SPOUSES
FREDELICTO FLORES (deceased) and FELICISIMA FLORES,
Petitioners, -
versus - SPOUSES
DOMINADOR PINEDA and VIRGINIA SACLOLO, and FLORENCIO, CANDIDA, MARTA, GODOFREDO,
BALTAZAR and LUCENA, all surnamed PINEDA, as heirs of the deceased TERESITA
S. PINEDA, and UNITED DOCTORS MEDICAL CENTER, INC.,
Respondents. |
G.R. No. 158996
Present: QUISUMBING, J., Chairperson, carpio
MORALES, TINGA, VELASCO, JR., and BRION, JJ.
Promulgated: November 14, 2008 |
|
||||
x -------------------------------------------------------------------------------------------x
|
|
|||||
|
|
|||||
|
D E C I S I O N
|
|||||
|
|
|||||
|
BRION, J.: |
|
||||
|
|
|||||
This petition involves a medical negligence case
that was elevated to this Court through an appeal by certiorari under
Rule 45 of the Rules of Court. The
petition assails the Decision[1] of the Court of
Appeals (CA) in CA G.R. CV No. 63234, which affirmed with modification the
Decision[2]
of the Regional Trial Court (RTC) of Nueva Ecija, Branch
WHEREFORE,
premises considered, the assailed Decision of the Regional Trial Court of
Baloc, Sto. Domingo, Nueva Ecija, Branch 37 is hereby AFFIRMED but with
modifications as follows:
1)
Ordering defendant-appellants Dr. and
Dra. Fredelicto A. Flores and the United Doctors Medical Center, Inc. to jointly
and severally pay the plaintiff-appellees – heirs of Teresita Pineda, namely,
Spouses Dominador Pineda and Virginia Saclolo and Florencio, Candida, Marta,
Godofredo, Baltazar and Lucena, all surnamed Pineda, the sum of P400,000.00
by way of moral damages;
2)
Ordering the above-named defendant-appellants
to jointly and severally pay the above-named plaintiff-appellees the sum of P100,000.00
by way of exemplary damages;
3)
Ordering the above-named
defendant-appellants to jointly and severally pay the above-named plaintiff-appellees the sum of P36,000.00
by way of actual and compensatory damages; and
4)
Deleting the award of attorney’s fees and
costs of suit.
SO ORDERED.
While
this case essentially involves questions of facts, we opted for the requested
review in light of questions we have on the findings of negligence below, on the
awarded damages and costs, and on the importance of this type of ruling on
medical practice.[3]
BACKGROUND
FACTS
Teresita
Pineda (Teresita) was a 51-year old unmarried woman living in Sto.
Domingo, Nueva Ecija. She consulted on
Teresita
did not return the next week as advised. However, when her condition persisted, she went
to further consult Dr. Flores at his UDMC clinic on
At
Based on these
preparations, Dr. Felicisima proceeded with the D&C operation with Dr.
Fredelicto administering the general anesthesia. The D&C operation lasted
for about 10 to 15 minutes. By
A day after the
operation (or on
Teresita’s complete laboratory
examination results came only on that day (
By
Believing that
Teresita’s death resulted from the negligent handling of her medical needs, her
family (respondents) instituted an action for damages against Dr.
Fredelicto Flores and Dr. Felicisima Flores (collectively referred to as the petitioner
spouses) before the RTC of Nueva Ecija.
The RTC ruled in favor
of Teresita’s family and awarded actual, moral, and exemplary damages, plus
attorney’s fees and costs.[12] The CA affirmed the judgment, but modified
the amount of damages awarded and deleted the award for attorney’s fees and
costs of suit.[13]
Through this petition
for review on certiorari, the petitioner spouses –Dr. Fredelicto (now
deceased) and Dr. Felicisima Flores – allege that the RTC and CA committed a reversible
error in finding them liable through negligence for the death of Teresita
Pineda.
ASSIGNMENT OF ERRORS
The
petitioner spouses contend that they exercised due care and prudence in the
performance of their duties as medical professionals. They had attended to the patient to the best
of their abilities and undertook the management of her case based on her
complaint of an on-and-off vaginal bleeding.
In addition, they claim that nothing on record shows that the death of
Teresita could have been averted had they employed means other than what they had
adopted in the ministration of the patient.
THE COURT’S RULING
We do not find the petition meritorious.
The
respondents’ claim for damages is predicated on their allegation that the
decision of the petitioner spouses to proceed with the D&C operation,
notwithstanding Teresita’s condition and the laboratory test results, amounted
to negligence. On the other hand, the
petitioner spouses contend that a D&C operation is the proper and accepted
procedure to address vaginal bleeding – the medical problem presented to them. Given that the patient died after the D&C,
the core issue is whether the decision to proceed with the D&C operation
was an honest mistake of judgment or one amounting to negligence.
Elements of a Medical Negligence
Case
A
medical negligence case is a type of claim to redress a wrong committed
by a medical professional, that has caused bodily harm to or the death of a
patient. There are four elements
involved in a medical negligence case, namely: duty, breach, injury, and
proximate causation.[14]
Duty
refers to the standard of behavior which imposes restrictions on one’s conduct.[15] The standard in turn refers to the amount of
competence associated with the proper discharge of the profession. A physician is expected to use at least the
same level of care that any other reasonably competent doctor would use under
the same circumstances. Breach of duty
occurs when the physician fails to comply with these professional
standards. If injury results to the
patient as a result of this breach, the physician is answerable for negligence.[16]
As
in any civil action, the burden to prove the existence of the necessary elements
rests with the plaintiff.[17] To successfully pursue a claim, the plaintiff must
prove by preponderance of evidence that, one, the physician either
failed to do something which a reasonably prudent health care provider would
have done, or that he did something that a reasonably prudent provider would
not have done; and two, the failure or action caused injury to
the patient.[18] Expert testimony is therefore essential since
the factual issue of whether a physician or surgeon has exercised the requisite
degree of skill and care in the treatment of his patient is generally a matter
of expert opinion.[19]
Standard of Care and Breach of
Duty
D&C
is the classic gynecologic procedure for the evaluation and possible
therapeutic treatment for abnormal vaginal bleeding.[20]
That this is the recognized procedure is
confirmed by Drs. Salvador Nieto (Dr. Nieto) and Joselito Mercado (Dr.
Mercado), the expert witnesses presented by the respondents:
DR.
NIETO: [W]hat I know among
obstetricians, if there is bleeding, they perform what we call D&C for
diagnostic purposes.
xxx xxx xxx
Q: So are you trying to tell the Court that
D&C can be a diagnostic treatment?
A: Yes, sir. Any doctor knows this.[21]
Dr. Mercado, however, objected with respect
to the time the D&C operation should have been conducted in Teresita’s case.
He opined that given the blood sugar
level of Teresita, her diabetic condition should have been
addressed first:
Q: Why do you
consider the time of performance of the D&C not appropriate?
A: Because I
have read the record and I have seen the urinalysis, [there is] spillage in the
urine, and blood sugar was 10.67
Q: What is the
significance of the spillage in the urine?
A: It is a sign
that the blood sugar is very high.
Q: Does it indicate sickness?
A: 80 to 95% it
means diabetes mellitus. The blood sugar
was 10.67.
xxx xxx
xxx
COURT: In
other words, the operation conducted on the patient, your opinion, that it is
inappropriate?
A: The timing
of [when] the D&C [was] done, based on the record, in my personal opinion,
that D&C should be postponed a day or two.[22]
The petitioner spouses countered that, at the
time of the operation, there was nothing to indicate that Teresita was
afflicted with diabetes: a blood sugar
level of 10.67mmol/l did not necessarily mean that she was a diabetic
considering that this was random blood sugar;[23]
there were other factors that might have caused Teresita’s blood sugar to rise
such as the taking of blood samples during lunchtime and while patient was being
given intra-venous dextrose.[24] Furthermore, they claim that their principal
concern was to determine the cause of and to stop the vaginal bleeding.
The petitioner spouses’ contentions, in our view,
miss several points. First, as early as
[Expert
testimony for the plaintiff showed that] tests should have been ordered
immediately on admission to the hospital in view of the symptoms presented, and
that failure to recognize the existence of diabetes constitutes negligence.[28]
Third, the
petitioner spouses cannot claim that their principal concern was the vaginal
bleeding and should not therefore be held accountable for complications coming
from other sources. This is a very
narrow and self-serving view that even reflects on their competence.
Taken together, we find
that reasonable prudence would have shown that diabetes and its complications
were foreseeable harm that should have been taken into consideration by the petitioner
spouses. If a patient suffers from
some disability that increases the magnitude of risk to him, that disability
must be taken into account so long as it is or should have been known to the
physician.[29] And when the patient is exposed to an
increased risk, it is incumbent upon the physician to take commensurate and adequate
precautions.
Taking into account
Teresita’s high blood sugar,[30] Dr. Mendoza opined that the attending physician
should have postponed the D&C operation in order to conduct a confirmatory
test to make a conclusive diagnosis of diabetes and to refer the case to an
internist or diabetologist. This was
corroborated by Dr. Delfin Tan (Dr. Tan), an obstetrician and gynecologist,
who stated that the patient’s diabetes should have been managed by an internist
prior to, during, and after the operation.[31]
Apart from bleeding as a
complication of pregnancy, vaginal bleeding is only rarely so heavy and
life-threatening that urgent first-aid measures are required.[32]
Indeed,
the expert witnesses declared that a D&C operation on a hyperglycemic
patient may be justified only when it is an emergency case – when there is
profuse vaginal bleeding. In this case,
we choose not to rely on the assertions of the petitioner spouses that there
was profuse bleeding, not only because the statements were self-serving, but
also because the petitioner spouses were inconsistent in their
testimonies. Dr. Fredelicto testified
earlier that on April 28, he personally saw the bleeding,[33]
but later on said that he did not see it and relied only on Teresita’s
statement that she was bleeding.[34]
He went on to state that he scheduled
the D&C operation without conducting any physical examination on the
patient.
The likely story is that
although Teresita experienced vaginal bleeding on April 28, it was not sufficiently
profuse to necessitate an immediate emergency D&C operation. Dr. Tan[35] and Dr. Mendoza[36]
both testified that the medical records
of Teresita failed to indicate that there was profuse vaginal bleeding. The claim that there was profuse vaginal
bleeding although this was not reflected in the medical records strikes us as
odd since the main complaint is vaginal bleeding. A medical record is the only
document that maintains a long-term transcription of patient care and as such, its
maintenance is considered a priority in hospital practice. Optimal
record-keeping includes all patient inter-actions. The records should always be clear,
objective, and up-to-date.[37] Thus, a medical record that does not indicate
profuse medical bleeding speaks loudly and clearly of what it does not contain.
That
the D&C operation was conducted principally to diagnose the cause of the vaginal
bleeding further leads us to conclude that it was merely an elective procedure,
not an emergency case. In an elective
procedure, the physician must conduct a thorough pre-operative evaluation of
the patient in order to adequately prepare her for the operation and minimize
possible risks and complications. The internist is responsible for generating a
comprehensive evaluation of all medical problems during the pre-operative
evaluation.[38]
The
aim of pre-operative evaluation is not to screen broadly for undiagnosed
disease, but rather to identify and quantify comorbidity that may impact on the
operative outcome. This evaluation is
driven by findings on history and physical examination suggestive of organ
system dysfunction…The goal is to uncover problem areas that may require
further investigation or be amenable to preoperative optimization.
If
the preoperative evaluation uncovers significant comorbidity or evidence of
poor control of an underlying disease process, consultation with an internist
or medical specialist may be required to facilitate the work-up and direct
management. In this process,
communication between the surgeons and the consultants is essential to define
realistic goals for this optimization process and to expedite surgical
management.[39]
[Emphasis supplied.]
Significantly, the
evidence strongly suggests that the pre-operative evaluation was less than
complete as the laboratory results were fully reported only on the day
following the D&C operation. Dr.
Felicisima only secured a telephone report of the preliminary laboratory result
prior to the D&C. This preliminary
report did not include the 3+ status of sugar in the patient’s urine[40] – a result highly
confirmatory of diabetes.
Because
the D&C was merely an elective procedure, the patient’s uncontrolled
hyperglycemia presented a far greater risk than her on-and-off vaginal bleeding. The presence of hyperglycemia in a surgical
patient is associated with poor clinical outcomes, and aggressive glycemic
control positively impacts on morbidity and mortality.[41] Elective surgery in people with uncontrolled
diabetes should preferably be scheduled after acceptable
glycemic control has been achieved.[42] According to Dr. Mercado, this is done by
administering insulin on the patient.[43]
The
management approach in this kind of patients always includes insulin
therapy in combination with dextrose and potassium infusion. Insulin xxx promotes glucose uptake by the
muscle and fat cells while decreasing glucose production by the
liver xxx. The net effect is to lower blood glucose levels.[44]
The prudent move is to
address the patient’s hyperglycemic state immediately and promptly before any
other procedure is undertaken. In this
case, there was no evidence that insulin was administered on Teresita prior to
or during the D&C operation. Insulin
was only administered two days after the operation.
As Dr. Tan testified,
the patient’s hyperglycemic condition should have been managed not only
before and during the operation, but also immediately after. Despite the possibility that Teresita was afflicted
with diabetes, the possibility was casually ignored even in the post-operative
evaluation of the patient; the concern, as the petitioner spouses expressly
admitted, was limited to the complaint of vaginal bleeding. Interestingly, while the ultrasound test
confirmed that Teresita had a myoma in her uterus, she was advised that she could
be discharged a day after the operation and that her recovery could take place
at home. This advice implied that a day
after the operation and even after the complete laboratory results were
submitted, the petitioner spouses still did not recognize any post-operative
concern that would require the monitoring of Teresita’s condition in the
hospital.
The above facts, point
only to one conclusion – that the petitioner spouses failed, as medical
professionals, to comply with their duty to observe the standard of care to be
given to hyperglycemic/diabetic patients undergoing surgery. Whether this breach of duty was the proximate
cause of Teresita’s death is a matter we shall next determine.
Injury and Causation
As
previously mentioned, the critical and clinching factor in a medical negligence
case is proof of the causal connection between the negligence which the
evidence established and the plaintiff’s injuries;[45]
the plaintiff must plead and prove not only that he had been injured and
defendant has been at fault, but also that the defendant’s fault caused the
injury. A verdict in a malpractice action cannot be based on speculation or
conjecture. Causation must be proven
within a reasonable medical probability based upon competent expert testimony.[46]
The
respondents contend that unnecessarily subjecting Teresita to a D&C
operation without adequately preparing her, aggravated her hyperglycemic state
and caused her untimely demise. The
death certificate of Teresita lists down the following causes of death:
Immediate cause: Cardiorespiratory
arrest
Antecedent
cause: Septicemic shock, ketoacidocis
Underlying
cause: Diabetes
Mellitus II
Other
significant conditions
contributing
to death: Renal Failure – Acute[47]
Stress,
whether physical or emotional, is a factor that can aggravate diabetes; a D&C
operation is a form of physical stress. Dr.
Mendoza explained how surgical stress can aggravate the patient’s
hyperglycemia: when stress occurs, the diabetic’s body, especially the
autonomic system, reacts by secreting hormones which are counter-regulatory; she
can have prolonged hyperglycemia which, if unchecked, could lead to death.[48] Medical literature further explains that if the
blood sugar has become very high, the patient becomes comatose (diabetic coma).
When this happens over several days, the
body uses its own fat to produce energy, and the result is high levels of waste
products (called ketones) in the blood and urine (called diabetic
ketoacidiosis, a medical emergency with a significant mortality).[49] This was apparently what happened in Teresita’s
case; in fact, after she had been referred to the internist Dr. Jorge,
laboratory test showed that her blood sugar level shot up to 14.0mmol/l, way
above the normal blood sugar range. Thus,
between the D&C and death was the diabetic complication that could have
been prevented with the observance of standard medical precautions. The D&C operation and Teresita’s death due
to aggravated diabetic condition is therefore sufficiently established.
The
trial court and the appellate court pinned the liability for Teresita’s death on
both the petitioner spouses and this Court finds no reason to rule
otherwise. However, we clarify that Dr.
Fredelicto’s negligence is not solely the act of ordering an “on call” D&C
operation when he was mainly an anaesthesiologist
who had made a very cursory examination of the patient’s vaginal bleeding
complaint. Rather, it was his failure from
the very start to identify and confirm, despite the patient’s complaints and his
own suspicions, that diabetes was a risk factor that should be guarded against,
and his participation in the imprudent decision to proceed with the D&C
operation despite his early suspicion and the confirmatory early laboratory
results. The latter point comes out
clearly from the following exchange during the trial:
Q: On what aspect did you and your wife consult [with] each other?
A: We discussed on the finding of the
laboratory [results] because the hemoglobin was below normal, the blood sugar
was elevated, so that we have to evaluate these laboratory results – what it
means.
Q: So it was you and your wife who made the
evaluation when it was phoned in?
A: Yes, sir.
Q: Did your wife, before performing D&C
ask your opinion whether or not she can proceed?
A: Yes, anyway, she asked me whether we can
do D&C based on my experience.
Q: And your answer was in
the positive notwithstanding the elevation of blood sugar?
A: Yes, sir, it was both
our disposition to do the D&C. [Emphasis
supplied.][50]
If Dr. Fredelicto believed
himself to be incompetent to treat the diabetes, not being an internist or a diabetologist
(for which reason he referred Teresita to Dr. Jorge),[51] he should have likewise
refrained from making a decision to proceed with the D&C operation since he
was niether an obstetrician nor a gynecologist.
These findings lead us
to the conclusion that the decision to proceed with the D&C operation,
notwithstanding Teresita’s hyperglycemia and without adequately preparing her
for the procedure, was contrary to the standards observed by the medical profession. Deviation from this standard amounted to a
breach of duty which resulted in the patient’s death. Due to this negligent conduct, liability must
attach to the petitioner spouses.
Liability of the Hospital
In the proceedings
below, UDMC was the spouses Flores’ co-defendant. The RTC found the hospital jointly and
severally liable with the petitioner spouses, which decision the CA affirmed. In a Resolution dated
Award of Damages
Both
the trial and the appellate court awarded actual damages as compensation for
the pecuniary loss the respondents suffered. The loss was presented in terms of
the hospital bills and expenses the respondents incurred on account of
Teresita’s confinement and death. The
settled rule is that a plaintiff is entitled to be compensated for proven pecuniary
loss.[52]
This proof the respondents successfully
presented. Thus, we affirm the award of actual damages of P36,000.00
representing the hospital expenses the patient incurred.
In addition to the award
for actual damages, the respondent heirs of Teresita are likewise entitled to P50,000.00
as death indemnity pursuant to Article 2206 of the Civil Code, which
states that “the amount of damages for death caused by a xxx quasi-delict
shall be at least three thousand pesos,[53]
even though there may have been mitigating circumstances xxx.” This is
a question of law that the CA missed in its decision and which we now decide in
the respondents’ favor.
The same article allows the
recovery of moral damages in case of death caused by a quasi-delict and enumerates the spouse, legitimate or illegitimate
ascendants or descendants as the persons entitled thereto. Moral
damages are designed to compensate the claimant for the injury suffered, that
is, for the mental anguish, serious anxiety, wounded feelings which the
respondents herein must have surely felt with the unexpected loss of their daughter. We affirm the appellate court’s award of P400,000.00 by way of moral damages to the respondents.
We similarly affirm the
grant of exemplary damages. Exemplary
damages are imposed by way of example or correction for the public good.[54] Because of the petitioner spouses’ negligence
in subjecting Teresita to an operation without first recognizing and addressing
her diabetic condition, the appellate court awarded exemplary damages to
the respondents in the amount of P100,000.00. Public policy requires such imposition to
suppress the wanton acts of an offender.[55] We therefore affirm the CA’s award as an
example to the medical profession and to stress that the public good requires
stricter measures to avoid the repetition of the type of medical malpractice
that happened in this case.
With the award of
exemplary damages, the grant of attorney’s fees is legally in order.[56]
We therefore reverse the CA decision deleting these awards, and grant the respondents
the amount of P100,000.00 as attorney’s fees taking into consideration the legal route
this case has taken.
WHEREFORE,
we AFFIRM the Decision of the CA
dated P36,000.00; moral damages of P400,000.00;
and exemplary damages of P100,000.00.
We MODIFY the CA Decision by additionally granting an award of P50,000.00
as death indemnity and by reversing the deletion of the award of attorney’s
fees and costs and restoring the award of P100,000.00 as attorney’s fees. Costs of litigation are adjudged against
petitioner spouses.
To summarize, the
following awards shall be paid to the family of the late Teresita Pineda:
1. The sum of P36,000.00 by way of actual and
compensatory damages;
2. The sum of P50,000.00 by way of death indemnity;
3. The sum of P400,000.00 by way of moral damages;
4. The sum of P100,000.00 by way of exemplary damages;
5. The sum of P100,000.00 by way of attorney’s fees; and
6. Costs.
SO
ORDERED.
|
|
ARTURO D. BRION Associate Justice |
WE CONCUR:
LEONARDO A. QUISUMBING
Acting Chief Justice |
|
|
CONCHITA CARPIO MORALES Associate Justice |
DANTE O. TINGA Associate Justice |
|
PRESBITERO J. VELASCO, JR. Associate Justice |
|
|
|
LEONARDO A. QUISUMBING Acting Chief Justice |
[1] Dated
[2] Dated
[3] See: Dela
Cruz v. CA and People of the
[4] TSN,
[5] “D&C” refers to dilatation
and curettage, an operation in which the cervix of the uterus is expanded,
using an instrument called dilator, and the lining (endometrium) of the uterus
is lightly scraped with a curet (The Bantam Medical Dictionary, 5th
ed., p. 192).
[6] The
laboratory tests conducted were for complete blood count, urinalysis, stool
examination, blood sugar examination, BUN determination, uric acid
determination, and cholesterol determination; rollo, p. 12.
[7] “mmol/l” refers to millimoles per liter of
blood; the normal fasting blood sugar is between 3.9 to 6.05mmol/l; infra
note 19.
[8] “g/l”
refers to grams per liter of blood; the normal CBC count is 120 to 170 g/l.
[9] Myoma of the uterus; myoma is a benign tumor of muscle (The Bantam Medical Dictionary, 5th ed., p. 437).
[10] Diabetes
is a condition where the cells of the body cannot metabolize sugar properly
due to a total or relative lack of insulin. The body then breaks down its own
fat, proteins, and glycogen to produce sugar, resulting in high sugar levels in
the blood (otherwise known as hyperglycemia, infra note 26), with
excess by-products called ketones being produced by the liver. (Dr. Gordon
French, Clinical Management of Diabetes Mellitus During Anesthesia and
Surgery, http://www.nda.ox.ac.uk/wfsa/html/u11/u1113_01.htm,
last visited
[11] Records,
Volume II, Exhibit”B” (Death Certificate); TSN,
[12] The amount of P36,000.00 by way of
actual and compensatory damages; P1,000,000.00 by way of moral damages; P500,000.00
by way of exemplary damages; P30,000.00 by way of attorney’s fees, plus P1,000.00
fee per appearance; rollo, p. 97
[13] Supra
note 1.
[14] Reyes
v. Sisters of
[15] Martin,
C.R.A., Law Relating to Medical Malpractice (2nd ed.), p.
361.
[16] 61 Am.
Jur. 2d §200.
[17] REVISED
RULES OF COURT, Rule 133, Section 1.
[18] Professional
Services, Inc. v.
[19] Reyes
v. Sisters of
[20] Sabiston
Textbook of Surgery (17th ed.), pp. 2255-2256.
[21] TSN,
[22] TSN,
[23]
Random blood sugar is defined without regard as to last meal, as
distinguished from fasting blood sugar where the blood sample has
been taken after patient has fasted for at least 8 hours. The current criteria
for the diagnosis of diabetes mellitus emphasize that fasting blood glucose
is the most reliable and convenient test for identifying diabetes in
asymptomatic individual. (Harrison’s Principles of Internal Medicine,
17th ed., p. 2277)
[24] TSN,
[25] TSN,
[26] TSN,
[27] TSN,
[28] Solis,
P., Medical Jurisprudence (1980 ed.), p. 141, citing Hill v. Stewart,
209 So 2d 809 Miss 1968.
[29] Winfield
and Jolowicz, On Tort (15th ed.), p. 181.
[30] High blood sugar is also known as hyperglycemia.
It refers to a condition where there is excessive glucose in the bloodstream
(that is, fasting blood sugar level > 6 mmol/l) due to insufficient insulin
in blood and excessive carbohydrate intake; untreated, it may lead to diabetic
coma. (The Bantam Medical Dictionary,
5th ed., p. 322)
[31] TSN,
[32]
[33] TSN,
[34] TSN,
[35] TSN,
[36] TSN,
[37] Schwartz’s
Manual of Surgery (8th ed.), pp. 246-147.
[38] Kelly’s
Textbook of Internal Medicine (4th ed.), Chapter 25 on Pre-operative
Medical Evaluation.
[39] Sabiston
Textbook of Surgery (17th ed.), p. 222, supra note 20.
[40] TSN,
[41] Gordon French, MD, Clinical Management of
Diabetes Mellitus During Anesthesia and Surgery, http://www.nda.ox.ac.uk/wfsa/html/u11/u1113_01.htm,
last visited
[42] Samuel
Dagogo-Jack, MD and K. George M.M. Alberti, Management
of Diabetes Mellitus in Surgical Patients, http://spectrum.diabetesjournals.org/cgi/content/full/15/1/44,
last visited September 21, 2008.
[43] TSN,
[44] Raymond A. Plodkowski, MD and Steven V. Edelman, MD,
Pre-Surgical Evaluation of Diabetic Patients, http://clinical.diabetesjournals.org/cgi/content/full/19/2/92, last visited
[45] 61 Am.
Jur. §359, p. 527.
[46] 61 Am.
Jur. 2d §359.
[47] Records,
Volume II, Exh. “B.”
[48] TSN,
[49] Gordon
French, MD, Clinical Management of Diabetes Mellitus During Anesthesia and
Surgery, http://www.nda.ox.ac.uk/wfsa/html/u11/u1113_01.htm,
last visited September 21, 2008; Diabetic ketoacidosis is acute,
life-threatening, metabolic acidosis that represents the most extreme result of
uncontrolled diabetes mellitus, Kelly’s Textbook on Internal Medicine (4th
ed.), Chapter 411 on Diabetic Ketoacidosis, etc.
[50] TSN,
[51] TSN,
[52] CIVIL
CODE, Article 2199.
[53] The
amount has been increased to P50,000.00 according to jurisprudence.
[54] CIVIL CODE, Article 2229.
[55] Civil Aeronautics Administration v. CA, G.R. L-51806,
[56] CIVIL CODE, Article 2208 (2).