The Lungs and the Law (An Essay)

Jig Galinato, RN, MN, MAN, LLB

Part 1. The Medical Angle

Firstly, the assessment of the respiratory system, as ancillary to the

diagnosis of a disease process, is primarily a medical function. As nurses,
the significance of such a procedure is more for the “assessment and
diagnosis of human responses to actual or potential health problems.” 1 In
short, nurses assess for the symptoms; doctors assess for the disease. Thus,
if there is one profession who should ponder on doing their respiratory
assessment correctly, these should be doctors, not nurses.

Even in the fundamental assessment book of Jarvis 2, the stethoscope

should be laid on the skin, not on the dress over the skin. Otherwise, the
accuracy of the assessment would be affected. There’s also the need to
assess from the topmost intercostal space to the lowermost intercostal
space in systematic ladder-like downward fashion in both anterior and
posterior chest to assess all the lobes of the lungs. Yet, how many times
have it been reported, to the point of being a cliché, of medical doctors just
placing their stethoscope in one area, telling the patients to breathe, and
that’s it. Such cavalier attitude towards assessment performed by the
supposed apex members of the medical team is seen, and unfortunately
emulated, by the other members: nurses, med techs, radiation technicians;
even by med students. How is assessment in the clinical area supposed to
improve when the medical profession itself can’t be bothered to tell its
members to do their jobs properly? As a result, we got patients who are
misdiagnosed, undertreated, or untreated; simply because some doctor
relied on his intuition rather than standard procedure.

Ineluctably, if there are to be real changes, or improvements in

medical respiratory assessment, doctors, as captains of the ship 3, must lead
the way.
1
American Nurses Association, 2002.
2
Jarvis, Physical Assessment, 2012.
3
Kozier, Fundamentals of Nursing, 2012.

Part 2. The Nursing Angle

Nurses must do its share in sticking to the standards of its assessment

techniques. Assessment, after all, is the most important step in the nursing
process.4 If it breaks, the entire chain of nursing process breaks. Nurses
must understand that if they commit a mistake in assessment, and there is a
proximate cause between such mistake and the patient’s injuries or death,
they could be held civilly liable for damages. 5 Indeed, nurses in the
Philippines must learn that they are not mere henchmen of doctors. Nurses
should not just simply follow the doctor’s orders or condone their
ineptitude. Nurses should make sure that they cause no harm to the patient,
and that “just following doky’s orders” is never an excuse.6

In the case of Our lady of Lourdes Hospital v Spouses Romeo and

Regine Capanzana7, a nurse neglected to assess the respiratory status of a
patient experiencing respiratory distress, and whose significant others is
complaining that such patient’s oxygen tank is running empty. As a result,
the patient suffered cardiopulmonary arrest which caused her brain damage
and subsequent vegetative state, to wit: “hypoxic encelopathy due to
pulmonary cardiac arrest on the background of pulmonary edema.” The
nurse was held liable along with the hospital for Php 299,102.04 for actual
damages, Php 1,950,296.80 for compensatory damages, Php 100,000 for
moral damages, and Php 100,000 for attorney’s fees.8

The doctors in the above case got out scot-free, even if the RTC found
out that they failed to assess the patient’s heart disease—a rheumatic heart
disease with mitral stenosis—which led to the patients pulmonary
hypertension, then pulmonary edema, and eventual respiratory arrest; all
because the nurse didn’t assess the respiratory function of the patient; an
assessment which, in my humble asseveration, could, and should, have been
done with greater accuracy and thoroughness by the admitting physician.
 The lesson to be learned from this case, for me, is that nurses must do
everything in their power not to be the “fall guy”, the “stodge”, or the
“scapegoat.” They must assess each patient like their jobs, liberty, and
dignity depend on it; and must never rely solely on the good doctor’s
proclamation that the “coast is clear.”

4
Kozier, Fundamentals of Nursing, 2012.
5
Aquino, Civil Law Review 2018.
6
See Par. 6, Article 11, RA 3815.
7
GR 189218, March 22, 2017.
8
ibid

Part 3 (last part). The Legal Angle.

Laws, and jurisprudence, ultimately are the ones that ensure doctors
and nurses do their jobs properly. The practice of medicine in our time is
highly evolved. The science is in such an advanced state, that the maladies
of yore do not court death as they often do. The science is there. It’s just up
to doctors and nurses to stick to their job descriptions and comply with the
standards. And this is as true in the area of respiratory assessment.

Because it’s when the children of medicine or nursing let their egos
govern and break rules that patients die. In the case of Rogelio Nogales v
Capitol Medical Center, Dr. Oscar Estrada et al 9, a pregnant mother was
admitted with preeclampsia, a condition characterized by severe
hypertension with risk for convulsion accompanying the pregnancy. In
jurisprudence, the mother with pre-eclampsia is usually made to give birth
by Caesarian Section for her safety, not through NSVD (normal spontaneous
vaginal delivery); she may even legally undergo abortion—terminate and
expel the fetus—to save her life.10 That is probably why, in this case, the
anesthesiologist of Capitol Medical Center offered his services to Dr Oscar
Estrada. But Estrada refused the services of the anesthesiologist and
proceeded with the NSVD, as documented by the nurse in the nurses notes
(good job of the nurse). Nevertheless, the good anesthesiologist remained in
the hospital to monitor the situation. Indeed, the worst happened: the blood
pressure of the mother spiked and she experienced convulsions. Magnesium
sulfate was injected to her, to no avail. Doctor Estrada pulled the baby out
by forceps delivery, tearing a chunk of the mother’s cervix and injuring the
baby’s head in the process (the baby came out pale and apneic). A series of
medical treatments was done with many specialists involved, but the mother
ultimately died to postpartum haemorrhage. The Supreme Court upheld the
decision reached by the RTC (Regional Trial Court) after eleven (11) years
of trial: that it was the malpractice of Dr. Oscar Estrada and the negligence
of Capitol Medical Center that caused the patient’s death. As a result,
Capitol Medical Center is made vicariously liable with Dr. Estrada for Php
105,000 for actual damages, and Php 700,000 for moral damages.

This case has everything to do with respiratory assessment. The

Preeclamptic mother with hypertension and convulsion, is obviously in
danger of cardiovascular and pulmonary complications. It is the doctor who
is in charge of thorough assessment and opting for surgery in this case, not
the nurse. But that does not mean that the nurse should just stand by and
let herself be legally implicated and damned. She did what she was
supposed to do: document the doctor’s actions and defend herself. Clearly,
not far away from proper assessment, respiratory or otherwise, is defensive
and accurate documentation.

9
GR 142625, Dec 19, 2006.
10
Reyes, Criminal Law, 2016. See Par 4, Art. 11 of RA 3815.