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Cappuccilli v. Carcieri

Supreme Court of Rhode Island

December 15, 2017

Sevan (Bjorklund) Cappuccilli
David A. Carcieri, M.D., d/b/a Medical Office of David A. Carcieri, M.D. et al.

         Providence County Superior Court (PC 09-1491) Associate Justice Daniel A. Procaccini

          For Plaintiff: Mark B. DeCof, Esq. Douglas E. Chabot, Esq. Michael P. Quinn, Jr., Esq.

          For Defendants: Ryan K. Deady, Esq. William F. White, Esq

          Present: Suttell, C.J., Goldberg, Flaherty, Robinson, and Indeglia, JJ.



         The plaintiff, Sevan (Bjorklund) Cappuccilli[1] (Ms. Cappuccilli or plaintiff), [2] appeals from a Providence County Superior Court judgment in favor of the defendants, David A. Carcieri, M.D., d/b/a Medical Office of David A. Carcieri, M.D. (Dr. Carcieri or defendant), and Women & Infants Hospital of Rhode Island (Women & Infants).

         The plaintiff's claim against defendants arises from an injury that she alleges that she suffered at Women & Infants when she underwent an emergency cesarean section (C-section). After a three-and-a-half-week trial, the jury returned a verdict for defendants. The plaintiff subsequently moved for a new trial pursuant to Rule 59 of the Superior Court Rules of Civil Procedure. The trial justice denied the motion on November 25, 2014, concluding that reasonable minds could differ as to whether Dr. Carcieri's conduct fell below the appropriate standard of care. For the reasons set forth, we affirm the judgment of the Superior Court.

         I Facts and Travel

         On March 15, 2006, Ms. Cappuccilli was admitted to Women & Infants. Doctor Carcieri, who specializes in obstetrics and gynecology, was also at Women & Infants that day, supervising and teaching Brown University medical residents. At the time she was admitted, Ms. Cappuccilli was full term and in labor with her fifth child. Although he was not Ms. Cappuccilli's primary obstetrician, Dr. Tawfik "Fred" Hawwa cared for her upon her admittance.[3] Ms. Cappuccilli testified that "everything [was] fine, the baby's heart rate[, ] everything was going great."

         But Ms. Cappuccilli's labor soon took a turn for the worse when her baby began evidencing signs of distress between 12:22 p.m. and 12:29 p.m. At trial, Ms. Cappuccilli recalled "all of a sudden * * * his heart rate was dropping tremendously." As a result of the fetal bradycardia, [4] Dr. Hawwa determined that Ms. Cappuccilli needed an emergency C-section. Doctor Hawwa, unavailable to do the surgery himself, called Dr. Carcieri and asked him to perform the procedure as soon as possible. Doctor Carcieri had had no previous contact with Ms. Cappuccilli, but he nevertheless agreed; and he began the emergency C-section.

         A. The C-Section

         Doctor Carcieri delivered "a very healthy baby" without any complications. Soon after the baby's delivery, however, problems arose with Ms. Cappuccilli. Doctor Carcieri testified that Ms. Cappuccilli's uterus had an "odd coloration" of a "purplish appearance" and resembled what is referred to as a "Couvelaire uterus."[5] Doctor Carcieri exteriorized[6] the uterus to get a closer look at the uterine incision, encountering no resistance in doing so. Upon further observation, Dr. Carcieri discovered a two-centimeter extension of the uterine incision, [7] which is a horizontal cut in the uterus through which the baby is removed. Doctor Carcieri stitched the incision along with its lengthened extension and returned the uterus.

         Nevertheless, the extension continued bleeding. Doctor Hawwa, who had since joined Dr. Carcieri in the operating room, "scrubbed in" to help stop the bleeding. They soon discovered that the bleeding derived from the retroperitoneum, [8] which is where the ovarian vein is located. Doctor Carcieri testified that Dr. Hawwa "proceeded to open the retroperitoneum * * * and clean out all that clot and clean out all that irregular blood" and that it was then that the bleeding intensified. Doctor Carcieri described the bleeding as like "cranberry sauce * * * it just came pouring out." Doctor Hawwa recalled that the blood "clotted and it looked like it had been there for a while. It almost looked like * * * jello." Doctor Hawwa estimated based on the blood's appearance and consistency that it had been there for "a while. Between 45, 30 minutes to an hour."

         Doctor Carcieri and Dr. Hawwa testified that they soon discovered the source of the massive bleeding: the ovarian vein had separated into two pieces, referred to in the medical records as an ovarian vein laceration. Doctor Carcieri testified that he and Dr. Hawwa attempted to "tie [the vein] off twice, " but "it was very odd. It was almost like tissue paper so when we tied it, put a tie on it * * * it immediately broke away." Doctor Hawwa testified that "the vein was very, very friable, like, it just crumbled." After Dr. Carcieri and Dr. Hawwa were unable to stop the bleeding, Dr. Richard Moore assisted. Doctor Moore ultimately succeeded in controlling the bleeding, but not before Ms. Cappuccilli lost between 5, 000 and 8, 000 cubic centimeters of blood-more blood than she had in her body.[9]

         B. C-Section Aftermath

         Following her surgery, Ms. Cappuccilli was transferred to the Trauma Intensive Care Unit at Rhode Island Hospital, where she required two more surgeries and remained in a medically-induced coma for a short time. After the procedure, Ms. Cappuccilli was "terribly traumatized by [the] whole thing." When released from the hospital, she experienced severe abdominal pains and swelling in her limbs. She continues to receive treatments for what she testified was diagnosed as lymphedema, a condition that causes swelling in her abdomen, legs, and upper body.[10] She also testified that she began seeing a psychiatrist-Dr. Carmen Monzon-for treatment of depression, anxiety, and nightmares, and started taking medication at Dr. Monzon's direction. Doctor Monzon believed that Ms. Cappuccilli could be suffering from Post-Traumatic Stress Disorder. Ms. Cappuccilli alleges that Women & Infants' risk- management team paid for her prescription for Zoloft[11] in August 2006; the admission of evidence concerning that payment is at issue in this appeal.

         Moreover, although her son-Robert-was delivered successfully, he received a two-to-three centimeter wound to his right temple, described in a record as a "laceration from scalpel." The admissibility of a photograph of Robert's injury and of a medical record referencing it is also at issue in this appeal.

         C. Timing and Nature of Lacerated Ovarian Vein

         At trial, Ms. Cappuccilli and defendants disputed the condition of her ovarian vein, as well as the timing of its opening. Doctor Carcieri testified that he believed that the vein was abnormal. Based on this belief, he testified that the vein ruptured by itself prior to the C-section. Further, he thought that the bleeding from the vein rupture caused the fetal distress that necessitated the emergency C-section. Doctor Carcieri testified that neither he nor Dr. Hawwa were able to tie the vein off because "it was not a normal vein." Doctor Carcieri described that the vein felt "like tissue paper when [he] touched it, " unlike any other vein he had encountered.

         Ms. Cappuccilli disputed Dr. Carcieri's characterization of the vein as abnormal in part because Dr. Carcieri did not notify either Ms. Cappuccilli or Women & Infants about the alleged abnormality, nor did he reference it in his operative note.[12] Ms. Cappuccilli instead believed that the vein injury occurred during the C-section at the hands of Dr. Carcieri. She pointed to numerous records kept at Women & Infants and Rhode Island Hospital to support that claim.[13]Doctor Carcieri disputed the reliability of this evidence, testifying that often the person dictating these records is the "low man on the totem pole" and is not someone intimately involved in the case. In addition, Dr. Moore testified that "there are many records made in the medical records that are not fact." He further described some of the records as "medical record notes that were cut and paste, whether they were done by an intern or medical assistant * * *."

         In line with Dr. Carcieri and Dr. Hawwa's testimony, Dr. Moore testified that, based on the injury's location, he did not believe a scalpel lacerated the vein, stating: "I don't see how you get to that area in the span of doing a C-section." He believed that the "bleeding had been happening in that retroperitoneum space long before [Dr. Carcieri and Dr. Hawwa] opened it, " based on the large collection of blood already in the area. Doctor Moore also reiterated that "[t]his was a vein that was like tissue paper. In fact, it was like wet tissue paper * * *. This was an abnormal vein." He continued, "the difficulty of ligating that vein off was because it was friable, it was venous complex, it was torturous and it was very abnormal and very difficult to tie off. I have tied up thousands of infundibulum ligaments, ovarian veins and this is not a normal vein that I have tied off before." Similarly, Dr. Hawwa testified that, after he had trouble tying the vein, he determined that "this vein is not a normal vein. I have never seen anything like it before and I have never seen anything like it since then. It is, it is a tough vein. * * * [W]e were discussing that something must be wrong with this vein, otherwise it would have taken the tie. A vein should take a tie and hold steady."

         D. Expert Testimony at Trial

         On March 20, 2009, Ms. Cappuccilli filed a medical malpractice action against defendants alleging that they negligently cut or tore her ovarian vein during the C-section. Over the course of a three-and-a-half-week trial, each side presented expert testimony, and a total of fifteen witnesses testified: eleven on behalf of plaintiff and four on behalf of defendants. The plaintiff presented Dr. Fred Duboe, an obstetrician gynecologist, who gave his opinion that the injury occurred during the C-section and is not an injury that would occur absent negligence. Doctor Duboe further noted that "the most likely mechanism for the injury was through forceful manipulation of the uterus exteriorizing it or placing it back into the incision upon repair of the uterine incision." Alternatively, Dr. Duboe also maintained that the laceration could have occurred during dissection into the retroperitoneal area and, contrary to Dr. Carcieri's contention, said that such an injury is not anatomically impossible. In addition, plaintiff presented vascular expert Dr. Paul Collier to support her theory that the vein was injured during the C-section. Doctor Collier offered the opinion that the vein did not rupture spontaneously prior to the C-section because, if it had, Ms. Cappuccilli's medical condition would have destabilized more than it had. Doctor Collier also gave the opinion that plaintiff's veins were not abnormal and, instead, the tissue-paper-like quality is "to be expected."

         The defendants presented Dr. Michael Arnold, also a specialist in obstetrics and gynecology, who testified to his belief that the bleeding began prior to the procedure and "wasn't something that had happened immediately at the time of the surgery." Rather, basing his opinion on the amount of blood, changes in Ms. Cappuccilli's anesthesia record, and her uterus's Couvelaire appearance, Dr. Arnold believed that Ms. Cappuccilli's ovarian vein spontaneously ruptured around 12:15 p.m. Doctor Arnold also rejected Dr. Duboe's testimony that exteriorizing the uterus can damage the ovarian vein, commenting that it "anatomically and physically * * * doesn't make sense." Finally, defendants presented Dr. Robert Higgins, who opined that Ms. Cappuccilli was not diagnosed with lymphedema, but rather with edema and swelling of the limbs.

         E. Motion for New Trial

         The trial justice charged the jury on two theories of negligence: (1) a traditional departure from the standard of care; and (2) res ipsa loquitur. On October 29, 2014, the jury returned a verdict for defendants. The plaintiff moved for a new trial, and the trial justice heard arguments on November 25, 2014. During the motion hearing, plaintiff claimed the jury "bought" the story that the vein ruptured spontaneously despite overwhelming circumstantial evidence that the injury occurred during the C-section rather than before it. The plaintiff alleged that the defense's theory that the vein ruptured spontaneously was "manufactured" and stemmed solely from Dr. Carcieri, Dr. Hawwa, and Dr. Moore's testimony, which plaintiff believed was not credible due to contradicting evidence. She urged the trial justice to "make a finding that those three doctors are not worthy of belief."

         In a bench decision, the trial justice denied the motion for new trial. In his ruling, he explained that his "independent review of the evidence * * * leads to the conclusion that reasonable minds could differ on this critical issue." The trial justice continued that "one assigned expert was [not] substantially better qualified or more credible and more worthy of belief than the others. The battle of the experts in this case can best be described as a draw." He concluded: "Simply put, the evidence relating to negligence on the part of Dr. Carcieri was equivocal." The plaintiff timely appealed on December 12, 2014.

         II Standard of Review

         When "plaintiffs raise multiple issues on appeal, our standard of review differs with respect to each issue." Bates-Bridgmon v. Heong's Market, Inc., 152 A.3d 1137, 1143 (R.I. 2017).

         A. Denial of a Motion for New Trial

         In deciding a motion for new trial, a trial justice independently appraises "'the evidence in the light of his [or her] charge to the jury' and 'may set aside a verdict when [his or her] judgment tells [him or her] that it is wrong because it fails to respond truly to the merits of the controversy and to administer substantial justice and is against the fair preponderance of the evidence.'" Martin v. Lawrence, 79 A.3d 1275, 1283 (R.I. 2013) (quoting Connor v. Schlemmer, 996 A.2d 98, 114-15 (R.I. 2010)). "If, after conducting this analysis, the trial justice concludes that the evidence is evenly balanced or that reasonable minds could differ on the verdict, she [or he] should not disturb the jury's decision." Id. (quoting Accetta v. Provencal, 962 A.2d 56, 62 (R.I. 2009)) (emphasis added).

         "This Court will not upset that determination unless the moving party demonstrates that the trial justice overlooked or misconceived material and relevant evidence or was otherwise clearly wrong." Bates-Bridgmon, 152 A.3d at 1144 (quoting Free & Clear Co. v. Narragansett Bay Commission, 131 A.3d 1102, 1109 (R.I. 2016)). "[T]he trial justice need not engage in an exhaustive review and analysis of the evidence and testimony presented at trial * * * [but] need only make reference to such facts disclosed by the testimony as have motivated his or her conclusion." Hough v. McKiernan, 101 A.3d 853, 856 (R.I. 2014) (quoting Bourdon's, Inc. v. Ecin Industries, Inc., 704 A.2d 747, 758 (R.I. 1997)).

         B. Evidentiary Rulings

         "Generally, the admissibility of evidence 'is within the sound discretion of the trial justice' * * *." Martin, 79 A.3d at 1281 (quoting Fravala v. City of Cranston, 996 A.2d 696, 703 (R.I. 2010)). "[T]his Court will not interfere with the trial justice[']s decision unless a clear abuse of that discretion is apparent." Berman v. Sitrin, 101 ...

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