you would have been warned or notified of her blood

loss status because of a band that she would have

worn?” Dr. Green: “That’s one of the identifiers. It’s

very similar to an allergy band for other staff

members. But again, we were already taken care of

her, so this is something we already knew about.”

Appellant’s Attorney: “Is it also fair to say that on

a patient who has a bloodless medicine designation,

that it should be the most skilled person in the

surgical practice who performs the surgery on her?”

Dr. Green: “What is that based on?” Appellant’s

Attorney: “I’m asking you is that your

understanding or was that your understanding

then?” Dr. Green: “The surgery is performed the

same way. There is no different way to do a C-

section for a bloodless patient, for a Jehovah’s

Witness, than someone that does accept blood. We

have techniques. We are meticulous with every

surgery. There is no different technique because she

is Jehovah’s Witness. There is no special way to do a

C-section on a Jehovah’s Witness.”

Dr. Daniels: “So while I was at Drexel, I was a

clinical assistant-your first year at Drexel, you’re a

clinical assistant. You pass your boards. I passed my

boards my first year. You then become an assistant

professor. I was also in charge of the medical

students for 2007 until January of 2010. I was also-I

ran the fourth-year clerkship pathway. So medical

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students who were interested in OB/GYN, went into

this OB/GYN pathway which I also ran. And I was

also in charge of what we call the physician refresher

programs. The physicians who were in the field of

obstetrics and gynecology, who had been out of

practice for a while, who were trying to get back into

practice, had a way to learn-to make sure their skills

were up-to-date and to learn new evidence and to

work on their skills.” Appellees’ Attorney: “Do you

know of any specialized training for the care of

bloodless medicine patients?” Dr. Daniels: “No.”

Appellees’ Attorney: “Did Appellant’s Attorney ever

bring to your attention during her examination of

you here or in the deposition, any training or

specialized training which exists anywhere for care of

bloodless medicine patients?” Dr. Daniels: “No.”

“The standard of care for treating obstetric

patients who do not accept allogenic blood

transfusions is the same as the population at large.

Entry into a bloodless program does not change the

standard of care ... Dr. Paynter opines that the

physicians and nurses in this case did not have any

formal training in the care of Bloodless Medicine

patients. The primary reason for this “lack” of

training is that no such formal training exists. I am

unaware of such a training program even in the most

comprehensive academic medical centers.”

Dr. Paynter’s obviously confused and mischaracterized an

administrative function staffed by individuals without medical

training, who are tasked with assisting patients in understanding

the ramifications and risks of refusing blood transfusions,

offering them alternatives to blood transfusions, and ensuring

that medical staff are made aware that a particular patient is a

“bloodless patient” - one who does not accept blood

transfusions. See Cohen MIL, Ex. C at 4 (Frank expert report);58