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Campano v. United States

United States District Court, D. Hawaii

March 7, 2018

MARITES CAMPANO and RAPHAEL CAMPANO, Individually and as the Court-Appointed Next Friend for the Minor Children R.M.B.C, R.B.B.C., and M.R.B.C., Plaintiffs,
v.
UNITED STATES OF AMERICA, Defendant.

          FINDINGS OF FACT AND CONCLUSIONS OF LAW

          Kevin S.C. Chang United States Magistrate Judge.

         The Court conducted a jury-waived trial in this matter on December 5 to 8 and 11 to 12, 2017. L. Richard Fried, Jr., Esq., John D. Thomas, Jr., Esq., and Geoffrey K.S. Komeya, Esq., appeared on behalf of Plaintiffs Marites and Rafael Campano, [1]individually and as the court-appointed next friend for the minor children R.M.B.C., R.B.B.C., and M.R.B.C. (collectively “Plaintiffs”). Assistant U.S. Attorney Harry Yee appeared on behalf of Defendant United States of America (“Defendant”). The Court has considered all the evidence presented, observed the demeanor of witnesses and evaluated their credibility and candor, considered the arguments of counsel, and considered the applicable law. Pursuant to Federal Rule of Civil Procedure 52, the Court makes the following Findings of Fact and Conclusions of Law, and CONCLUDES, for the reasons articulated below, that Plaintiffs are entitled to $24, 743, 668.53 in damages. Any finding of fact that should more properly be deemed a conclusion of law and any conclusion of law that should more properly be deemed a finding of fact shall be so construed.

         FINDINGS OF FACT

         I. Introduction

         1. This is a medical negligence case involving severe and permanent injuries to Plaintiff Marites Campano (“Marites”), including end-stage renal disease (“ESRD”) requiring hemodialysis, multiple renal transplants, and immunosuppressant medication to prevent rejection of the transplant, all for the remainder of Marites' life.

         2. Marites was severely and permanently injured as a result of sepsis caused by a group A streptococcus (“GAS”) bacterial infection that was not timely diagnosed or treated with antibiotic therapy by her physicians and care providers at Tripler Army Medical Center (“Tripler” or “TAMC”) (“incident”).

         3. Plaintiffs initiated this action against Defendant under the Federal Tort Claims Act (“FTCA”), 28 U.S.C. §§ 1346(b) and 2671 et seq., alleging that Marites' care and treatment at Tripler starting on July 22, 2013, fell below the requisite standard of care, and that as a result of this violation by Tripler of its duty of care, Marites suffered severe and permanent injuries.

         4. Plaintiffs filed their administrative claims on September 8, 2014, under the provisions of the FTCA. The claims were received by the Department of the Army on September 10, 2014.

         5. Plaintiffs commenced the instant lawsuit on October 20, 2015, after Defendant failed to either admit or deny said administrative claims within six months of the filing thereof.

         6. Plaintiffs have complied with all jurisdictional and procedural prerequisites to suit. They have timely and properly presented their claims under the FTCA to the appropriate Federal agency.

         II. Parties

         7. At all times relevant to this action, Plaintiffs were domiciled in and citizens of the City and County of Honolulu, State of Hawaii.

         A. Marites Campano

         8. Marites was born in 1976 in Ilocos Norte, a province in the Philippines. [Testimony of Marites B. Campano in Transcript of Non-Jury Trial Before the Honorable Kevin S.C. Chang, United States Magistrate Judge on Tuesday, December 12, 2017 (“Marites 12/12”)[2] at 39:13, 14-17.]

         9. In 1993, Marites graduated from St. Joseph High School in Dingras, Ilocos Norte. [Id. at 40:10-20.]

         10. In 1998, Marites obtained an Associate's Degree in Computer/Secretarial Science from the Divine Word College of Laoag in Laoag City, Philippines. [Id. at 40:21-41:9.]

         11. Marites was employed as a sales clerk at a store called Fashion and Decor in Ilocos Norte and as a cashier at SM, the biggest shopping center in the Philippines, located in Manila. [Id. at 48:1-7.]

         12. Marites also led hundreds of young people for seven to eight years as an “SK Chairman, ” an elected youth governmental official in her area in the Philippines. [Id. at 48:11-49:2.]

         13. In November 2007, Marites came to the United States. [Id. at 39:19.]

         14. From 2008 to 2010, Marites was a cashier at Golden Coin restaurant. [Id. at 43:18-21.]

         15. In 2010, Marites obtained a Certified Nursing Assistant certification from Healthcare Training and Career Consultants, Inc. [Id. at 41:10-42:1.]

         16. From 2010 until her injury at Tripler in July 2013, Marites was employed as a full-time Certified Nursing Assistant at The Plaza at Mililani. [Id. at 42:13-17; 50:15-17.]

         B. Rafael Campano

         17. Plaintiff Rafael Castro Campano (“Rafael”) was born in 1976 in Ilocos Norte. [Rafael 12/7 at 131:6-14.]

         18. In 1993, Rafael graduated from high school in the Philippines. [Id. at 131:17-20.]

         19. In 1996, Rafael received a Diploma of Technology in Automotive Mechanics from the Mariano Marcos State University Institute of Technology in Laoag City, Philippines. [Id. at 131:21-132:10.]

         20. In 2001, Rafael received a Bachelor's Degree in Physical Therapy from the Mariano Marcos State University in Batac City, Ilocos Norte. [Id. at 132:11-21.]

         21. In September 2004, Rafael moved to Hawaii. [Id. at 135:12-14.]

         22. After arriving in Hawaii, Rafael was briefly employed as a building maintenance worker, then as a physical therapy aide. [Id. at 135:24-136:18.]

         23. In October 2005, Rafael enlisted in the U.S. Navy, and remains in the Navy's employ. [Id. at 136:19-24.]

         24. In December 2013, Rafael received a Bachelor of Science in Nursing from Hawaii Pacific University. [Id. at 132:22-133:6.]

         25. In January 2014, Rafael became a licensed Registered Nurse in Hawaii. [Id. at 135:4-7.]

         26. Rafael hopes to obtain a Master's Degree in Nursing, but Marites' injuries have prevented him from doing so. [Id. at 133:13-20.]

         27. Had Marites not suffered the injuries from the subject incident, Rafael believes that he would have entered a Master's Degree program and possibly already obtained a degree. [Id. at 133:18-25.]

         28. A Master's Degree in Nursing would improve Rafael's chances for promotion in the Navy because such accomplishments factor into career advancement. [Id. at 134:3-13, 17-19.]

         29. Rafael also aspires to be an Advanced Practice Registered Nurse. [Id. at 134:20-135:3.]

         30. Rafael's current rank is Lieutenant Junior Grade, and his promotion to full Lieutenant is expected in December 2017. [Id. at 134:14-16; 136:25-137:6.]

         C. The Campano Family

         31. Marites and Rafael have been together since 1998, and were married on April 8, 2005. [Marites 12/12 at 49:21-22, 24.]

         32. Marites and Rafael's eldest son, Plaintiff R.M.B.C., was born in 1999 in the Philippines. He came to Hawaii in 2004 with Rafael, but returned to the Philippines until 2007, at which time he moved to Hawaii with Marites and his younger brother, Plaintiff R.B.B.C. [R.M.B.C. 12/7 at 87:23-88:8, 88:24-89:1.]

         33. R.M.B.C. attends high school in San Diego and is currently a senior with a 4.0 grade point average. [Id. at 105:25-106:7.]

         34. R.M.B.C. plans to attend college at the University of Hawaii at Manoa, Northern Arizona University, or Washington State University. [Id. at 106:10-13.]

         35. R.M.B.C. aspires to become a fighter pilot in the Air Force. [Id. at 106:14-19.]

         36. Marites and Rafael's younger son, R.B.B.C., was born in 2001 in the Philippines. He is presently attending high school in San Diego and has a 3.6 grade point average. [R.B.B.C. 12/7 at 116:9-25, 127:1-5.]

         37. R.B.B.C. is considering majoring in mechanical engineering and would like to join the Navy as a mechanical engineer. [Id. at 128:13-17.]

         38. Marites and Rafael's youngest child and daughter, Plaintiff M.R.B.C, was born during the incident at Tripler. [Rafael 12/7 at 140:6-15; Ex. J-1, TAMC2 3679-81, 3838-39, 5059; Ex. J-2, TAMC 2057-59, 3054.]

         39. Rafael recently relocated to San Diego, California, to be trained at Balboa Naval Hospital. [Rafael 12/7 at 142:1-10.]

         40. Prior to the relocation, the Campano family lived in Mililani with Rafael's brother, Paquito, and Marites' mother. [Id. at 142:14-20.]

         41. Rafael hopes to serve in the Navy for eight more years, at which time he will be eligible for retirement. [Id. at 145:14-25.]

         42. Following Rafael's retirement, Plaintiffs intend to return to Hawaii. [Id. at 146:3-8.]

         43. In the event Marites requires hemodialysis again, the Campanos would return to Hawaii because of the required family support, even if it means that Rafael is forced to leave the Navy prior to his eligibility for retirement. [Id. at 143:14-145:4.]

         III. Stipulations

         A. Stipulation as to Liability

         44. The parties stipulated to Defendant's sole liability for the injuries sustained by Marites in the July 22, 2013 hospitalization at Tripler. [Doc. No. 123.] The parties additionally stipulated that they shall not elicit any testimony or offer any proof at trial on the issue of liability. [Id.]

         B. Stipulation as to Expert Qualifications

         45. The parties stipulated that the knowledge, skill, experience, training and/or education of the following witnesses satisfy Federal Rule of Evidence ("FRE") 702's standards for expert qualifications in their respective fields of expertise as set out in the table below:

No.

Expert Name

Field of Expertise

Party

1.

Ching, Jeffrey D.S., M.D.

Emergency and Internal Medicine

D

2.

Fountaine, John

Life Care Planning

D

3.

Friedman, Stuart

Nephrology

D

4.

Klein, Keith L., M.D.

Nephrology, Internal Medicine, Life Expectancy

P

5.

Loudat, Thomas A., Ph.D.

Economics

P

6.

Marvit, Robert C, M.D.

Psychiatry, General Medicine

P

7.

Meyers, Jeffrey E.

Economic Loss Projections and Statistics

D

8.

Ponce, Danilo E., M.D.

Psychiatry

P

9.

Riddick-Grisham, Susan R.N.

Life Care Planning, Case Management

P

10.

Smith, Eric S., Ph.D.

Forensic Psychology

D

         The parties were not required to present oral testimony at trial regarding the qualifications of the above witnesses for purposes of establishing FRE Rule 702 qualifications. [Doc. No. 124.]

         C. Stipulation as to Past and Future Wage Loss Damages

         46. The parties stipulated that the incident caused Marites to suffer $538, 092.00 in past and future wage loss, as reflected in the table below:

Item

Compensation Loss

Net Income Taxes

Total Net Wage Loss

Past Wage Loss

$89, 012.00

$8, 470.00

$80, 543.00

Present Value Future Wage Loss

$507, 202.00

$49, 652.00

$457, 549.00

TOTALS

$596, 215.00

$58, 122.00

$538, 092.00

         [Doc. No. 126.]

         D. Stipulations as to Exhibits

         47. The parties stipulated to the admissibility for all purposes of all exhibits on the joint exhibit list, Exhibits J-l through J-91, and to the authenticity of Plaintiffs' Exhibits P-56 through 71. [Doc. No. 115.]

         48. The parties stipulated to the admissibility for all purposes of Joint Exhibits J-92A and J-92B. [Doc. No. 130.]

         IV. The Incident

         49. Marites' estimated due date was July 24, 2013. Despite Marites' advanced maternal age, her pregnancy was uncomplicated. There was no indication of issues with Marites or M.R.B.C., or anticipation of problems with the birth. [Ex. J-l at TAMC2 2523, 2533-34, 7323-24, 7380-82; Ex. J-3 at TAMC (CHRONO) 153-54; Ex. J-ll at MAKALAPA 927-28, 984-86].

         50. Marites presented to Tripler at 11:40 a.m. on July 22, 2013, and was admitted to labor and delivery. Labor was thereafter induced. [Ex. J-l at TAMC2 3669, 3830; Ex. J-2 at TAMC 860-611888, 2049-57.]

         51. Within hours of arrival, Marites became clammy and pale, and experienced intermittent episodes of hypotensive low blood pressure and a tachycardic heart rate ranging from 120 to 150 beats per minute. Notwithstanding the administration of multiple fluid boluses and an IV, Marites' symptoms did not improve. [Ex. J-1 at TAMC2 3673-77, 3834-37, 4469, 5057-59; Ex. J-2 at TAMC 1117, 1888, 2049-57, 2505.]

         52. M.R.B.C. was born at 1:10 a.m. on July 23, 2013. [Ex. J-1 at TAMC2 3679-81, 3838-39; Ex. J-2 at TAMC 2057-59.]

         53. Marites experienced repeated and increasing episodes of hypotension and tachycardia after her transfer to the postpartum unit. [Ex. J-1 at TAMC2 3185, 3190, 3198, 3218; Ex. J-2 at TAMC 1404, 1409, 1417, 1437.]

         54. A number of measures were taken to alleviate Marites' fluctuating level of pain. [Exs. J-1, J-2.]

         55. Marites was not producing urine due to her failing kidneys. As a result, she was catheterized at least eight times to drain her bladder. [Ex. J-2 at TAMC 1117, 1120-21, 3496.]

         56. At approximately 5:45 a.m. on July 24, 2013, the Tripler Rapid Response Team independently noticed Marites' condition. [Ex. J-2 at TAMC 3477-80; Rafael 12/7 at 149:25-150:10.]

         57. By the time the Rapid Response Team intervened, Marites had been in near constant pain for approximately 48 hours and her condition deteriorated into sepsis. [Ex. J-1 at TAMC2 5927-28, 6885-86; Ex. J-2 at TAMC 458; Ex. J-11 at MAKALAPA 534-35.]

         58. Despite her need for immediate escalation of care and acute intervention, Marites' admission to the intensive care unit (“ICU”) was delayed for another two hours. [Ex. J-1 at TAMC2 5269.]

         59. By the time she was finally admitted to the ICU, Marites' blood tests indicated she was in metabolic acidosis with accompanying compensatory respiratory alkalosis. [Ex. J-2 at TAMC 3478, 3542-44.]

         60. The respiratory alkalosis caused her respiratory rate to increase in an effort to compensate for the increased acidosis, which in turn led to a decreased level of carbon dioxide in her bloodstream. [Id. at TAMC 3477-79, 3543.]

         61. After arriving at the ICU, Marites was intubated due to worsening respiratory distress. [Id. at TAMC 3604.]

         62. Concerned with vaginal bleeding in the afternoon of July 24, 2013, the OB/GYN team decided that Marites should undergo a dilation and curettage (“D&C”) procedure. [Id. at TAMC 3569-70.]

         63. The same day, Drs. Tamarin McCartin and Jason Patzwald performed the D&C procedure. Although they did not identify any sources of bleeding or infection, they remarked that Marites' acute renal failure and disseminated intravascular coagulation (“DIC”) were presumed to be secondary to sepsis and that her condition was critical. [Ex. J-1 at TAMC2 2332-33; Ex. J-2 at TAMC 3067-68, 3460, 3599, 3581-82.]

         64. Dr. Bradford Whitcomb, a gynecologic oncologist, evaluated Marites in the operating room and noted her overwhelming sepsis and renal failure. [Ex. J-2 at TAMC 3583.]

         65. Dr. Jeffrey Ching described Marites' hospital stay as a “stormy ICU and hospital course” during which her condition deteriorated to “classic sepsis and disseminated intravascular coagulopathy (DIC) with markedly abnormal labs, positive blood cultures and eventually multi-organ injury.” [Dr. Ching 12/11 at 102:14-18, 103:10-12; Ex. J-47 (Dr. Jeffrey Ching Report) at 2].

         66. DIC further complicated Marites' condition. DIC is a complex reaction, usually from a very serious infection, where blood functions stop working, which eventually leads to multi-organ failure or multi-organ damage. [Dr. Ching 12/11 at 102:22-103:3.]

         67. Marites suffered many of the typical complications of DIC including multi-organ system failure and permanent multi-organ damage of her kidneys. [Id. at 103:4-9.]

         68. Marites also sustained adult respiratory distress syndrome, a complication related to DIC where the lungs fill with fluid, making it difficult to breathe. Marites had to be placed on a respirator as a result. [Id. at 103:13-104:2.]

         69. Marites required multiple red blood cell and platelet transfusions as a result of the DIC. [Id. at 102:19-21.]

         70. Dr. Nealanjon Das, a nephrologist, evaluated Marites during the night on July 24, 2013. He opined that Marites had suffered permanent and irreversible kidney damage from the sepsis and determined that her prognosis for regaining dialysis-independent renal function was “very grim”. [Ex. J-1 at TAMC2 2993; Ex. J-2 at TAMC 454, 463-64.]

         71. Dr. Das ordered Marites to be placed on continuous renal replacement therapy (“CRRT”), or kidney dialysis. [Ex. J-1 at TAMC2 2993, 3699; Ex. J-2 at TAMC 454, 2073.]

         72. An infectious disease consult confirmed that Marites' sepsis was related to a GAS infection leading to bacteremia, toxic shock syndrome, and puerperal sepsis. [Ex. J-1 at TAMC2 2999-3001; Ex. J-2 TAMC 460-62.]

         73. Marites required heavy sedation while intubated. She had an abnormal heart rhythm, her lungs were compromised by the infection, and she was agitated. [Ex. J-1 at TAMC2 3002-06; Ex. J-2 at TAMC 463-64, 466-67.]

         74. On July 27, 2013, Marites extubated herself and oxygen was administered via mask. [Ex. J-1 at TAMC2 4641-42; Rafael 12/7 at 153:17-154:23.]

         75. While off the ventilator, Marites experienced issues with oxygen saturation and her mental status declined. She was agitated, confused, and disoriented. [Ex. J-1 TAMC2 2557-60; Ex. J-2 TAMC 18-20].

         76. Marites had to be reintubated due to oxygen saturation issues. [Ex. J-1 at TAMC2 2563.]

         77. On August 4, 2013, Marites was transferred to the Progressive Care Unit (“PCU”). [Ex. J-1 at TAMC2 2625.]

         78. On August 5, 2013, sonogram and ultrasound studies indicated that Marites likely had gallstones that would require surgical attention, but her compromised condition prevented her from tolerating a surgical procedure. [Id. at TAMC2 3032-34.]

         79. Marites experienced intense pain in her abdomen related to her gallbladder and stones. On August 6, 2013, an endoscopic retrograde cholangiopancreatography (“ERCP”) procedure was performed to stent her biliary duct in an effort to relieve her pain. [Ex. J-1 at TAMC2 3850-51; Ex. J-2 at TAMC 493-95, 502-03.]

         80. The ERCP procedure also revealed that Marites had a large duodenal ulcer, which was likely a stress ulcer from her condition at the time. [Ex. J-1 at TAMC2 2391-92, 7651-52; Ex. J-2 at TAMC 3019-20; Ex. J-11 at MAKALAPA 1251-52; Dr. Ching 12/11 at 109:4-8.]

         81. On August 7, 2013, Marites began hallucinating and experienced increased confusion and changes to her mental status. She was unaware of her whereabouts and could not recognize Rafael. [Ex. J-1 TAMC2 2676, 3852-53; Ex. J-2 TAMC 504-05.]

         82. Marites' physicians contemplated transfer to Queen's Medical Center (“Queen's”) due to concerns that Marites may need a liver transplant. However, Dr. Linda Wong, a transplant surgeon at Queen's, rejected Marites because she believed that Marites' condition was merely cholestasis. [Ex. J-1 at TAMC2 2683-87.]

         83. Marites was alert and oriented only to herself, and was uncooperative with nursing assessments. She stated “I'm going to die, ” became increasingly clingy with Rafael, and had limited interaction with visitors and her sons. The ongoing changes to Marites' mental status prevented her from identifying herself or Rafael at times. [Id. at TAMC2 2692-93.]

         84. On August 8, 2013, Marites had to be placed in wrist restraints because she continually attempted to pull out her nasogastric feeding tube. [Id. at TAMC2 2693-94.]

         85. Because the precise neurological cause for Marites' neurological abnormalities could not be identified, she underwent a lumbar puncture to check for causes such as meningitis. [Id. at TAMC2 2704.]

         86. The results of the tests of Marites' cerebrospinal fluid were not consistent with meningitis. [Id. at TAMC2 3871-72.]

         87. From August 9 to 10, 2013, Marites alternated from distant and random stares, to chattiness with repetition of certain phrases, to constantly opening her eyes, to constantly closing her eyes. [Id. at TAMC2 2705, 2720-21, 4079-84.]

         88. Although an MRI showed increased reactivity in the pituitary gland, Marites' providers concluded that her altered mental status was most likely attributable to bilirubin encephalopathy. [Id. at TAMC2 2728, 3881-84, 7273-77; Ex. J-11 at MAKALAPA 877-81.]

         89. Marites' mental status slowly improved in the days that followed, but she continued to suffer from multiple medical conditions, including a bleeding duodenal ulcer, gallstones, and impaired renal function. [Ex. J-1 at TAMC2 3906-07, 7258; Ex. J-2 at TAMC 558-59; Ex. J-3 at TAMC CHRON 87; Ex. J-11 at MAKALAPA 862.]

         90. On August 15, 2013, Marites was referred for a permanent catheter placement to facilitate her hemodialysis. [Ex. J-1 at TAMC2 2421-23.]

         91. On August 17, 2013, Marites was transferred from the PCU to the Mother Baby ward. [Id. at TAMC2 2786.]

         92. On August 24, 2013, Marites was discharged from Tripler. [Id. at TAMC2 2791.]

         V. Post-Discharge

         93. Marites began receiving outpatient dialysis three times a week at Pearlridge Dialysis Clinic on August 27, 2013. [Id. at TAMC2 2988-89; Ex. J-2 at TAMC 449-50.]

         94. On September 4, 2013, Marites went to the emergency department at Tripler with intense abdominal pain. [Ex. J-1 at TAMC2 7199-7205.]

         95. Radiological studies indicated that Marites continued to have symptomatic cholecystitis (gallstones), but she also had ascites, or a large collection of fluid in the abdomen. [Id.]

         96. Dr. Ching attributed Marites' ascites to her experience at Tripler. [Dr. Ching 12/11 at 108:15-22.]

         VI. Second Hospitalization

         97. Marites was admitted to the PCU and scheduled for a paracentesis procedure to drain fluid from her abdomen. [Ex. J-1 at TAMC2 7208-10; Ex. J-3 at TAMC CHRON 36-38, 352-57; Ex. J-11 at MAKALAPA 811-15.]

         98. Blood cultures returned positive for bacterial peritonitis, but because of her acute condition, Marites' providers were reluctant to subject her to invasive procedures. [Ex. J-1 at TAMC2 208-09.]

         99. As a compromise, on September 7, 2013, a percutaneous cholecystostomy was performed, which involves the insertion of a drainage catheter into the gallbladder lumen under radiologic guidance to provide temporary relief from accumulated fluid and sludge until definitive surgical treatment can be performed. [Id. at TAMC2 222-23, 6848-51, 7644-745; Ex. J-2 TAMC 3038-39, 3285-87; Ex. J-11 at MAKALAPA 495-99.]

         100. The percutaneous cholecystostomy immediately improved Marites' symptoms, but her condition deteriorated over the next ten days. The increasing abdominal pain prompted an ultrasound on September 17, 2013, which revealed several foci of ascites. [Ex. J-1 at TAMC2 305-07.]

         101. On September 18, 2013, Marites' providers recommended a full-blown diagnostic abdominal laparotomy and washout surgery, along with a surgical cholecystostomy (gallbladder removal), having determined that her condition could not be resolved with percutaneous drainage. [Id. at TAMC2 314.]

         102. Two liters of ascites fluid were drained from Marites' abdomen during the surgery. [Id. at TAMC2 9-11, 314-16, 417, 7631-33; Ex. J-2 at TAMC 3023-25, 3094-95; Ex. J-11 at MAKALAPA 1231-33.]

         103. While Marites initially showed signs of improvement, she developed an ileus in her intestine and was unable to consume food by mouth. [Id. at TAMC2 541-42, 548-50.]

         104. Upon discovery of a bile leak, Marites underwent an ERCP procedure to install a biliary stent. [Id. at TAMC2 556, 560-61, 7642-43.]

         105. Post-operative attempts to return Marites to food by mouth were unsuccessful, resulting in persistent nausea and vomiting. [Id. at TAMC2 379-81.]

         106. Marites was finally discharged on October 3, 2013.

         VII. Issues Following Second Hospitalization

         107. In the weeks that followed, Marites had difficulty adjusting to her condition and being a new mother to M.R.B.C. [Ex. J-13 at DSI 36-53.]

         108. Marites required a wheelchair and four-wheel walker for mobility which, in a small multi-level townhouse living with six other people, proved to be especially challenging. [Id.]

         109. Marites became depressed and suffered from insomnia. [Id. at DSI 50-51.]

         110. On December 25, 2013, Rafael took Marites to the Pali Momi emergency department because she was experiencing intermittent severe dizziness. Marites was diagnosed with vertigo. [Ex. J-14 at PALI MOMI 8-14, 20-21, 39.]

         111. On January 16, 2014, a repeat paracentesis was performed and two liters of fluid were removed. [Ex. J-1 at TAMC2 7070-72, 7584-87; Ex. J-2 at TAMC 3189-92; Ex. J-11 at MAKALAPA 674-76; Ex. J-16 at SURG ASSO 35-36.]

         112. On January 17, 2014, Marites returned to the Makalapa Clinic for pain at her permacath site and was provided additional antibiotics to address community-acquired MRSA. [Ex. J-3 at TAMC CHRON 253-55; Ex. J-11 at MAKALAPA 671-73.]

         113. On January 22, 2014, Marites was diagnosed with cellulitis at the catheter insertion site. [Ex. J-1 at TAMC2 7061-65; Ex. J-3 at TAMC CHRON 246-51; Ex. J-11 at MAKALAPA 665-69.]

         114. On February 19, 2014, Marites underwent another paracentesis. The procedure was unsuccessful due to suspected adhesions that impaired the ability to drain fluid. [Ex. J-1 at TAMC2 7048-52; Ex. J-3 at TAMC CHRON 231-36; Ex. J-11 at MAKALAPA 652-56.]

         115. Marites was referred to Queen's transplant program for evaluation of candidacy for a kidney transplant, and was accepted into the program on February 28, 2014. [Ex. J-12 at QMC 120, 131, 139-48.]

         116. Marites subsequently began experiencing episodes of hypertension. [Ex. J-1 at TAMC2 7041-44; Ex. J-3 at TAMC CHRON 224-27; Ex. J-11 at MAKALAPA 645-48.]

         117. Marites' nephrologist, Dr. Noah Solomon, suspected that her continuing insomnia stemmed from her depression and post-traumatic stress disorder (“PTSD”) related to the incident. He recommended psychiatric evaluation and treatment. [Ex. J-15 at NOKS 53-54, 188-89.]

         118. Dr. Solomon further recommended that Marites proceed with an AV fistula installation by a vascular surgeon due to the extended time of her need for dialysis and the lack of any indication that she would ...


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