Kacey Ryder v. Dr. Gary Manuel

NOT DESIGNATED FOR PUBLICATION

STATE OF LOUISIANA
COURT OF APPEAL, THIRD CIRCUIT

14-1025

KACEY RYDER

VERSUS

DR. GARY MANUEL

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APPEAL FROM THE
NINTH JUDICIAL DISTRICT COURT
PARISH OF RAPIDES, NO. 249,304
HONORABLE HARRY F. RANDOW, DISTRICT JUDGE

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JIMMIE C. PETERS
JUDGE

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Court composed of Jimmie C. Peters, Marc T. Amy, and Shannon J. Gremillion,
Judges.

AFFIRMED.

Lionel H. Sutton III
935 Gravier Street, Suite 1910
New Orleans, LA 70112
(504) 592-3230
COUNSEL FOR PLAINTIFF/APPELLANT:
Kacey Ryder

Eugene J. Sues
Gold, Weems, Bruser, Sues & Rundell
2001 MacArthur Drive
P. O. Box 6118
Alexandria, LA 71307-6118
(318) 445-6471
COUNSEL FOR DEFENDANT/APPELLEE:
Dr. Gary Manuel

PETERS, J.

Kacey Ryder brought this medical malpractice suit against Dr. Gary Manuel

for damages she sustained in a surgical procedure he performed. The trial court

granted Dr. Manuel summary judgment dismissing her claims against him, and she

appeals this judgment. For the following reasons, we affirm the trial court

judgment in all respects.

DISCUSSION OF THE RECORD

Ms. Ryder came under the professional care of Dr. Manuel, an Alexandria,

Louisiana physician specializing in obstetrics and gynecology, for complaints of

chronic pelvic pain. After an ultrasound of the pelvis returned negative results, Dr.

Manuel suspected that Ms. Ryder suffered from endometriosis and recommended a

diagnostic laparoscopy to confirm or discount his suspicions.

On April 18, 2011, or the day before the scheduled procedure, Ms. Ryder

appeared at the Central Louisiana Surgical Hospital (Surgical Hospital) and

completed the pre-surgery paperwork. Included among the papers she signed that

day was the informed consent form at issue in this litigation.

During the April 19, 2011 procedure performed at the Surgical Hospital, Dr.

Manuel punctured one or more of Ms. Ryder’s blood vessels. When this was

discovered, he immediately terminated the laparoscopy, consulted with his partner,

Dr. Joel Hall, also an Alexandria, Louisiana obstetrics and gynecology physician,

and with Dr. Meyer Kaplan, an Alexandria, Louisiana general surgeon. Dr.
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Manuel then converted the procedure to a laparotomy, sutured the punctured

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The difference between the two procedures is incision size. A laparotomy is a surgical
procedure involving a large incision through the abdominal wall to gain access into the
abdominal cavity. A laparoscopy is an operation performed in the abdomen or pelvis through
small incisions (usually 0.5–1.5 cm) with the aid of a camera. It can either be used to inspect and
diagnose a condition or to perform surgery.

vessels, and transferred Ms. Ryder to the recovery room. At the time, Ms. Ryder

appeared to be stable.

Later that day, a Surgical Hospital anesthesiologist contacted Dr. Manuel

and informed the doctor that Ms. Ryder’s condition was decompensating. Dr.

Manuel returned Ms. Ryder to the Surgical Hospital operating room, where he

performed a second laparotomy and discovered a large amount of blood in Ms.

Ryder’s peritoneal cavity. He consulted again with Dr. Hall and Dr. Kaplan, as

well as Dr. Gary Jones, a vascular surgeon. Dr. Jones then took over the

procedure, identified a puncture in the right iliac vein, placed a suture, and

irrigated the abdomen. Dr. Manuel then caused Ms. Ryder to be transferred to the

intensive care unit of Rapides Regional Medical Center in Alexandria, Louisiana,

where she remained until April 29, 2011.

On March 15, 2012, Ms. Ryder filed a complaint with the Louisiana

Patient’s Compensation Fund asserting that Dr. Manuel had deviated from the

standard of care in his treatment of her and had not obtained her informed consent

for the procedure. On November 18, 2013, the medical review panel rejected the

complaint with written reasons. Ms. Ryder filed suit against Dr. Manuel on

February 3, 2014, repeating her assertions to the medical review panel.

After issue was joined in the litigation, Dr. Manuel filed the motion for

summary judgment now before us. In this April 14, 2014 motion, Dr. Manuel

asserted that Ms. Ryder could not meet her burden of proving that the applicable

standard of care was breached or that the informed consent was not proper. In

support of the motion, Dr. Manuel submitted a memorandum and the medical

review panel opinion. In response to this motion, Ms. Ryder filed an opposition to

which she attached the consent form, medical records, photographs, and her own

affidavit.
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After a June 16, 2014 hearing, the trial court granted the summary judgment

and dismissed Ms. Ryder’s claims against Dr. Manuel. In its oral reasons for

judgment, the trial court concluded:

I think at the end of the day, my initial impression was there had to be
expert evidence regarding . . . the failure to check this abdominal
incision and operation to correct the injury. I think as to whether
that’s a material risk and I think the failure to have that expert
evidence merits the court in granting the motion for summary
judgment.

The trial court executed a judgment granting the summary judgment and

dismissing Ms. Ryder’s claims on June 23, 2014, and thereafter Ms. Ryder

perfected this appeal. In her appeal, she asserts three assignments of error:

1. The trial court erred in finding that the consent form met the
requirements of LA-R.S. 40:1299.40.

2. The trial court erred in finding that Kacey Ryder consented to the
subsequent surgeries.

3. The trial court erred in granting the motion for summary judgment.

OPINION

Assignment of Error Number One

In her first assignment of error, Ms. Ryder contends that the trial court erred
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in finding that the consent form met the requirements of La.R.S. 40:1299.40. On

April 18, 2011, La.R.S. 40:1299.40(A)(1) provided in pertinent part:

A. (1) Notwithstanding any other law to the contrary,
written consent to medical treatment means a handwritten
consent to any medical or surgical procedure or course of
procedures which: sets forth in general terms the nature and
purpose of the procedure or procedures, together with the
known risks, if any, of death, brain damage, quadriplegia,
paraplegia, the loss or loss of function of any organ or limb, of
disfiguring scars associated with such procedure or procedures;
acknowledges that such disclosure of information has been

2
Louisiana Revised Statutes 40:1299.40 was amended and reenacted by 2012 La. Acts
No. 759, effective June 12, 2012, to consist of R.S. 40:1299.39.5 to R.S. 40:1299.39.7, but was
in full force and effect at the time Ms. Ryder executed the consent form. The general subject
matter of the act remains unchanged.
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made and that all questions asked about the procedure or
procedures have been answered in a satisfactory manner; and is
signed by the patient for whom the procedure is to be
performed, or if the patient for any reasons lacks legal capacity
to consent by a person who has legal authority to consent on
behalf of such patient in such circumstances. Such consent
shall be presumed to be valid and effective, in the absence of
proof that execution of the consent was induced by
misrepresentation of material facts.

The consent form signed by Ms. Ryder begins with the following

statement:

Louisiana [R]evised Statute 40:1299.40A requires that your physician
obtain your informed consent to all medical and surgical treatment.
What you are being asked to sign is a confirmation that your physician
had discussed the nature, purpose, prospects for success and risks of,
and the alternatives to, the proposed medical or surgical treatment.
You are also being asked to sign a confirmation that you have been
given an opportunity to answer whatever questions you had and that
your questions have been answered in a satisfactory manner. Please
read the form carefully. Ask your physician about anything you do not
understand. He or she will be pleased to explain.

This language is followed by the statement that Ms. Ryder was being offered a

diagnostic laparoscopy for her pelvic pain and that ―the nature and purpose of the

procedure is [sic] look into the pelvis through a scope to determine if there is any

pelvic pathology and render treatment if indicated[.]‖

Next, the form lists thirteen specific potential risks of the procedure with the
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following lead-in statement to the listing:

I understand that medicine is not an exact science and that
complications do occur. I confirm that I have been given no guarantee
or assurance by the physician whose name appears below or by
anyone else as to the results that may be obtained by treatment. The
following risks known to be associated with this treatment and with
any associated anesthetic, have been explained to me.

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The twelve of the thirteen risks associated with the procedure include death; brain
damage; paralysis from the neck down (quadriplegia); paralysis from the waist down
(paraplegia); loss or loss of function of an arm or leg; disfigurement, including disfiguring scars;
puncture of bowel or blood vessel; abdominal infection and complications of infection;
abdominal incision and operation to correct injury; injury to bladder; injury to ureter; and
possible air embolus. The thirteenth risk is listed as ―Loss or loss of function of the following
organs:[,]‖ but does not define the organs at risk.
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The second page of the form explains that there is no alternative to the

procedure and includes the following acknowledgment and authorization language:

I acknowledge that I have read and understand this consent form (or
that it has been read to me), that I understand the information
contained in it, including all of the medical terminology, about which
I have asked if unsure; that I have been given an adequate opportunity
to ask whatever questions I had about the treatment; that all of my
questions about the treatment have been answered by my physician in
a satisfactory manner; and that I understand the nature and purpose of
the treatment, its risk, and the alternatives.

I hereby authorize and direct Dr. Manuel and/or his associates or
assistants of his or her choice, to perform, Abdominal Endoscopy
(Diagnostic Laparoscopy) on myself. I further authorize and direct
him or her to perform any other procedure with the exception of
________ which in his or her judgment is advisable for my well-
being, and to provide such additional services as he or she may deem
appropriate, including, but not limited to, the administration of any
anesthetic agent and the disposal of removed tissue.

Finally, at the bottom of the second page is a signature line for Ms. Ryder as

well as one for a witness to the signature and the physician. All three signature

lines are executed.

We find that the consent form meets the requirements of La.R.S.

40:1299.40. Thus, we find no merit in Ms. Ryder’s first assignment of error.

Assignment of Error Numbers Two and Three

In her second assignment of error, Ms. Ryder asserts that the trial court erred

in finding that she consented to the subsequent surgeries, and in her third

assignment of error, she asserts that the trial court erred in granting summary

judgment in favor of Dr. Manuel. Since both of these assignments of error address

the correctness of the summary judgment itself, we will consider them together.

It is well-settled that ―[a]ppellate review of the granting of a motion for

summary judgment is de novo, using the identical criteria that govern the trial

court’s consideration of whether summary judgment is appropriate.‖ Smitko v. Gulf

S. Shrimp, Inc., 11-2566, p. 7 (La. 7/2/12), 94 So.3d 750, 755. Louisiana Code of
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Civil Procedure Article 966 governs summary judgment proceedings and provides

a goal of the ―just, speedy, and inexpensive determination of every action except

those disallowed by Article 969.‖ La.Code Civ.P. art. 966(A)(2).

The trial court is to render summary judgment ―if the pleadings, depositions,

answers to interrogatories, and admissions, together with any affidavits, if any,

admitted for purposes of the motion for summary judgment, show that there is no

genuine issue as to material fact, and that mover is entitled to judgment as a matter

of law.‖ La.Code Civ.P. art. 966(B)(2). The burden of proof applicable to a

motion for summary judgment is set forth in La.Code Civ.P. art. 966(C)(2), which

reads as follows:

The burden of proof remains with the movant. However, if the
movant will not bear the burden of proof at trial on the matter that is
before the court on the motion for summary judgment, the movant’s
burden on the motion does not require him to negate all essential
elements of the adverse party’s claim, action, or defense, but rather to
point out to the court that there is an absence of factual support for
one or more elements essential to the adverse party’s claim, action, or
defense. Thereafter, if the adverse party fails to produce factual
support sufficient to establish that he will be able to satisfy his
evidentiary burden of proof at trial, there is no genuine issue of
material of fact.

Because Dr. Manuel does not have the burden of proof at trial, he need only

―point out to the court that there is an absence of factual support for one or more

elements essential to‖ Ms. Ryder’s claims against him. Id. Dr. Manuel sought to

satisfy this burden by introducing the opinion of the medical review panel, which

reads in pertinent part as follows:

Claimant herein contends that defendant, Dr. Gary Manuel,
breached the applicable standard of care in the following respects:
performing a procedure so as to cause multiple punctures of multiple
vessels; performing a procedure for which he lacked the appropriate
qualification and knowledge; failing to obtain an appropriate informed
consent for the procedures performed, specifically, laparotomy,
abdominal incision or additional operations; and failing to obtain
consent which adequately disclosed risk of an abdominal incision and
operation to correct injury.
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After careful review of the evidence submitted for our review,
we find that the actions of the defendant herein, Dr. Gary Manuel, did
not constitute a deviation from the applicable standard of care. The
punctured veins were recognized complications of the procedure of
which the patient executed an informed consent. The consent form,
while unusual and less than optimal, was more than adequate to
address the complication, as well as the remedial steps taken. Further,
review of the record indicates that Dr. Manuel did have a consent
discussion with the patient and her mother on March 3, 2011. When
the complication was noted, Dr. Manuel took prompt and appropriate
action to rectify the situation, including converting to a laparotomy
and obtaining appropriate consults. Lastly, the physician was clearly
qualified to perform the procedure, and notably, was board certified in
his field, and calling in additional surgical support was the appropriate
action to take. The remaining allegations of breach by the claimant as
against this defendant are not supported by the evidence, and in all
respects, the care rendered by this physician to this patient was
appropriate.

In order to prevail on a claim of lack of informed consent, Ms. Ryder must

prove (1) the existence of a material risk unknown to her; (2) a failure on the part

of Dr. Manuel to disclose the risk to her; (3) disclosure of the risk would have led a

reasonable patient in Ms. Ryder’s position to reject the medical procedure or to

choose a different course of treatment; and (4) an injury caused to Ms. Ryder as a

result of the failure to disclose the material risk. Hondroulis v. Schuhmacher, 553

So.2d 398 (La.1988)

It is well settled in Louisiana law that when a patient signs a consent form,

there is a presumption that the consent is valid. Baker v. Williams, 02-67 (La.App.

3 Cir. 8/28/02), 825 So.2d 563, writ denied, 02-2447 (La. 11/22/02), 829 So.2d

1055. In order to rebut the presumption of consent, Ms. Ryder must show

misrepresentation of materiality on the part of Dr. Manuel. La.R.S 40:1299.39.5.

In explaining this burden, the supreme court in Hondroulis, 553 So.2d at 412

(emphasis added) (citations omitted), stated:

The determination of materiality is a two-step process. The
first step is to define the existence and nature of the risk and the
likelihood of its occurrence. “Some” expert testimony is necessary to
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establish this aspect of materiality because only a physician or other
qualified expert is capable of judging what risk exists and the
likelihood of occurrence. The second prong of the materiality test is
for the trier of fact to decide whether the probability of that type harm
is a risk that a reasonable patient would consider in deciding on
treatment. The focus is on whether a reasonable person in the
patient’s position probably would attach significance to the specific
risk. This determination of materiality does not require expert
testimony.
There must be a causal relationship between the doctor’s failure
to disclose material information and material risk of damage to the
patient. Because of the likelihood of a patient’s bias in testifying in
hindsight on this hypothetical matter, this court and others have
adopted an objective standard of causation: whether a reasonable
patient in the plaintiff’s position would have consented to the
treatment or procedure had the material information and risks been
disclosed.

Furthermore, in the event of an emergent situation, the supreme court in

Hondroulis stated:

[A] doctor is not required to disclose material risks or information
when a genuine emergency arises because the patient is unconscious
or otherwise incapable of consenting, and harm from a failure to treat
is imminent and outweighs harm threatened by the proposed treatment

Id.

The laparotomy was an emergent procedure, inherent within the consent

given to repair the risk of a punctured blood vessel and save Ms. Ryder’s life. Ms.

Ryder signed a consent form authorizing Dr. Manuel to perform any other

procedure that, within his judgment, was advisable for her well-being. Performing

a laparotomy to stop a life-threatening bleed was certainly advisable in this case to

which any reasonable person would consent.

While the consent form does not specifically address the possibility of a

laparotomy procedure, it specifically lists the puncture of a blood vessel as a risk

associated with the laparoscopy procedure, and it further authorizes Dr. Manuel ―to

perform any other procedure . . . which in [his] judgment is advisable for [her]

well-being.‖ The medical review panel found that the informed consent form

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signed by Ms. Ryder was more than adequate to address the complication, as well

as the remedial steps taken; that Dr. Manuel had a consent discussion with Ms.

Ryder and her mother on March 3, 2011; and that punctured veins were recognized

complications of the procedure of which Ms. Ryder executed an informed consent.

The trial court, at the hearing for summary judgment, found that there had to be

expert evidence regarding the remedial steps taken and whether or not they were a

material risk. Without an expert to establish whether the risk of a laparotomy was

material, Ms. Ryder could not prevail on her claim of lack of informed consent.

Viewing the record in its entirety, we find that it was reasonable for the trial court

to conclude that Ms. Ryder needed to produce expert testimony to rebut the

opinion of the medical review panel finding that the informed consent given by

Ms. Ryder was adequate under the circumstances. Her own self-serving affidavit

is not sufficient due to a patient’s likelihood of bias in testifying in hindsight.

Accordingly, we find no merit in Ms. Ryder’s second assignment of error.

Finally, Ms. Ryder asserts that there remain genuine issues of material fact

with regard to the issue of whether Dr. Manuel breached the applicable standard of

care in his treatment of her. We first note that the opinion of the medical review

panel is sufficient evidence to present a prima facie case on behalf of Dr. Manuel

and to shift the burden of proof to Ms. Ryder. Williams v. Mem’l Med. Ctr., 03-

1806 (La.App. 4 Cir. 3/17/04), 870 So.2d 1044, writ denied, 04-963 (La. 6/4/04),

876 So.2d 93. In attempting to meet her burden, Ms. Ryder presented no expert

evidence to rebut the unanimous medical review panel opinion in favor of Dr.

Manuel, and as a result, summary judgment is appropriate in this case.

DISPOSITION

For the foregoing reasons, we affirm the trial court judgment granting the

motion for summary judgment in favor of Dr. Gary Manuel and dismissing the
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claims of Kacey Ryder. We assess all costs of this appeal to Kacey Ryder.

AFFIRMED.

This opinion is NOT DESIGNATED FOR PUBLICATION.
Uniform Rules—Courts of Appeal, Rule 2-16.3.

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