FIRSTDIVISION

[G.R.No.124354.December29,1999]

ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural
guardiansoftheminors,ROMMELRAMOS,ROYRODERICKRAMOSandRON
RAYMOND RAMOS, petitioners, vs. COURT OF APPEALS, DELOS SANTOS
MEDICAL CENTER, DR. ORLINO HOSAKA and DRA. PERFECTA
GUTIERREZ,respondents.

DECISION
KAPUNAN,J.:

The Hippocratic Oath mandates physicians to give primordial consideration to the health and welfare of
theirpatients.Ifadoctorfailstoliveuptothisprecept,heismadeaccountableforhisacts.Amistake,through
grossnegligenceorincompetenceorplainhumanerror,mayspellthedifferencebetweenlifeanddeath.Inthis
sense,thedoctorplaysGodonhispatientsfate.[1]
In the case at bar, the Court is called upon to rule whether a surgeon, an anesthesiologist and a hospital
shouldbemadeliablefortheunfortunatecomatoseconditionofapatientscheduledforcholecystectomy.[2]
Petitioners seek the reversal of the decision[3] of the Court of Appeals, dated 29 May 1995, which
overturnedthedecision[4]oftheRegionalTrialCourt,dated30January1992,findingprivaterespondentsliable
fordamagesarisingfromnegligenceintheperformanceoftheirprofessionaldutiestowardspetitionerErlinda
Ramosresultinginhercomatosecondition.
Theantecedentfactsassummarizedbythetrialcourtarereproducedhereunder:

Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985, a 47-year old (Exh. A) robust woman (TSN,
October 19, 1989, p. 10). Except for occasional complaints of discomfort due to pains allegedly caused by the
presence of a stone in her gall bladder (TSN, January 13, 1988, pp. 4-5), she was as normal as any other woman.
Married to Rogelio E. Ramos, an executive of Philippine Long Distance Telephone Company, she has three
children whose names are Rommel Ramos, Roy Roderick Ramos and Ron Raymond Ramos (TSN, October 19,
1989, pp. 5-6).

Because the discomforts somehow interfered with her normal ways, she sought professional advice. She was
advised to undergo an operation for the removal of a stone in her gall bladder (TSN, January 13, 1988, p. 5). She
underwent a series of examinations which included blood and urine tests (Exhs. A and C) which indicated she
was t for surgery.

Through the intercession of a mutual friend, Dr. Buenviaje (TSN, January 13, 1988, p. 7), she and her husband
Rogelio met for the rst time Dr. Orlino Hozaka (should be Hosaka; see TSN, February 20, 1990, p. 3), one of
the defendants in this case, on June 10, 1985. They agreed that their date at the operating table at the DLSMC
(another defendant), would be on June 17, 1985 at 9:00 A.M.. Dr. Hosaka decided that she should undergo a
cholecystectomy operation after examining the documents (ndings from the Capitol Medical Center, FEU
Hospital and DLSMC) presented to him. Rogelio E. Ramos, however, asked Dr. Hosaka to look for a good
anesthesiologist. Dr. Hosaka, in turn, assured Rogelio that he will get a good anesthesiologist. Dr. Hosaka
charged a fee of P16,000.00, which was to include the anesthesiologists fee and which was to be paid after the
operation (TSN, October 19, 1989, pp. 14-15, 22-23, 31-33; TSN, February 27, 1990, p. 13; and TSN, November
9, 1989, pp. 3-4, 10, 17).

A day before the scheduled date of operation, she was admitted at one of the rooms of the DLSMC, located
along E. Rodriguez Avenue, Quezon City (TSN, October 19, 1989, p. 11).

At around 7:30 A.M. of June 17, 1985 and while still in her room, she was prepared for the operation by the
hospital staff. Her sister-in-law, Herminda Cruz, who was the Dean of the College of Nursing at the Capitol
Medical Center, was also there for moral support. She reiterated her previous request for Herminda to be with
her even during the operation. After praying, she was given injections. Her hands were held by Herminda as they
went down from her room to the operating room (TSN, January 13, 1988, pp. 9-11). Her husband, Rogelio, was
also with her (TSN, October 19, 1989, p. 18). At the operating room, Herminda saw about two or three nurses
and Dr. Perfecta Gutierrez, the other defendant, who was to administer anesthesia. Although not a member of the
hospital staff, Herminda introduced herself as Dean of the College of Nursing at the Capitol Medical Center who
was to provide moral support to the patient, to them. Herminda was allowed to stay inside the operating room.

At around 9:30 A.M., Dr. Gutierrez reached a nearby phone to look for Dr. Hosaka who was not yet in (TSN,
January 13, 1988, pp. 11-12). Dr. Gutierrez thereafter informed Herminda Cruz about the prospect of a delay in
the arrival of Dr. Hosaka. Herminda then went back to the patient who asked, Mindy, wala pa ba ang Doctor?
The former replied, Huwag kang mag-alaala, darating na iyon (ibid.).

Thereafter, Herminda went out of the operating room and informed the patients husband, Rogelio, that the doctor
was not yet around (id., p. 13). When she returned to the operating room, the patient told her, Mindy, inip na inip
na ako, ikuha mo ako ng ibang Doctor. So, she went out again and told Rogelio about what the patient said (id.,
p. 15). Thereafter, she returned to the operating room.

At around 10:00 A.M., Rogelio E. Ramos was already dying [and] waiting for the arrival of the doctor even as
he did his best to nd somebody who will allow him to pull out his wife from the operating room (TSN, October
19, 1989, pp. 19-20). He also thought of the feeling of his wife, who was inside the operating room waiting for
the doctor to arrive (ibid.). At almost 12:00 noon, he met Dr. Garcia who remarked that he (Dr. Garcia) was also
tired of waiting for Dr. Hosaka to arrive (id., p. 21). While talking to Dr. Garcia at around 12:10 P.M., he came to
know that Dr. Hosaka arrived as a nurse remarked, Nandiyan na si Dr. Hosaka, dumating na raw. Upon hearing
those words, he went down to the lobby and waited for the operation to be completed (id., pp. 16, 29-30).

At about 12:15 P.M., Herminda Cruz, who was inside the operating room with the patient, heard somebody say
that Dr. Hosaka is already here. She then saw people inside the operating room moving, doing this and that, [and]
preparing the patient for the operation (TSN, January 13, 1988, p. 16). As she held the hand of Erlinda Ramos,
she then saw Dr. Gutierrez intubating the hapless patient. She thereafter heard Dr. Gutierrez say, ang hirap ma-
intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan (id., p. 17). Because of the remarks of Dra.
Gutierrez, she focused her attention on what Dr. Gutierrez was doing. She thereafter noticed bluish discoloration
of the nailbeds of the left hand of the hapless Erlinda even as Dr. Hosaka approached her. She then heard Dr.
Hosaka issue an order for someone to call Dr. Calderon, another anesthesiologist (id., p. 19). After Dr. Calderon
arrived at the operating room, she saw this anesthesiologist trying to intubate the patient. The patients nailbed
became bluish and the patient was placed in a trendelenburg position - a position where the head of the patient is
placed in a position lower than her feet which is an indication that there is a decrease of blood supply to the
patients brain (Id., pp. 19-20). Immediately thereafter, she went out of the operating room, and she told Rogelio
E. Ramos that something wrong was x x x happening (Ibid.). Dr. Calderon was then able to intubate the patient
(TSN, July 25, 1991, p. 9).

Meanwhile, Rogelio, who was outside the operating room, saw a respiratory machine being rushed towards the
door of the operating room. He also saw several doctors rushing towards the operating room. When informed by
Herminda Cruz that something wrong was happening, he told her (Herminda) to be back with the patient inside
the operating room (TSN, October 19, 1989, pp. 25-28).
Herminda Cruz immediately rushed back, and saw that the patient was still in trendelenburg position (TSN,
January 13, 1988, p. 20). At almost 3:00 P.M. of that fateful day, she saw the patient taken to the Intensive Care
Unit (ICU).

About two days thereafter, Rogelio E. Ramos was able to talk to Dr. Hosaka. The latter informed the former that
something went wrong during the intubation. Reacting to what was told to him, Rogelio reminded the doctor that
the condition of his wife would not have happened, had he (Dr. Hosaka) looked for a good anesthesiologist
(TSN, October 19, 1989, p. 31).

Doctors Gutierrez and Hosaka were also asked by the hospital to explain what happened to the patient. The
doctors explained that the patient had bronchospasm (TSN, November 15, 1990, pp. 26-27).

Erlinda Ramos stayed at the ICU for a month. About four months thereafter or on November 15, 1985, the
patient was released from the hospital.

During the whole period of her connement, she incurred hospital bills amounting to P93,542.25 which is the
subject of a promissory note and afdavit of undertaking executed by Rogelio E. Ramos in favor of DLSMC.
Since that fateful afternoon of June 17, 1985, she has been in a comatose condition. She cannot do anything. She
cannot move any part of her body. She cannot see or hear. She is living on mechanical means. She suffered brain
damage as a result of the absence of oxygen in her brain for four to ve minutes (TSN, November 9, 1989, pp.
21-22). After being discharged from the hospital, she has been staying in their residence, still needing constant
medical attention, with her husband Rogelio incurring a monthly expense ranging from P8,000.00 to P10,000.00
(TSN, October 19, 1989, pp. 32-34). She was also diagnosed to be suffering from diffuse cerebral parenchymal
damage (Exh. G; see also TSN, December 21, 1989, p. 6).[5]

Thus, on 8 January 1986, petitioners filed a civil case[6] for damages with the Regional Trial Court of
Quezon City against herein private respondents alleging negligence in the management and care of Erlinda
Ramos.
During the trial, both parties presented evidence as to the possible cause of Erlindas injury. Plaintiff
presentedthetestimoniesofDeanHermindaCruzandDr.MarianoGavinotoprovethatthedamagesustainedby
Erlinda was due to lack of oxygen in her brain caused by the faulty management of her airway by private
respondentsduringtheanesthesiaphase.Ontheotherhand,privaterespondentsprimarilyreliedontheexpert
testimony of Dr. Eduardo Jamora, a pulmonologist, to the effect that the cause of brain damage was Erlindas
allergicreactiontotheanestheticagent,ThiopentalSodium(Pentothal).
After considering the evidence from both sides, the Regional Trial Court rendered judgment in favor of
petitioners,towit:

After evaluating the evidence as shown in the nding of facts set forth earlier, and applying the aforecited
provisions of law and jurisprudence to the case at bar, this Court nds and so holds that defendants are liable to
plaintiffs for damages. The defendants were guilty of, at the very least, negligence in the performance of their
duty to plaintiff-patient Erlinda Ramos.

On the part of Dr. Perfecta Gutierrez, this Court nds that she omitted to exercise reasonable care in not only
intubating the patient, but also in not repeating the administration of atropine (TSN, August 20, 1991, pp. 5-10),
without due regard to the fact that the patient was inside the operating room for almost three (3) hours. For after
she committed a mistake in intubating [the] patient, the patient's nailbed became bluish and the patient,
thereafter, was placed in trendelenburg position, because of the decrease of blood supply to the patient's brain.
The evidence further shows that the hapless patient suffered brain damage because of the absence of oxygen in
her (patient's) brain for approximately four to ve minutes which, in turn, caused the patient to become
comatose.

On the part of Dr. Orlino Hosaka, this Court nds that he is liable for the acts of Dr. Perfecta Gutierrez whom he
had chosen to administer anesthesia on the patient as part of his obligation to provide the patient a `good
anesthesiologist', and for arriving for the scheduled operation almost three (3) hours late.

On the part of DLSMC (the hospital), this Court nds that it is liable for the acts of negligence of the doctors in
their `practice of medicine' in the operating room. Moreover, the hospital is liable for failing through its
responsible ofcials, to cancel the scheduled operation after Dr. Hosaka inexcusably failed to arrive on time.

In having held thus, this Court rejects the defense raised by defendants that they have acted with due care and
prudence in rendering medical services to plaintiff-patient. For if the patient was properly intubated as claimed
by them, the patient would not have become comatose. And, the fact that another anesthesiologist was called to
try to intubate the patient after her (the patient's) nailbed turned bluish, belie their claim. Furthermore, the
defendants should have rescheduled the operation to a later date. This, they should have done, if defendants acted
with due care and prudence as the patient's case was an elective, not an emergency case.

xxx

WHEREFORE, and in view of the foregoing, judgment is rendered in favor of the plaintiffs and against the
defendants. Accordingly, the latter are ordered to pay, jointly and severally, the former the following sums of
money, to wit:

1) the sum of P8,000.00 as actual monthly expenses for the plaintiff Erlinda Ramos reckoned from November
15, 1985 or in the total sum of P632,000.00 as of April 15, 1992, subject to its being updated;

2) the sum of P100,000.00 as reasonable attorney's fees;

3) the sum of P800,000.00 by way of moral damages and the further sum of P200,000.00 by way of exemplary
damages; and,

4) the costs of the suit.

SO ORDERED.[7]

PrivaterespondentsseasonablyinterposedanappealtotheCourtofAppeals.Theappellatecourtrendereda
Decision,dated29May1995,reversingthefindingsofthetrialcourt.Thedecretalportionofthedecisionofthe
appellatecourtreads:

WHEREFORE, for the foregoing premises the appealed decision is hereby REVERSED, and the complaint
below against the appellants is hereby ordered DISMISSED. The counterclaim of appellant De Los Santos
Medical Center is GRANTED but only insofar as appellees are hereby ordered to pay the unpaid hospital bills
amounting to P93,542.25, plus legal interest for justice must be tempered with mercy.

SO ORDERED.[8]

ThedecisionoftheCourtofAppealswasreceivedon9June1995bypetitionerRogelioRamoswhowas
mistakenlyaddressedasAtty.RogelioRamos.Nocopyofthedecision,however,wassentnorreceivedbythe
CoronelLawOffice,thencounselonrecordofpetitioners.Rogelioreferredthedecisionoftheappellatecourtto
a new lawyer, Atty. Ligsay, only on 20 June 1995, or four (4) days before the expiration of the reglementary
period for filing a motion for reconsideration. On the same day, Atty. Ligsay, filed with the appellate court a
motionforextensionoftimetofileamotionforreconsideration.Themotionforreconsiderationwassubmitted
on4July1995.However,theappellatecourtdeniedthemotionforextensionoftimeinitsResolutiondated25
July 1995.[9] Meanwhile petitioners engaged the services of another counsel, Atty. Sillano, to replace Atty.
Ligsay.Atty.Sillanofiledon7August1995amotiontoadmitthemotionforreconsiderationcontendingthatthe
period to file the appropriate pleading on the assailed decision had not yet commenced to run as the Division
ClerkofCourtoftheCourtofAppealshadnotyetservedacopythereoftothecounselonrecord.Despitethis
explanation,theappellatecourtstilldeniedthemotiontoadmitthemotionforreconsiderationofpetitionersin
itsResolution,dated29March1996,primarilyonthegroundthatthefifteenday(15)periodforfilingamotion
forreconsiderationhadalreadyexpired,towit:

We said in our Resolution on July 25, 1995, that the ling of a Motion for Reconsideration cannot be extended;
precisely, the Motion for Extension (Rollo, p. 12) was denied. It is, on the other hand, admitted in the latter
Motion that plaintiffs/appellees received a copy of the decision as early as June 9, 1995. Computation wise, the
period to le a Motion for Reconsideration expired on June 24. The Motion for Reconsideration, in turn, was
received by the Court of Appeals already on July 4, necessarily, the 15-day period already passed. For that alone,
the latter should be denied.

Even assuming admissibility of the Motion for Reconsideration, but after considering the Comment/Opposition,
the former, for lack of merit, is hereby DENIED.

SO ORDERED.[10]

AcopyoftheaboveresolutionwasreceivedbyAtty.Sillanoon11April1996.Thenextday,oron12April
1996,Atty.SillanofiledbeforethisCourtamotionforextensionoftimetofilethepresentpetitionforcertiorari
underRule45.The Court granted the motion for extension of time and gave petitioners additional thirty (30)
daysaftertheexpirationofthefifteenday(15)periodcountedfromthereceiptoftheresolutionoftheCourtof
Appealswithinwhichtosubmitthepetition.Theduedatefellon27May1996.Thepetitionwasfiledon9May
1996,wellwithintheextendedperiodgivenbytheCourt.
PetitionersassailthedecisionoftheCourtofAppealsonthefollowinggrounds:
I

IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF RESPONDENTS DRA. GUTIERREZ,

DRA. CALDERON AND DR. JAMORA;
II

IN FINDING THAT THE NEGLIGENCE OF THE RESPONDENTS DID NOT CAUSE THE
UNFORTUNATE COMATOSE CONDITION OF PETITIONER ERLINDA RAMOS;
III

IN NOT APPLYING THE DOCTRINE OF RES IPSA LOQUITUR.[11]

Beforewediscussthemeritsofthecase,weshallfirstdisposeoftheproceduralissueonthetimelinessof
thepetitioninrelationtothemotionforreconsiderationfiledbypetitionerswiththeCourtofAppeals.Intheir
Comment,[12]privaterespondentscontendthatthepetitionshouldnotbegivenduecoursesincethemotionfor
reconsiderationofthepetitionersonthedecisionoftheCourtofAppealswasvalidlydismissedbytheappellate
courtforhavingbeenfiledbeyondthereglementaryperiod.Wedonotagree.
A careful review of the records reveals that the reason behind the delay in filing the motion for
reconsiderationisattributabletothefactthatthedecisionoftheCourtofAppealswasnotsenttothencounselon
recordofpetitioners,theCoronelLawOffice.Infact,acopyofthedecisionoftheappellatecourtwasinstead
senttoandreceivedbypetitionerRogelioRamoson9June1995whereinhewasmistakenlyaddressedasAtty.
RogelioRamos.BasedontheothercommunicationsreceivedbypetitionerRogelioRamos,theappellatecourt
apparently mistook him for the counsel on record. Thus, no copy of the decision of the appellate court was
furnished to the counsel on record. Petitioner, not being a lawyer and unaware of the prescriptive period for
filingamotionforreconsideration,referredthesametoalegalcounselonlyon20June1995.
Itiselementarythatwhenapartyisrepresentedbycounsel,allnoticesshouldbesenttothepartyslawyerat
hisgivenaddress.Withafewexceptions,noticetoalitigantwithoutnoticetohiscounselonrecordisnonotice
atall.Inthepresentcase,sinceacopyofthedecisionoftheappellatecourtwasnotsenttothecounselonrecord
of petitioner, there can be no sufficient notice to speak of. Hence, the delay in the filing of the motion for
reconsiderationcannotbetakenagainstpetitioner.Moreover,sincetheCourtofAppealsalreadyissuedasecond
Resolution,dated29March1996,whichsupersededtheearlierresolutionissuedon25July1995,anddeniedthe
motion for reconsideration of petitioner, we believe that the receipt of the former should be considered in
determining the timeliness of the filing of the present petition. Based on this, the petition before us was
submittedontime.
Afterresolvingthe foregoing procedural issue, we shall now look into the meritsofthecase.For a more
logicalpresentationofthediscussionweshallfirstconsidertheissueontheapplicabilityofthedoctrineofres
ipsaloquiturtotheinstantcase.Thereafter, the first two assigned errors shall be tackled in relation to the res
ipsaloquiturdoctrine.
ResipsaloquiturisaLatinphrasewhichliterallymeansthethingorthetransactionspeaksforitself.The
phrase res ipsa loquitur is a maxim for the rule that the fact of the occurrence of an injury, taken with the
surrounding circumstances, may permit an inference or raise a presumption of negligence, or make out a
plaintiffsprimafaciecase,andpresentaquestionoffactfordefendanttomeetwithanexplanation.[13]Where
thethingwhichcausedtheinjurycomplainedofisshowntobeunderthemanagementofthedefendantorhis
servants and the accident is such as in ordinary course of things does not happen if those who have its
management or control use proper care, it affords reasonable evidence, in the absence of explanation by the
defendant,thattheaccidentarosefromorwascausedbythedefendantswantofcare.[14]
The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a matter of common
knowledgeandexperience,theverynatureofcertaintypesofoccurrencesmayjustifyaninferenceofnegligence
onthepartofthepersonwhocontrolstheinstrumentalitycausingtheinjuryintheabsenceofsomeexplanation
by the defendant who is charged with negligence.[15] It is grounded in the superior logic of ordinary human
experience and on the basis of such experience or common knowledge, negligence may be deduced from the
mereoccurrenceoftheaccidentitself.[16]Hence,resipsaloquiturisappliedinconjunctionwiththedoctrineof
commonknowledge.
However,muchhasbeensaidthatresipsaloquiturisnotaruleofsubstantivelawand,assuch,doesnot
create or constitute an independent or separate ground of liability.[17] Instead, it is considered as merely
evidentiary or in the nature of a procedural rule.[18] It is regarded as a mode of proof, or a mere procedural
conveniencesinceitfurnishesasubstitutefor,andrelievesaplaintiffof,theburdenofproducingspecificproof
of negligence.[19] In other words, mere invocation and application of the doctrine does not dispense with the
requirementofproofofnegligence.It is simply a step in the process of such proof, permitting the plaintiff to
present along with the proof of the accident, enough of the attending circumstances to invoke the doctrine,
creatinganinferenceorpresumptionofnegligence,andtotherebyplaceonthedefendanttheburdenofgoing
forwardwiththeproof.[20]Still,beforeresorttothedoctrinemaybeallowed,thefollowingrequisitesmustbe
satisfactorilyshown:
1.Theaccidentisofakindwhichordinarilydoesnotoccurintheabsenceofsomeonesnegligence
2.Itiscausedbyaninstrumentalitywithintheexclusivecontrolofthedefendantordefendantsand

3.Thepossibilityofcontributingconductwhichwouldmaketheplaintiffresponsibleiseliminated.[21]
In the above requisites, the fundamental element is the control of the instrumentality which caused the
damage.[22]Suchelementofcontrolmustbeshowntobewithinthedominionofthedefendant.Inordertohave
the benefit of the rule, a plaintiff, in addition to proving injury or damage, must show a situation where it is
applicable,andmustestablishthattheessentialelementsofthedoctrinewerepresentinaparticularincident.[23]
Medicalmalpractice[24]casesdonotescapetheapplicationofthisdoctrine.Thus,resipsaloquiturhasbeen
applied when the circumstances attendant upon the harm are themselves of such a character as to justify an
inferenceofnegligenceasthecauseofthatharm.[25]Theapplicationofresipsaloquiturinmedicalnegligence
casespresentsaquestionoflawsinceitisajudicialfunctiontodeterminewhetheracertainsetofcircumstances
does,asamatteroflaw,permitagiveninference.[26]
 Althoughgenerally,expertmedicaltestimonyisrelieduponinmalpracticesuitstoprovethataphysician
hasdoneanegligentactorthathehasdeviatedfromthestandardmedicalprocedure,whenthedoctrineofres
ipsa loquitur is availed by the plaintiff, the need for expert medical testimony is dispensed with because the
injuryitselfprovidestheproofofnegligence.[27]Thereasonisthatthegeneralruleonthenecessityofexpert
testimonyappliesonlytosuchmattersclearlywithinthedomainofmedicalscience,andnottomattersthatare
within the common knowledge of mankind which may be testified to by anyone familiar with the facts.[28]
Ordinarily,onlyphysiciansandsurgeonsofskillandexperiencearecompetenttotestifyastowhetherapatient
has been treated or operated upon with a reasonable degree of skill and care. However, testimony as to the
statements and acts of physicians and surgeons, external appearances, and manifest conditions which are
observablebyanyonemaybegivenbynonexpertwitnesses.[29]Hence,incaseswheretheresipsaloquituris
applicable,thecourtispermittedtofindaphysiciannegligentuponproperproofofinjurytothepatient,without
the aid of expert testimony, where the court from its fund of common knowledge can determine the proper
standard of care.[30] Where common knowledge and experience teach that a resulting injury would not have
occurredtothepatientifduecarehadbeenexercised,aninferenceofnegligencemaybedrawngivingrisetoan
applicationofthedoctrineofresipsaloquiturwithoutmedicalevidence,whichisordinarilyrequiredtoshow
notonlywhatoccurredbuthowandwhyitoccurred.[31]Whenthedoctrineisappropriate,allthatthepatient
mustdoisproveanexusbetweentheparticularactoromissioncomplainedofandtheinjurysustainedwhile
under the custody and management of the defendant without need to produce expert medical testimony to
establishthestandardofcare.Resorttoresipsaloquiturisallowedbecausethereisnootherway,underusual
andordinaryconditions,bywhichthepatientcanobtainredressforinjurysufferedbyhim.
Thus,courtsofotherjurisdictionshaveappliedthedoctrineinthefollowingsituations:leavingofaforeign
objectinthebodyofthepatientafteranoperation,[32]injuriessustainedonahealthypartofthebodywhichwas
notunder,orinthearea,oftreatment,[33]removalofthewrongpartofthebodywhenanotherpartwasintended,
[34]knockingoutatoothwhileapatientsjawwasunderanestheticfortheremovalofhistonsils,[35]andlossof
an eye while the patient plaintiff was under the influence of anesthetic, during or following an operation for
appendicitis,[36]amongothers.
Nevertheless,despitethefactthatthescopeofresipsaloquiturhasbeenmeasurablyenlarged,itdoesnot
automatically apply to all cases of medical negligence as to mechanically shift the burden of proof to the
defendanttoshowthatheisnotguiltyoftheascribednegligence.Resipsaloquitur is not a rigid or ordinary
doctrinetobeperfunctorilyusedbutaruletobecautiouslyapplied,dependinguponthecircumstancesofeach
case.It is generally restricted to situations in malpractice cases where a layman is able to say, as a matter of
common knowledge and observation, that the consequences of professional care were not as such as would
ordinarilyhavefollowedifduecarehadbeenexercised.[37]Adistinctionmustbemadebetweenthefailureto
secureresults,andtheoccurrenceofsomethingmoreunusualandnotordinarilyfoundiftheserviceortreatment
renderedfollowedtheusualprocedureofthoseskilledinthatparticularpractice.It mustbeconceded that the
doctrineofresipsaloquiturcanhavenoapplicationinasuitagainstaphysicianorsurgeonwhichinvolvesthe
merits of a diagnosis or of a scientific treatment.[38] The physician or surgeon is not required at his peril to
explainwhyanyparticulardiagnosiswasnotcorrect,orwhyanyparticularscientifictreatmentdidnotproduce
thedesiredresult.[39]Thus,resipsaloquiturisnotavailableinamalpracticesuitiftheonlyshowingisthatthe
desiredresultofanoperationortreatmentwasnotaccomplished.[40]Therealquestion,therefore,iswhetheror
notintheprocessoftheoperationanyextraordinaryincidentorunusualeventoutsideoftheroutineperformance
occurred which is beyond the regular scope of customary professional activity in such operations, which, if
unexplained would themselves reasonably speak to the average man as the negligent cause or causes of the
untowardconsequence.[41]Iftherewassuchextraneousinterventions,thedoctrineofresipsaloquiturmaybe
utilizedandthedefendantiscalledupontoexplainthematter,byevidenceofexculpation,ifhecould.[42]
Wefindthedoctrineofresipsaloquiturappropriateinthecaseatbar.Aswillhereinafterbeexplained,the
damage sustained by Erlinda in her brain prior to a scheduled gall bladder operation presents a case for the
applicationofresipsaloquitur.
 AcasestrikinglysimilartotheonebeforeusisVossvs.Bridwell,[43]wheretheKansasSupremeCourtin
applyingtheresipsaloquiturstated:

The plaintiff herein submitted himself for a mastoid operation and delivered his person over to the care, custody
and control of his physician who had complete and exclusive control over him, but the operation was never
performed. At the time of submission he was neurologically sound and physically t in mind and body, but he
suffered irreparable damage and injury rendering him decerebrate and totally incapacitated. The injury was one
which does not ordinarily occur in the process of a mastoid operation or in the absence of negligence in the
administration of an anesthetic, and in the use and employment of an endoctracheal tube. Ordinarily a person
being put under anesthesia is not rendered decerebrate as a consequence of administering such anesthesia in the
absence of negligence. Upon these facts and under these circumstances a layman would be able to say, as a
matter of common knowledge and observation, that the consequences of professional treatment were not as such
as would ordinarily have followed if due care had been exercised.

Here the plaintiff could not have been guilty of contributory negligence because he was under the inuence of
anesthetics and unconscious, and the circumstances are such that the true explanation of event is more accessible
to the defendants than to the plaintiff for they had the exclusive control of the instrumentalities of anesthesia.

Upon all the facts, conditions and circumstances alleged in Count II it is held that a cause of action is stated
under the doctrine of res ipsa loquitur.[44]

Indeed,theprinciplesenunciatedintheaforequotedcaseapplywithequalforcehere.In the present case,

Erlindasubmittedherselfforcholecystectomyandexpectedaroutinegeneralsurgerytobeperformedonhergall
bladder.Onthatfatefuldayshedeliveredherpersonovertothecare,custodyandcontrolofprivaterespondents
whoexercisedcompleteandexclusivecontroloverher.Atthetimeofsubmission,Erlindawasneurologically
soundand,exceptforafewminordiscomforts,waslikewisephysicallyfitinmindandbody.However, during
theadministrationofanesthesiaandpriortotheperformanceofcholecystectomyshesufferedirreparabledamage
to her brain. Thus, without undergoing surgery, she went out of the operating room already decerebrate and
totallyincapacitated.Obviously, brain damage, which Erlinda sustained, is an injury which does not normally
occurintheprocessofagallbladderoperation.Infact,thiskindofsituationdoesnothappenintheabsenceof
negligence of someone in the administration of anesthesia and in the use of endotracheal tube. Normally, a
personbeingputunderanesthesiaisnotrendereddecerebrateasaconsequenceofadministeringsuchanesthesia
if the proper procedure was followed. Furthermore, the instruments used in the administration of anesthesia,
including the endotracheal tube, were all under the exclusive control of private respondents, who are the
physiciansincharge.Likewise,petitionerErlindacouldnothavebeenguiltyofcontributorynegligencebecause
shewasundertheinfluenceofanestheticswhichrenderedherunconscious.
Consideringthatasoundandunaffectedmemberofthebody(thebrain)isinjuredordestroyedwhilethe
patientisunconsciousandundertheimmediateandexclusivecontrolofthephysicians,weholdthatapractical
administration of justice dictates the application of res ipsa loquitur. Upon these facts and under these
circumstancestheCourtwouldbeabletosay,asamatterofcommonknowledgeandobservation,ifnegligence
attendedthemanagementandcareofthepatient.Moreover,theliabilityofthephysiciansandthehospitalinthis
caseisnotpredicateduponanallegedfailuretosecurethedesiredresultsofanoperationnoronanallegedlack
ofskillinthediagnosisortreatmentasinfactnooperationortreatmentwaseverperformedonErlinda.Thus,
uponalltheseinitialdeterminationacaseismadeoutfortheapplicationofthedoctrineofresipsaloquitur.
Nonetheless, in holding that res ipsa loquitur is available to the present case we are not saying that the
doctrineisapplicableinanyandallcaseswhereinjuryoccurstoapatientwhileunderanesthesia,ortoanyand
allanesthesiacases.Eachcasemustbeviewedinitsownlightandscrutinizedinordertobewithintheresipsa
loquiturcoverage.
Havinginmindtheapplicabilityoftheresipsaloquiturdoctrineandthepresumptionofnegligenceallowed
therein, the Court now comes to the issue of whether the Court of Appeals erred in finding that private
respondentswerenotnegligentinthecareofErlindaduringtheanesthesiaphaseoftheoperationand,ifinthe
affirmative,whethertheallegednegligencewastheproximatecauseofErlindascomatosecondition. Corollary
thereto,weshallalsodetermineiftheCourtofAppealserredinrelyingonthetestimoniesofthewitnessesfor
theprivaterespondents.
In sustaining the position of private respondents, the Court of Appeals relied on the testimonies of Dra.
Gutierrez, Dra. Calderon and Dr. Jamora. In giving weight to the testimony of Dra. Gutierrez, the Court of
Appeals rationalized that she was candid enough to admit that she experienced some difficulty in the
endotrachealintubation[45]ofthepatientandthus,cannotbesaidtobecoveringhernegligencewithfalsehood.
Theappellatecourtlikewiseopinedthatprivaterespondentswereabletoshowthatthebraindamagesustained
byErlindawasnotcausedbytheallegedfaultyintubationbutwasduetotheallergicreactionofthepatientto
the drugThiopental Sodium (Pentothal), a shortacting barbiturate, as testified on by their expert witness, Dr.
Jamora.Ontheotherhand,theappellatecourtrejectedthetestimonyofDeanHermindaCruzofferedinfavorof
petitionersthatthecauseofthebraininjurywastraceabletothewrongfulinsertionofthetubesincethelatter,
beinganurse,wasallegedlynotknowledgeableintheprocessofintubation.In soholding,theappellate court
returned a verdict in favor of respondents physicians and hospital and absolved them of any liability towards
Erlindaandherfamily.
We disagree with the findings of the Court of Appeals. We hold that private respondents were unable to
disprove the presumption of negligence on their part in the care of Erlinda and their negligence was the
proximatecauseofherpiteouscondition.
In the instant case, the records are helpful in furnishing not only the logical scientific evidence of the
pathogenesisoftheinjurybutalsoinprovidingtheCourtthelegalnexusuponwhichliabilityisbased.Aswill
beshownhereinafter,privaterespondentsowntestimonieswhicharereflectedinthetranscriptofstenographic
notesarerepleteofsignpostsindicativeoftheirnegligenceinthecareandmanagementofErlinda.
WithregardtoDra.Gutierrez,wefindhernegligentinthecareofErlindaduringtheanesthesiaphase.As
bornebytherecords,respondentDra.Gutierrezfailedtoproperlyintubatethepatient.Thisfactwasattestedto
by Prof. Herminda Cruz, Dean of the Capitol Medical Center School of Nursing and petitioner's sisterinlaw,
whowasintheoperatingroomrightbesidethepatientwhenthetragiceventoccurred.WitnessCruztestifiedto
thiseffect:
ATTY.PAJARES:
Q:Inparticular,whatdidDra.PerfectaGutierrezdo,ifanyonthepatient?
A:Inparticular,Icouldseethatshewasintubatingthepatient.
Q:DoyouknowwhathappenedtothatintubationprocessadministeredbyDra.Gutierrez?
ATTY.ALCERA:
ShewillbeincompetentYourHonor.
COURT:
Witnessmayanswerifsheknows.
A:As I have said, I was with the patient, I was beside the stretcher holding the left hand of the patient and all of a
suddenIheardsomeremarkscomingfromDra.PerfectaGutierrezherself.ShewassayingAnghirapmaintubate
nito,maliyataangpagkakapasok.Olumalakiangtiyan.
xxx
ATTY.PAJARES:
Q:Fromwhomdidyouhearthosewordslumalakiangtiyan?
A:FromDra.PerfectaGutierrez.
xxx
Afterhearingthephraselumalakiangtiyan,whatdidyounoticeonthepersonofthepatient?
A:Inotice(sic)somebluishdiscolorationonthenailbedsofthelefthandwhereIwasat.
 Q:WherewasDr.OrlinoHo[s]akathenatthatparticulartime?
A:Isawhimapproachingthepatientduringthattime.
Q:Whenheapproachedthepatient,whatdidhedo,ifany?
A:HemadeanordertocallontheanesthesiologistinthepersonofDr.Calderon.
Q:DidDr.Calderon,uponbeingcalled,arriveinsidetheoperatingroom?
A:Yessir.
Q:Whatdid[s]hedo,ifany?
A:[S]hetriedtointubatethepatient.
Q:Whathappenedtothepatient?
A:WhenDr.Calderontry(sic)tointubatethepatient,afterawhilethepatientsnailbedbecamebluishandIsawthe
patientwasplacedintrendelenburgposition.
xxx
Q:Doyouknowthereasonwhythepatientwasplacedinthattrendelenburgposition?

A:AsfarasIknow,whenapatientisinthatposition,thereisadecreaseofbloodsupplytothebrain.[46]
xxx
Theappellatecourt,however,disbelievedDeanCruz'stestimonyinthetrialcourtbydeclaringthat:

A perusal of the standard nursing curriculum in our country will show that intubation is not taught as part of
nursing procedures and techniques. Indeed, we take judicial notice of the fact that nurses do not, and cannot,
intubate. Even on the assumption that she is fully capable of determining whether or not a patient is properly
intubated, witness Herminda Cruz, admittedly, did not peep into the throat of the patient. (TSN, July 25, 1991, p.
13). More importantly, there is no evidence that she ever auscultated the patient or that she conducted any type of
examination to check if the endotracheal tube was in its proper place, and to determine the condition of the heart,
lungs, and other organs. Thus, witness Cruz's categorical statements that appellant Dra. Gutierrez failed to
intubate the appellee Erlinda Ramos and that it was Dra. Calderon who succeeded in doing so clearly suffer from
lack of sufcient factual bases.[47]

Inotherwords,whattheCourtofAppealsistryingtoimpressisthatbeinganurse,andconsideredalayman
in the process of intubation, witness Cruz is not competent to testify on whether or not the intubation was a
success.
We do not agree with the above reasoning of the appellate court. Although witness Cruz is not an
anesthesiologist, she can very well testify upon matters on which she is capable of observing such as, the
statements and acts of the physician and surgeon, external appearances, and manifest conditions which are
observablebyanyone.[48]Thisispreciselyallowedunderthedoctrineofresipsaloquiturwherethetestimony
ofexpertwitnessesisnotrequired.Itistheacceptedrulethatexperttestimonyisnotnecessaryfortheproofof
negligenceinnontechnicalmattersorthoseofwhichanordinarypersonmaybeexpectedtohaveknowledge,or
where the lack of skill or want of care is so obvious as to render expert testimony unnecessary.[49] We take
judicialnoticeofthefactthatanesthesiaprocedureshavebecomesocommon,thatevenanordinarypersoncan
tellifitwasadministeredproperly.Assuch,itwouldnotbetoodifficulttotellifthetubewasproperlyinserted.
Thiskindofobservation,webelieve,doesnotrequireamedicaldegreetobeacceptable.
At any rate, without doubt, petitioner's witness, an experienced clinical nurse whose long experience and
scholarshipledtoherappointmentasDeanoftheCapitolMedicalCenterSchoolofNursing,wasfullycapable
ofdeterminingwhetherornottheintubationwasasuccess.Shehadextensiveclinicalexperiencestartingasa
staffnurseinChicago,Illinoisstaffnurseandclinicalinstructorinateachinghospital,theFEUNRMFDeanof
the Laguna College of Nursing in San Pablo City and then Dean of the Capitol Medical Center School of
Nursing.[50]Reviewing witness Cruz' statements, we find that the same were delivered in a straightforward
manner,withthekindofdetail,clarity,consistencyandspontaneitywhichwouldhavebeendifficulttofabricate.
With her clinical background as a nurse, the Court is satisfied that she was able to demonstrate through her
testimonywhattrulytranspiredonthatfatefulday.
Most of all, her testimony was affirmed by no less than respondent Dra. Gutierrez who admitted that she
experienceddifficultyininsertingthetubeintoErlindastrachea,towit:
ATTY.LIGSAY:
Q:Inthisparticularcase,Doctora,whileyouwereintubatingatyourfirstattempt(sic),youdidnotimmediatelyseethe
trachea?
DRA.GUTIERREZ:
A:Yessir.
Q:Didyoupullawaythetubeimmediately?
A:Youdonotpullthe...
Q:Didyouordidyounot?
A:Ididnotpullthetube.
Q:Whenyousaidmahirapyataito,whatwereyoureferringto?
A:Mahirapyataitongiintubate,thatwasthepatient.
Q:So,youfoundsomedifficultyininsertingthetube?

A:Yes,becauseof(sic)myfirstattempt,Ididnotseerightaway.[51]
Curiously in the case at bar, respondent Dra. Gutierrez made the haphazard defense that she encountered
hardshipintheinsertionofthetubeinthetracheaofErlindabecauseitwaspositionedmoreanteriorly(slightly
deviatedfromthenormalanatomyofaperson)[52]makingithardertolocateand,sinceErlindaisobeseandhas
ashortneckandprotrudingteeth,itmadeintubationevenmoredifficult.
Theargumentdoesnotconvinceus.Ifthiswasindeedobserved,privaterespondentsadducednoevidence
demonstratingthattheyproceededtomakeathoroughassessmentofErlindasairway,priortotheinductionof
anesthesia, even if this would mean postponing the procedure. From their testimonies, it appears that the
observationwasmadeonlyasanafterthought,asameansofdefense.
Thepreoperativeevaluationofapatientpriortotheadministrationofanesthesiaisuniversallyobservedto
lessen the possibility of anesthetic accidents. Preoperative evaluation and preparation for anesthesia begins
whentheanesthesiologistreviewsthepatientsmedicalrecordsandvisitswiththepatient,traditionally,theday
before elective surgery.[53] It includes taking the patients medical history, review of current drug therapy,
physical examination and interpretation of laboratory data.[54] The physical examination performed by the
anesthesiologistisdirectedprimarilytowardthecentralnervoussystem,cardiovascularsystem,lungsandupper
airway.[55] A thorough analysis of the patient's airway normally involves investigating the following:cervical
spine mobility, temporomandibular mobility, prominent central incisors, diseased or artificial teeth, ability to
visualizeuvulaandthethyromentaldistance.[56]Thus,physicalcharacteristicsofthepatientsupperairwaythat
couldmaketrachealintubationdifficultshouldbestudied.[57]Wheretheneedarises,aswheninitialassessment
indicates possible problems (such as the alleged short neck and protruding teeth of Erlinda) a thorough
examinationofthepatientsairwaywouldgoalongwaytowardsdecreasingpatientmorbidityandmortality.
Inthecaseatbar,respondentDra.GutierrezadmittedthatshesawErlindaforthefirsttimeonthedayofthe
operationitself,on 17 June 1985.Before this date, no prior consultations with, or preoperative evaluation of
Erlinda was done by her. Until the day of the operation, respondent Dra. Gutierrez was unaware of the
physiologicalmakeupandneedsofErlinda.Shewaslikewisenotproperlyinformedofthepossibledifficulties
shewouldfaceduringtheadministrationofanesthesiatoErlinda.RespondentDra.Gutierrezactofseeingher
patient for the first time only an hour before the scheduled operative procedure was, therefore, an act of
exceptional negligence and professional irresponsibility. The measures cautioning prudence and vigilance in
dealingwithhumanliveslieatthecoreofthephysicianscenturiesoldHippocraticOath.Herfailuretofollow
thismedicalprocedureis,therefore,aclearindiciaofhernegligence.
RespondentDra.Gutierrez,however,attemptstoglossoverthisomissionbyplayingaroundwiththetrial
court'signoranceofclinicalprocedure,hopingthatshecouldgetawaywithit.RespondentDra.Gutierreztried
tomuddlethedifferencebetweenanelectivesurgeryandanemergencysurgeryjustsoherfailuretoperformthe
requiredpreoperativeevaluationwouldescapeunnoticed.Inhertestimonysheasserted:

ATTY. LIGSAY:

Q: Would you agree, Doctor, that it is good medical practice to see the patient a day before so you can introduce
yourself to establish good doctor-patient relationship and gain the trust and condence of the patient?

DRA. GUTIERREZ:

A: As I said in my previous statement, it depends on the operative procedure of the anesthesiologist and in my
case, with elective cases and normal cardio-pulmonary clearance like that, I usually don't do it except on
emergency and on cases that have an abnormalities (sic).[58]

However,theexactoppositeistrue.Inanemergencyprocedure,thereishardlyenoughtimeavailablefor
thefastidiousdemandsofpreoperativeproceduresothatananesthesiologistisabletoseethepatientonlyafew
minutesbeforesurgery,ifatall.Electiveprocedures,ontheotherhand,areoperativeproceduresthatcanwait
fordays,weeksorevenmonths.Hence,inthesecases,theanesthesiologistpossessestheluxuryoftimetomake
a proper assessment, including the time to be at the patient's bedside to do a proper interview and clinical
evaluation. There is ample time to explain the method of anesthesia, the drugs to be used, and their possible
hazardsforpurposes of informed consent.Usually, the preoperative assessment is conducted at least one day
beforetheintendedsurgery,whenthepatientisrelaxedandcooperative.
ErlindascasewaselectiveandthiswasknowntorespondentDra.Gutierrez.Thus,shehadallthetimeto
makeathoroughevaluationofErlindascasepriortotheoperationandprepareherforanesthesia.However,she
neversawthepatientatthebedside.Sheherselfadmittedthatshehadseenpetitioneronlyintheoperatingroom,
and only on the actual date of the cholecystectomy.She negligently failed to take advantage of this important
opportunity.Assuch,herattempttoexculpateherselfmustfail.
HavingestablishedthatrespondentDra.Gutierrezfailedtoperformpreoperativeevaluationofthepatient
which,inturn,resultedtoawrongfulintubation,wenowdetermineifthefaultyintubationistrulytheproximate
causeofErlindascomatosecondition.
PrivaterespondentsrepeatedlyhammeredtheviewthatthecerebralanoxiawhichledtoErlindascomawas
duetobronchospasm[59]mediatedbyherallergicresponsetothedrug,ThiopentalSodium,introducedintoher
system. Towards this end, they presented Dr. Jamora, a Fellow of the Philippine College of Physicians and
DiplomateofthePhilippineSpecialtyBoardofInternalMedicine,whoadvancedprivaterespondents'theorythat
theoxygendeprivationwhichledtoanoxicencephalopathy,[60]wasduetoanunpredictabledrugreactiontothe
shortactingbarbiturate.Wefindthetheoryofprivaterespondentsunacceptable.
Firstofall,Dr.Jamoracannotbeconsideredanauthorityinthefieldofanesthesiologysimplybecauseheis
not an anesthesiologist. Since Dr. Jamora is a pulmonologist, he could not have been capable of properly
enlighteningthecourtaboutanesthesiapracticeandprocedureandtheircomplications.Dr. Jamora is likewise
not an allergologist and could not therefore properly advance expert opinion on allergicmediated processes.
Moreover, he is not a pharmacologist and, as such, could not have been capable, as an expert would, of
explaining to the court the pharmacologic and toxic effects of the supposed culprit, Thiopental Sodium
(Pentothal).
The inappropriateness and absurdity of accepting Dr. Jamoras testimony as an expert witness in the
anestheticpracticeofPentothaladministrationisfurthersupportedbyhisownadmissionthatheformulatedhis
opinionsonthedrugnotfromthepracticalexperiencegainedbyaspecialistorexpertintheadministrationand
useofSodiumPentothalonpatients,butonlyfromreadingcertainreferences,towit:
ATTY.LIGSAY:
Q:Inyourlineofexpertiseonpulmonology,didyouhaveanyoccasiontousepentothalasamethodofmanagement?
DR.JAMORA:
A:Wedoitinconjunctionwiththeanesthesiologistwhentheyhavetointubateourpatient.
Q:Butnotinparticularwhenyoupracticepulmonology?
A:No.
Q:Inotherwords,yourknowledgeaboutpentothalisbasedonlyonwhatyouhavereadfrombooksandnotbyyour
ownpersonalapplicationofthemedicinepentothal?
A:Basedonmypersonalexperiencealsoonpentothal.
Q:Howmanytimeshaveyouusedpentothal?
A:Theyuseditonme.Iwentintobronchospasmduringmyappendectomy.
Q:Andbecausetheyhaveuseditonyouandonaccountofyourownpersonalexperienceyoufeelthatyoucantestify
onpentothalherewithmedicalauthority?

A:No.ThatiswhyIusedreferencestosupportmyclaims.[61]
An anesthetic accident caused by a rare druginduced bronchospasm properly falls within the fields of
anesthesia,internalmedicineallergy,andclinicalpharmacology.Theresultinganoxicencephalopathybelongsto
the field of neurology. While admittedly, many bronchospasticmediated pulmonary diseases are within the
expertise of pulmonary medicine, Dr. Jamora's field, the anesthetic druginduced, allergic mediated
bronchospasmallegedinthiscaseiswithinthedisciplinesofanesthesiology,allergologyandpharmacology.On
thebasisoftheforegoingtranscript,inwhichthepulmonologisthimselfadmittedthathecouldnottestifyabout
the drug with medical authority, it is clear that the appellate court erred in giving weight to Dr. Jamoras
testimonyasanexpertintheadministrationofThiopentalSodium.
Theprovisionintherulesofevidence[62]regardingexpertwitnessesstates:
Sec. 49. Opinion of expert witness. - The opinion of a witness on a matter requiring special knowledge,
skill, experience or training which he is shown to possess, may be received in evidence.
Generally,toqualifyasanexpertwitness,onemusthaveacquiredspecialknowledgeofthesubjectmatter
aboutwhichheorshe is to testify, either by the study of recognized authoritiesonthesubjectorbypractical
experience.[63]Clearly,Dr.Jamoradoesnotqualifyasanexpertwitnessbasedontheabovestandardsincehe
lacks the necessary knowledge, skill, and training in the field of anesthesiology.Oddly, apart from submitting
testimonyfromaspecialistinthewrongfield,privaterespondentsintentionallyavoidedprovidingtestimonyby
competentandindependentexpertsintheproperareas.
Moreover, private respondents theory, that Thiopental Sodium may have produced Erlinda's coma by
triggeringanallergicmediatedresponse,hasnosupportinevidence.Noevidenceofstridor,skinreactions,or
wheezing some of the more common accompanying signs of an allergic reaction appears on record. No
laboratorydatawereeverpresentedtothecourt.
Inanycase,privaterespondentsthemselvesadmitthatThiopentalinduced,allergicmediatedbronchospasm
happens only very rarely.If courts were to accept private respondents' hypothesis without supporting medical
proof, and against the weight of available evidence, then every anesthetic accident would be an act of God.
Evidently, the Thiopentalallergy theory vigorously asserted by private respondents was a mere afterthought.
Such an explanation was advanced in order to absolve them of any and all responsibility for the patients
condition.
 Inviewoftheevidenceathand,weareinclinedtobelievepetitionersstandthatitwasthefaultyintubation
whichwastheproximatecauseofErlindascomatosecondition.
Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by any
efficientinterveningcause,producesinjury,andwithoutwhichtheresultwouldnothaveoccurred.[64]Aninjury
ordamageisproximatelycausedbyanactorafailuretoact,wheneveritappearsfromtheevidenceinthecase,
thattheactoromissionplayedasubstantialpartinbringingaboutoractuallycausingtheinjuryordamageand
thattheinjuryordamagewaseitheradirectresultorareasonablyprobableconsequenceoftheactoromission.
[65]Itisthedominant,movingorproducingcause.

Applying the above definition in relation to the evidence at hand, faulty intubation is undeniably the
proximate cause which triggered the chain of events leading to Erlindas brain damage and, ultimately, her
comatosedcondition.
Privaterespondentsthemselvesadmittedintheirtestimonythatthefirstintubationwasafailure.This fact
was likewise observed by witness Cruz when she heard respondent Dra. Gutierrez remarked, Ang hirap ma
intubate nito, mali yata ang pagkakapasok.O lumalaki ang tiyan. Thereafter, witness Cruz noticed abdominal
distention on the body of Erlinda. The development of abdominal distention, together with respiratory
embarrassmentindicatesthattheendotrachealtubeenteredtheesophagusinsteadoftherespiratorytree.Inother
words, instead of the intended endotracheal intubation what actually took place was an esophageal intubation.
Duringintubation,suchdistentionindicatesthatairhasenteredthegastrointestinaltractthroughtheesophagus
insteadofthelungsthroughthetrachea.Entryintotheesophaguswouldcertainlycausesomedelayinoxygen
deliveryintothelungsasthetubewhichcarriesoxygenisinthewrongplace.That abdominal distention had
beenobservedduringthefirstintubationsuggeststhatthelengthoftimeutilizedininsertingtheendotracheal
tube(uptothetimethetubewaswithdrawnforthesecondattempt)wasfairlysignificant.Duetothedelayinthe
deliveryofoxygeninherlungsErlindashowedsignsofcyanosis.[66]AsstatedinthetestimonyofDr.Hosaka,
the lack of oxygen became apparent only after he noticed that the nailbeds of Erlinda were already blue.[67]
However, private respondents contend that a second intubation was executed on Erlinda and this one was
successfullydone.Wedonotthinkso.Noevidenceexistsonrecord,beyondprivaterespondents'bareclaims,
which supports the contention that the second intubation was successful.Assuming that the endotracheal tube
finallyfounditswayintotheproperorificeofthetrachea,thesamegavenoguaranteeofoxygendelivery,the
hallmark of a successful intubation. In fact, cyanosis was again observed immediately after the second
intubation.Proceedingfromthisevent(cyanosis),itcouldnotbeclaimed,asprivaterespondentsinsist,thatthe
second intubation was accomplished. Even granting that the tube was successfully inserted during the second
attempt,itwasobviouslytoolate.Asaptlyexplainedbythetrialcourt,Erlindaalreadysufferedbraindamageas
aresultoftheinadequateoxygenationofherbrainforaboutfourtofiveminutes.[68]
The above conclusion is not without basis. Scientific studies point out that intubation problems are
responsibleforonethird(1/3)ofdeathsandseriousinjuriesassociatedwithanesthesia.[69]Nevertheless,ninety
eight percent (98%) or the vast majority of difficult intubations may be anticipated by performing a thorough
evaluation of the patients airway prior to the operation.[70] As stated beforehand, respondent Dra. Gutierrez
failed to observe the proper preoperative protocol which could have prevented this unfortunate incident. Had
appropriatediligenceandreasonablecarebeenusedinthepreoperativeevaluation,respondentphysiciancould
havebeenmuchmorepreparedtomeetthecontingencybroughtaboutbytheperceivedanatomicvariationsin
thepatientsneckandoralarea,defectswhichwouldhavebeeneasilyovercomebyapriorknowledgeofthose
variationstogetherwithachangeintechnique.[71]Inotherwords,anexperiencedanesthesiologist,adequately
alertedbyathoroughpreoperativeevaluation,wouldhavehadlittledifficultygoingaroundtheshortneckand
protruding teeth.[72] Having failed to observe common medical standards in preoperative management and
intubation,respondentDra.GutierreznegligenceresultedincerebralanoxiaandeventualcomaofErlinda.
WenowdeterminetheresponsibilityofrespondentDr.OrlinoHosakaastheheadofthesurgicalteam.As
thesocalledcaptain of the ship,[73] it is the surgeons responsibility to see to it that those under him perform
theirtaskinthepropermanner.RespondentDr.Hosakasnegligencecanbefoundinhisfailuretoexercisethe
properauthority(asthecaptainoftheoperativeteam)innotdeterminingifhisanesthesiologistobservedproper
anesthesia protocols. In fact, no evidence on record exists to show that respondent Dr. Hosaka verified if
respondentDra.Gutierrezproperlyintubatedthepatient.Furthermore,itdoesnotescapeusthatrespondentDr.
Hosaka had scheduled another procedure in a different hospital at the same time as Erlindas cholecystectomy,
andwasinfactoverthreehourslateforthelattersoperation.Becauseofthis,hehadlittleornotimetoconfer
withhisanesthesiologistregardingtheanesthesiadelivery.Thisindicatesthathewasremissinhisprofessional
duties towards his patient. Thus, he shares equal responsibility for the events which resulted in Erlindas
condition.
We now discuss the responsibility of the hospital in this particular incident. The unique practice (among
privatehospitals)offillingupspecialiststaffwithattendingandvisitingconsultants,[74]whoareallegedlynot
hospital employees, presents problems in apportioning responsibility for negligence in medical malpractice
cases.However,thedifficultyisonlymoreapparentthanreal.
In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the
conductoftheirworkwithinthehospitalpremises.Doctorswhoapplyforconsultantslots,visitingorattending,
arerequiredtosubmitproofofcompletionofresidency,theireducationalqualificationsgenerally,evidenceof
accreditationbytheappropriateboard(diplomate),evidenceoffellowshipinmostcases,andreferences.These
requirementsarecarefullyscrutinizedbymembersofthehospitaladministrationorbyareviewcommitteesetup
bythehospitalwhoeitheracceptorrejecttheapplication.[75]Thisisparticularlytruewithrespondenthospital.
Afteraphysicianisaccepted,eitherasavisitingorattendingconsultant,heisnormallyrequiredtoattend
clinicopathological conferences, conduct bedside rounds for clerks, interns and residents, moderate grand
roundsandpatientauditsandperformothertasksandresponsibilities,fortheprivilegeofbeingabletomaintain
aclinicinthehospital,and/orfortheprivilegeofadmittingpatientsintothehospital.Inadditiontothese,the
physicians performance as a specialist is generally evaluated by a peer review committee on the basis of
mortalityandmorbiditystatistics,andfeedbackfrompatients,nurses,internsandresidents.Aconsultantremiss
inhisduties,oraconsultantwhoregularlyfallsshortoftheminimumstandardsacceptabletothehospitalorits
peerreviewcommittee,isnormallypolitelyterminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting
consultantstaff.Whileconsultantsarenot,technicallyemployees,apointwhichrespondenthospitalassertsin
denyingallresponsibilityforthepatientscondition,thecontrolexercised,thehiring,andtherighttoterminate
consultantsallfulfilltheimportanthallmarksofanemployeremployeerelationship,withtheexceptionofthe
payment of wages. In assessing whether such a relationship in fact exists, the control test is determining.
Accordingly,onthebasisoftheforegoing,werulethatforthepurposeofallocatingresponsibilityinmedical
negligencecases,anemployeremployeerelationshipineffectexistsbetweenhospitalsandtheirattendingand
visiting physicians. This being the case, the question now arises as to whether or not respondent hospital is
solidarilyliablewithrespondentdoctorsforpetitionerscondition.[76]
The basis for holding an employer solidarily responsible for the negligence of its employee is found in
Article2180oftheCivilCodewhichconsidersapersonaccountablenotonlyforhisownactsbutalsoforthose
of others based on the formers responsibility under a relationship of patria potestas.[77] Such responsibility
ceaseswhenthepersonsorentityconcernedprovethattheyhaveobservedthediligenceofagoodfatherofthe
familytopreventdamage.[78]Inotherwords,whiletheburdenofprovingnegligencerestsontheplaintiffs,once
negligence is shown, the burden shifts to the respondents (parent, guardian, teacher or employer) who should
provethattheyobservedthediligenceofagoodfatherofafamilytopreventdamage.
In the instant case, respondent hospital, apart from a general denial of its responsibility over respondent
physicians,failedtoadduceevidenceshowingthatitexercisedthediligenceofagoodfatherofafamilyinthe
hiringandsupervisionofthelatter.Itfailedtoadduceevidencewithregardtothedegreeofsupervisionwhichit
exercisedoveritsphysicians.Inneglectingtooffersuchproof,orproofofasimilarnature,respondenthospital
thereby failed to discharge its burden under the last paragraph of Article 2180. Having failed to do this,
respondenthospitalisconsequentlysolidarilyresponsiblewithitsphysiciansforErlindascondition.
Basedontheforegoing,weholdthattheCourtofAppealserredinacceptingandrelyingonthetestimonies
of the witnesses for the private respondents. Indeed, as shown by the above discussions, private respondents
wereunabletorebutthepresumptionofnegligence.Uponthesedisquisitionsweholdthatprivaterespondents
aresolidarilyliablefordamagesunderArticle2176[79]oftheCivilCode.
We now come to the amount of damages due petitioners. The trial court awarded a total of P632,000.00
pesos(shouldbeP616,000.00)incompensatorydamagestotheplaintiff,subjecttoitsbeingupdatedcovering
theperiodfrom15November1985upto15April1992,basedonmonthlyexpensesforthecareofthepatient
estimatedatP8,000.00.
Atcurrentlevels,theP8000/monthlyamountestablishedbythetrialcourtatthetimeofitsdecisionwould
be grossly inadequate to cover the actual costs of homebased care for a comatose individual. The calculated
amount was not even arrived at by looking at the actual cost of proper hospice care for the patient. What it
reflectedweretheactualexpensesincurredandprovedbythepetitionersaftertheywereforcedtobringhome
thepatienttoavoidmountinghospitalbills.
Andyetideally,acomatosepatientshouldremaininahospitalorbetransferredtoahospicespecializingin
thecareofthechronicallyillforthepurposeofprovidingapropermilieuadequatetomeetminimumstandards
ofcare.Intheinstantcaseforinstance,Erlindahastobeconstantlyturnedfromsidetosidetopreventbedsores
andhypostaticpneumonia.Feedingisdonebynasogastrictube.Foodpreparationshouldbenormallymadebya
dietitiantoprovideherwiththecorrectdailycaloricrequirementsandvitaminsupplements. Furthermore, she
hastobeseenonaregularbasisbyaphysicaltherapisttoavoidmuscleatrophy,andbyapulmonarytherapistto
preventtheaccumulationofsecretionswhichcanleadtorespiratorycomplications.
Given these considerations, the amount of actual damages recoverable in suits arising from negligence
should at least reflect the correct minimum cost of proper care, not the cost of the care the family is usually
compelled to undertake at home to avoid bankruptcy.However, the provisions of the Civil Code on actual or
compensatorydamagespresentuswithsomedifficulties.
Wellsettledistherulethatactualdamageswhichmaybeclaimedbytheplaintiffarethosesufferedbyhim
ashehasdulyproved.TheCivilCodeprovides:

Art. 2199. - Except as provided by law or by stipulation, one is entitled to an adequate compensation only for
such pecuniary loss suffered by him as he has duly proved. Such compensation is referred to as actual or
compensatory damages.

Our rules on actual or compensatory damages generally assume that at the time of litigation, the injury
suffered as a consequence of an act of negligence has been completed and that the cost can be liquidated.
However,theseprovisionsneglecttotakeintoaccountthosesituations,asinthiscase,wheretheresultinginjury
mightbecontinuingandpossiblefuturecomplicationsdirectlyarisingfromtheinjury,whilecertaintooccur,are
difficulttopredict.
In these cases, the amount of damages which should be awarded, if they are to adequately and correctly
respondtotheinjurycaused,shouldbeonewhichcompensatesforpecuniarylossincurredandproved,uptothe
time of trial and one which would meet pecuniary loss certain to be suffered but which could not, from the
natureofthecase,bemadewithcertainty.[80]Inotherwords,temperatedamagescanandshouldbeawardedon
topofactualorcompensatorydamagesininstanceswheretheinjuryischronicandcontinuing.Andbecauseof
theuniquenatureofsuchcases,noincompatibilityariseswhenbothactualandtemperatedamagesareprovided
for.Thereasonisthatthesedamagescovertwodistinctphases.
Asitwouldnotbeequitableandcertainlynotinthebestinterestsoftheadministrationofjusticeforthe
victim in such cases to constantly come before the courts and invoke their aid in seeking adjustments to the
compensatorydamagespreviouslyawardedtemperatedamagesareappropriate.Theamountgivenastemperate
damages,thoughtoacertainextentspeculative,shouldtakeintoaccountthecostofpropercare.
In the instant case, petitioners were able to provide only homebased nursing care for a comatose patient
whohasremainedinthatconditionforoveradecade.Havingpremisedourawardforcompensatorydamageson
the amount provided by petitioners at the onset of litigation, it would be now much more in step with the
interestsofjusticeifthevalueawardedfortemperatedamageswouldallowpetitionerstoprovideoptimalcare
fortheirlovedoneinafacilitywhichgenerallyspecializesinsuchcare.Theyshouldnotbecompelledbydire
circumstancestoprovidesubstandardcareathomewithouttheaidofprofessionals,foranythinglesswouldbe
grosslyinadequate.Underthecircumstances,anawardofP1,500,000.00intemperatedamageswouldtherefore
bereasonable.[81]
InValenzuelavs.CourtofAppeals,[82]thisCourtwasconfrontedwithasituationwheretheinjurysuffered
bytheplaintiffwouldhaveledtoexpenseswhichweredifficulttoestimatebecausewhiletheywouldhavebeen
adirectresultoftheinjury(amputation),andwerecertaintobeincurredbytheplaintiff,theywerelikelytoarise
onlyinthefuture.WeawardedP1,000,000.00inmoraldamagesinthatcase.
Describingthenatureoftheinjury,theCourtthereinstated:
As a result of the accident, Ma. Lourdes Valenzuela underwent a traumatic amputation of her left lower
extremity at the distal left thigh just above the knee. Because of this, Valenzuela will forever be deprived
of the full ambulatory functions of her left extremity, even with the use of state of the art prosthetic
technology. Well beyond the period of hospitalization (which was paid for by Li), she will be required to
undergo adjustments in her prosthetic devise due to the shrinkage of the stump from the process of
healing.
These adjustments entail costs, prosthetic replacements and months of physical and occupational
rehabilitation and therapy. During her lifetime, the prosthetic devise will have to be replaced and
readjusted to changes in the size of her lower limb effected by the biological changes of middle-age,
menopause and aging. Assuming she reaches menopause, for example, the prosthetic will have to be
adjusted to respond to the changes in bone resulting from a precipitate decrease in calcium levels
observed in the bones of all post-menopausal women. In other words, the damage done to her would not
only be permanent and lasting, it would also be permanently changing and adjusting to the physiologic
changes which her body would normally undergo through the years. The replacements, changes, and
adjustments will require corresponding adjustive physical and occupational therapy. All of these
adjustments, it has been documented, are painful.
xxx.
A prosthetic devise, however technologically advanced, will only allow a reasonable amount of
functional restoration of the motor functions of the lower limb. The sensory functions are forever lost.
The resultant anxiety, sleeplessness, psychological injury, mental and physical pain are inestimable.[83]
TheinjurysufferedbyErlindaasaconsequenceofprivaterespondentsnegligenceiscertainlymuchmore
seriousthantheamputationintheValenzuelacase.
Petitioner Erlinda Ramos was in her midforties when the incident occurred.She has been in a comatose
stateforoverfourteenyearsnow.Theburdenofcarehassofarbeenheroicallyshoulderedbyherhusbandand
children,who,intheinterveningyearshavebeendeprivedoftheloveofawifeandamother.
Meanwhile, the actual physical, emotional and financial cost of the care of petitioner would be virtually
impossibletoquantify.Eventhetemperatedamageshereinawardedwouldbeinadequateifpetitionerscondition
remainsunchangedforthenexttenyears.
We recognized, in Valenzuela that a discussion of the victims actual injury would not even scratch the
surface of the resulting moral damage because it would be highly speculative to estimate the amount of
emotionalandmoralpain,psychologicaldamageandinjurysufferedbythevictimorthoseactuallyaffectedby
thevictimscondition.[84]Thehusbandandthechildren,allpetitionersinthiscase,willhavetolivewiththeday
todayuncertaintyofthepatientsillness,knowinganyhopeofrecoveryisclosetonil.Theyhavefashionedtheir
dailylivesaroundthenursingcareofpetitioner,alteringtheirlongtermgoalstotakeintoaccounttheirlifewith
acomatosepatient.They,nottherespondents,arechargedwiththemoralresponsibilityofthecareofthevictim.
Thefamilysmoralinjuryandsufferinginthiscaseisclearlyarealone.Fortheforegoingreasons,anawardof
P2,000,000.00inmoraldamageswouldbeappropriate.
Finally, by way of example, exemplary damages in the amount of P100,000.00 are hereby awarded.
Considering the length and nature of the instant suit we are of the opinion that attorneys fees valued at
P100,000.00arelikewiseproper.
Our courts face unique difficulty in adjudicating medical negligence cases because physicians are not
insurersoflifeand,theyrarelysetouttointentionallycauseinjuryordeathtotheirpatients.However,intentis
immaterialinnegligencecasesbecausewherenegligenceexistsandisproven,thesameautomaticallygivesthe
injuredarighttoreparationforthedamagecaused.
Established medical procedures and practices, though in constant flux are devised for the purpose of
preventingcomplications.Aphysiciansexperiencewithhispatientswouldsometimestempthimtodeviatefrom
established community practices, and he may end a distinguished career using unorthodox methods without
incident.However,whenfailuretofollowestablishedprocedureresultsintheevilpreciselysoughttobeaverted
by observance of the procedure and a nexus is made between the deviation and the injury or damage, the
physician would necessarily be called to account for it.In the case at bar, the failure to observe preoperative
assessment protocol which would have influenced the intubation in a salutary way was fatal to private
respondentscase.
WHEREFORE,thedecisionandresolutionoftheappellatecourtappealedfromareherebymodifiedsoas
to award in favor of petitioners, and solidarily against private respondents the following: 1) P1,352,000.00as
actualdamagescomputedasofthedateofpromulgationofthisdecisionplusamonthlypaymentofP8,000.00
up to the time that petitioner Erlinda Ramos expires or miraculously survives 2) P2,000,000.00 as moral
damages, 3) P1,500,000.00 as temperate damages 4) P100,000.00 each as exemplary damages and attorneys
feesand,5)thecostsofthesuit.
SOORDERED.
Davide,Jr.,C.J.,(Chairman),Puno,PardoandYnaresSantiago,JJ.,concur.

[1]IntheUnitedStatesalone,agreatnumberofpeopledieeveryyearasaresultofmedicalmishaps.The13December1999issueof
TIMEMAGAZINEfeaturedanarticleonmedicalnegligenceentitledDoctorsDeadlyMistakeswhichisquotedinpart:Itishardly
newsthatmedicalprofessionalsmakemistakesevendumb,deadlymistakes.Whatisshockingishowoftenithappens.Dependingon
whichstatisticsyoubelieve,thenumberofAmericanskilledbymedicalscrewupsissomewherebetween44,000and98,000every
yearthe eighth leading cause of death even by the more conservative figure, ahead of car crashes, breast cancer and AIDS.More
astonishingthanthehugenumbersthemselves,though,isthefactthatpublichealthofficialshadknownabouttheproblemforyears
andhadntmadeaconcertedefforttodosomethingaboutit.
[2]Cholecystectomyisthesurgicalexcisionofthegallbladder.

[3]CARollo,pp.129140.

[4]Records,pp.270279.

[5]Id.at270275.

[6]DocketedasCivilCaseNo.Q46885.

[7]Records,pp.276278.

[8]CARollo,p.166.

[9]Id.at145.

[10]Id.at195.

[11]Rollo,p.19.

[12]Id.at9198.

[13]57BAmJur2d,493(1989).

[14]Africa,etalvs.Caltex(Phil.),Inc.,etal,16SCRA449,454(1966).
[15]57BAmJur2d,supranote13at499.

[16]Ibid.

[17]Id.at502.

[18]Ibid.

[19]Id.

[20]Id.at503.

[21]Vossvs.Bridwell,364P2d955,970(1961)citingWordenv.UnionGasSystem,182Kan.686,324P.2d501Lambv.Hartford
AccidentandIndemnityCo.,Primmv.KansasPower&LightCo.,173Kan.443,249P.2d647.
[22]St.JohnsHospitalandSchoolofNursingvs.Chapman,434P.2d160,166(1967).

[23]57BAmJur2d,supranote13,at513.

[24]Itisthetypeofclaimwhichavictimhasavailabletohimorhertoredressawrongcommittedbyamedicalprofessionalwhich
hascausedbodilyharm.(GarciaRuedavs.Pascasio,278SCRA769,778[1997]).
[25]Vossvs.Bridwell,supranote21.

[26]Turneyvs.Anspaugh,581P.2d1301,1304(1978).

[27]SOLIS,MEDICALJURISPRUDENCE,239(1988).

[28]Vossvs.Bridwell,supranote21,at968citingMcMillenvs.Foncannon,127Kan.573,274P.237.

[29]Stockhamvs.Hall,65P.348,349(1937)citingYardvs.Gibbons,95Kan.802,149P.422,423.

[30]SOLIS,supranote27,at239.

[31]Vossvs.Bridwell,supranote21at970971.

[32]Armstrongvs.Wallace,47P.2d740(1935).

[33]Thomsenvs.Burgeson,79P.2d136(1938).

[34]Griffinvs.Norman,192NYS322(1922).

[35]Brownvs.Shortilledge,277P.134(1929).

[36]Meadowsvs.Patterson,109S.W.2d417(1937).

[37]Vossvs.Bridwell,supranote21,at969.

[38]Id.at968.

[39]Rhodesvs.DeHaan,337P.2d.1043,1047(1959).

[40]Vossvs.Bridwell,supranote21,at968.

[41]Sandersvs.Smith,27So.2d889,893(1946).

[42]Ibid.

[43]Vossvs.Bridwell,supranote21.

[44]Id.at971.
[45]Itisthemethodofintubatingapatientthroughtheoralcavity.Underthisprocedure,afterthepatienthasbeenpreoxygenatedand
paralyzed and is no longer breathing on his own, the anesthetist inserts an instrument called a laryngoscope into the patients oral
pharynx.Thepatientsneckishyperextended,thatis,bentbackasfaraspossiblesothattheanesthetistcanseeorvisualizethepatients
epiglottisandvocalcords.Theanesthetistwillthenthreadtheendotrachealtubebetweenthepatientsvocalcordsintothetrachea,and
thenhookthetubetothebreathingbagandanestheticmachine.
[46]TSN,January13,1988,pp.1620.

[47]CARollo,pp.134135.

[48]Stockhamvs.Hall,supranote29

[49]61AmJur2d,513(1989).

[50]TSN,January13,1988,p.3

[51]TSN,November15,1990,p.11.

[52]TSN,October9,1990,p.13.

[53]STOELTINGandMILLER,BASICSOFANESTHESIA,103(1994).

[54]Ibid.

[55]Id.at105(Underscoringsupplied).

[56]Id.at106.5

[57]Id.

[58]TSN,November15,1990,p.6.

[59]Constrictionoftheairpassagesofthelungbyspasmodiccontractionofthebronchialmuscles(asinasthma).

[60]Permanentdamagetothebraincausedbyinadequateoxygenation.

[61]TSN,February28,1991,pp.1011.

[62]Rule130,RULESOFCOURT.

[63]61AmJur2d,supranote49,516.

[64]BLACKSLAWDICTIONARY(FIFTHEDITION),1103(1979).

[65]Ibid.

[66]Itisabluishcolorationoftheskinormucousmembranescausedbylackofoxygenorabnormalhemoglobinintheblood.

[67]TSN,March27,1990,p.22.

[68]Records,p.274.

[69]FINUCAINE,AIRWAYMANAGEMENT,82(1990).

[70]Ibid.

[71]Id.Thebookprovidesathoroughdiscussiononthemanagementofdifficultintubations.

[72]Id.

[73]Underthisdoctrine,thesurgeonislikenedtoashipcaptainwhomustnotonlyberesponsibleforthesafetyofthecrewbutalsoof
the passengers of the vessel. The head surgeon is made responsible for everything that goes wrong within the four corners of the
operatingroom.Itenunciatestheliabilityofthesurgeonnotonlyforthewrongfulactsofthosewhoareunderhisphysicalcontrolbut
alsothosewhereinhehasextensionofcontrol.
[74]Thetermconsultantislooselyusedbyhospitalstodistinguishtheirattendingandvisitingphysiciansfromtheresidents,whoare
alsophysicians.Inmosthospitalsabroad,thetermvisitingorattendingphysician,notconsultant,isused.
[75]Theserequirementsareinfactfoundinthestandardapplicationformsforvisitingandattendingphysiciansofrespondenthospital.

[76]Thehospitalscontroloverrespondentphysiciansisallthemoresignificantwhenoneconsidersthefactthatitcontrolseverything
whichoccursinanoperatingroom,throughitsnursingsupervisorsandchargenurses.Nooperationscanbeundertakenwithoutthe
hospitalsdirectorindirectconsent.
[77]VITUG,COMPENDIUMOFCIVILLAWANDJURISPRUDENCE,822(1993).

[78] Art. 2180 of the Civil Code provides: The obligation imposed by Article 2176 is demandable not only for one's own acts or
omissions,butalsoforthoseorpersonsforwhomoneisresponsible.
Thefatherand,incaseofhisdeathorincapacity,themother,areresponsibleforthedamagescausedbytheminorchildrenwholivein
theircompany.
Guardians are liable for damages caused by the minors or incapacitated persons who are under their authority and live in their
company.
The owners and managers of an establishment or enterprise are likewise responsible for damages caused by their employees in the
serviceofthebranchesinwhichthelatterareemployedoronoccassionoftheirfunctions.
Employersshallbeliableforthedamagescausedbytheiremployeesandhouseholdhelpersactingwithinthescopeoftheirassigned
tasks,eventhoughtheformerarenotengagedinanybusinessorindustry.
[79]Whoeverbyactoromissioncausesdamagetoanother,therebeingfaultornegligence,isobligedtopayforthedamagedone.

[80]Art.2224,CIVILCODE.

[81]Shouldpetitionerremaininthesameconditionforanothertenyears,theamountawardedintheformoftemperatedamageswould
infact,beinadequate.
[82]253SCRA303(1996).

[83]Id.at327328.

[84]Id.at328.