Marina Vardanova Aramyan et al v. UNITED STATES OF AMERICA et al

Filing 88

FINDINGS OF FACT AND CONCLUSIONS OF LAW signed by Judge Margaret M. Morrow. (bp)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 vs. UNITED STATES OF AMERICA, Defendant. MARINA VARDANOVA ARAMYAN, an individual, ANI ARAMYAN, an individual, and ENESSA ARAMYAN, an individual, Plaintiffs, UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA

E-FILED: 02.09.10

) CASE NO. CV 08-00360 MMM (CWx) ) ) ) FINDINGS OF FACT AND ) CONCLUSIONS OF LAW ) ) ) ) ) ) ) )

On January 18, 2008, plaintiffs Marina, Ani and Enessa Aramyan filed this action against the United States of America, Dr. John Hoh, Asian Pacific Health Care Venture, Inc. ("APHV") and Healthnet of California. On April 25, 2008, the United States of America was substituted as defendant for Dr. Hoh and APHV pursuant to 28 U.S.C. § 2679(d)(2). Plaintiffs filed an amended complaint on May 12, 2008. On December 11, 2008, the claims against Healthnet were dismissed pursuant to the parties' stipulation. Plaintiffs' remaining claim for medical malpractice against the United States was tried to the court on July 28, 29 and 30, 2009. Having considered the evidence, the arguments of counsel, and the relevant law, the court makes the following findings of fact and conclusions of law pursuant to Rule 52 of the Federal Rules of Civil Procedure.

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1 2 3

I. FINDINGS OF FACT A. 1. The Aramyan Family

The plaintiffs in this action are Marina, Ani and Enessa Aramyan, the survivors and heirs of Arthur Aramyan, who passed away on January 19, 2006. Marina and Arthur were married in Baku, Azerbaijan. They had two children, Ani, who is now 23, and Enessa, who is now 20. In 2001, Mrs. Aramyan moved to the United States; the rest of the family followed in 2002. Mrs. Aramyan explained that the family moved to avoid discrimination against people of Armenian descent in Azerbaijan.1

2.

Mrs. Aramyan trained as a surgical technician in the United States, and has worked as a surgical technician for five years. Mr. Aramyan struggled to learn English and was less successful adapting to life in the United States and finding work. In Azerbaijan, Mr. Aramyan trained as a veterinarian and earned a living as a photographer. Although he was able to make some money working at a delivery business in the United States, Mrs. Aramyan's employment was the family's primary source of income.2 B. Asian Pacific Health Care Venture

3.

Asian Pacific Health Care Venture ("APHV") is a federal community health care center located in the Los Feliz neighborhood of Los Angeles; it primarily serves the working poor. Seventy-five percent of APHV's patients do not have insurance; 85% are

monolingual non-English speakers. Although APHV's patients are primarily Asian, 15% are Hispanic. In 2006, APHV had approximately 9,000 patients. It employed seven physicians and four nurse practitioners, and had 90-100 employees overall.3 4. Dr. John Hoh is APHV's medical director. He graduated from medical school at Temple University in 1983, and completed his internship and residency at Montefiore Medical Center between 1983 to 1986. In 1986, Dr. Hoh began a three year fellowship in geriatric Reporter's Transcript of Proceedings ("RT") at 27-30. Id. at 30-33. Id. at 373-75, 393.
2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 6. 5.

medicine. After holding various positions in the geriatric medicine field, he became the medical director of APHV. Dr. Hoh is board certified in internal medicine.4 As APHV's medical director, approximately 30% of Dr. Hoh's time is dedicated to administration and program design; 60-70% of his time is dedicated to direct primary care.5 APHV is a member of an Independent Physician Association ("IPA") known as Health Care L.A. ("HCLA" or the "IPA").6 IPAs function as intermediaries between health care providers and Health Model Organizations ("HMO's").7 HMOs pay IPAs a set amount per patient assigned to the IPA per month; the IPAs use these funds to pay different doctors within the IPA to provide care for the patients.8 Within an IPA, a patient's primary care physician is responsible for maintaining a database regarding the patient's medical history, identifying a patient's problems, and determining what treatments and tests should be performed.9 The primary care physician is frequently referred to as the "gatekeeper."10 Consistent with this, HCLA's procedures require that a patient who wants to see a specialist must first see a primary care physician for a referral.11 Patients can only be referred to specialists who have contracted with the IPA.12 The HMOs with which APHV works require that referral forms for specialists be signed by a patient's primary care physician; primary care providers are expected to see patients
4 5 6 7 8 9

Id. at 371-72. Id. at 375, 392. Id. at 331, 378. Id. at 222. Id. at 87. Id. at 223-24. Id. at 223. Id. at 332. Id. at 379-82.
3

10 11 12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 227.) 10. 9. 8. 7.

before making referrals and to provide documentation justifying the referral.13 Presently, there are about 300 HCLA patients assigned to APHV as the primary care physician; of these, approximately one-third have never scheduled appointments to visit APHV.14 C. Mr. Aramyan's Health Problems and Prescription for CABG Surgery

Mr. Aramyan suffered from heart-related problems for several years prior to his death. In 1997, he had a heart attack. Following the heart attack, an angiogram revealed that Mr. Aramyan's right coronary artery15 was closing off. As a result, in 1998, doctors placed a stent in the artery.16 Subsequently, Mr. Aramyan developed severe multi-vessel coronary artery disease. He had a history of hypertension,17 and at the time of the events relevant to this case, also had significant atherosclerosis.18 Mr. Aramyan smoked one pack of cigarettes a day for more than twenty years. He had begun an effort to quit smoking at the time of his death, however.19 In 2005, Mr. Aramyan began to experience chest pain.20 At the time, he had health insurance coverage through Medi-Cal. His primary care physician was Dr. Hakop

13 14 15

Id. at 380. Id. at 378-79. The coronary arteries deliver blood to the two ventricles comprising the heart. (Id. at

Id. at 33, 226. A stent is a metal device approximately a centimeter long which holds the artery open in order to permit blood to flow. (Id. at 226.)
17 18

16

Id. at 226-28.

Id. at 226. Atherosclerosis is the buildup of lipid and scar tissue in blood vessels, which results in coronary artery disease.
19 20

Id. at 310. Id. at 53.
4

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 14. 13. 12. 11.

G e v o r k y a n .2 1 Dr. Gevorkyan referred Mr. Aramyan to Dr. Mesropyan, a cardiologist. Dr. Mesropyan performed various tests in August 2005.22 On December 9, 2005, Mr. Aramyan had an angiogram at Glendale Adventist Medical Center. The angiogram indicated an ejection fraction of 24%.23 An ejection fraction is a measure of the ability of the left ventricle to pump blood to the body. A normal ejection fraction is 55-70%;24 this means that the left ventricle is able push 55-70% of the blood out of the ventricle.25 The angiogram also indicated considerable ischemia, or lack of blood flow to the heart.26 After the angiogram, Dr. Nucho, a cardiothoracic surgeon, concluded that Mr. Aramyan had coronary artery disease, and that he required coronary artery bypass graft, or "CABG," surgery.27 The physicians at Glendale Hospital recommended that Mr. Aramyan remain in the hospital and undergo the surgery immediately.28 Mr. Aramyan left the hospital, however, after signing a form that stated he was leaving against medical advice.29 During CABG surgery, veins are removed from a patient's legs and used to bypass blocked

21 22 23 24

Id. at 33. Id. at 53. Id. at 228.

Dr. Noble testified that 55-60% was normal; Dr. Yokoyama said that 60-70% was normal. RT at 228; id. at 150.)
25 26

Id. at 228. Id. at 244, 292. Id. at 34-37. Id. at 54. Id. at 55, Exh. 6.
5

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27 28 29

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 17. 16. 15.

arteries.30 The surgeon opens the patient's chest and obtains a vein from the patient's leg, using a special scope and making a small incision. This vein, known as a saphenous vein, is used to bypass the blocked coronary arteries.31 D. Mr. Aramyan's Selection of Dr. Yokoyama and Change of Medical Group

On December 12, 2005, the Aramyans consulted Dr. Andros, a general surgeon recommended by a family friend, for a second opinion. Dr. Andros concurred that Mr. Aramyan's condition required CABG surgery, and arranged an appointment with Dr. Taro Yokoyama, a cardiothoracic surgeon with the Pacific Cardiothoracic Surgery Group.32 Dr. Yokoyama is board certified in general surgery and thoracic surgery.33 He practices for the most part at St. Vincent's Medical Center and St. Joseph's Medical Center.34 He has been in practice for approximately thirty years and performs about 250 heart operations a year.35 On December 14, 2005, Dr. Yokoyama saw Mr. Aramyan at his office for a consultation. Mrs. Aramyan's brother, Gary Azoyan, accompanied Mr. Aramyan to the appointment to translate from English to Armenian.36 Dr. Yokoyama told Mr. Aramyan and Mr. Azoyan that he believed surgery was necessary.37 He said the need for surgery was not urgent, but that it should be performed as soon as possible.38

30 31 32 33 34 35

Id. at 229. Id. at 151. Id. at 38-39. Id. at 147. Id. Id. at 147-48. Id. at 156, Exh. 41 at 46. Id. at 188. Id. at 199.
6

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36 37 38

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18.

After the meeting with Dr. Yokoyama, Mr. Aramyan expressed confidence in the physician's abilities and decided that Dr. Yokoyama should perform the surgery.39

19.

Dr. Yokoyama's notes indicate he contemplated that the surgery, if approved, would be performed on December 19 or 26, 2005.40 This was not possible, however, as Dr. Yokoyama was not a member of Mr. Aramyan's medical group. In order for Dr. Yokoyama to perform the surgery, Mr. Aramyan had to change medical groups. Mrs. Aramyan's sister-in-law, Alisa Azoyan, arranged for Mr. Aramyan to switch to a group that would permit Dr. Yokoyama to perform the surgery.41

20.

The change in groups became effective January 1, 2006; APHV was assigned as Mr. Aramyan's primary care provider.42

21.

On January 5, 2006, Dr. Yokoyama's office faxed a request for authorization for the CABG surgery to the IPA.43 Normally, the IPA requires that a new patient be seen by the primary care physician to establish a relationship before it authorizes treatment by a specialist.44 For reasons not clarified at trial, the IPA in this case approved the surgery on January 6, despite the fact that Mr. Aramyan had not been seen at APHV.45 The IPA authorized the surgery to be performed at St. Vincent's Medical Center, rather than St. Joseph's, as originally contemplated by Dr. Yokoyama.46

22.

At some point, Dr. Yokoyama selected January 19, 2006 as the date for the surgery; Mrs.

39 40 41 42 43

Id. at 39-40 Id. Id. Id. at 43 Id. at 93; Exh. 41 at 28. Id. at 94, 107. Exh. 41 at 26. Id. at 96-97.
7

25 26 27 28
44 45 46

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 25. 24. 23.

Yokoyama informed Mrs. Aramyan that this was the earliest date available, and Mrs. Aramyan agreed that the surgery could be performed on that date.47 There was no testimony regarding the precise date on which January 19 was selected as the day for surgery. Mrs. Azoyan testified that she called Dr. Yokoyama's office in early January to find out when the surgery would be scheduled, suggesting that a date had not been selected at that time.48 Mrs. Yokoyama testified that the surgery was scheduled for January 19 after Dr. Yokoyama received the IPA's authorization to perform the surgery on January 9, 2006. Although she did not provide a specific date, Mrs. Yokoyama suggested that the January 19 date was set shortly after January 9, 2006.49 E. Requirements Prior to Surgery

In addition to obtaining the IPA's authorization for surgery, several other things had to occur before Mr. Aramyan could undergo the CABG procedure. First, a variety of pre-operative laboratory tests had to be performed. These included vein mapping, a chest x-ray, an EKG, a complete blood count, a biomedical profile, typing and cross-matching, and procedures known as PTT and pro-time.50 Vein mapping is required pre-operatively to determine whether the veins in a patient's leg are of sufficient diameter that they can be used in CABG surgery.51 The procedure is typically performed by a technician in a diagnostic laboratory several days before

47 48 49

Id. at 41. Id. at 185.

Id. at 110 ("Q. On or around ­ after you received authorization for the surgery, was surgery scheduled in fact for Mr. Aramyan near the 19th of January, 2006? A. Yes, it was. Q. So that would be another procedural requirement that was completed. A. Correct. Q. So as of about this time, January 6, 2006, two procedural requirements had been completed. A. Correct"). Id. at 107-08. The court lists the names of the procedures mentioned at trial here. The nature and purpose of every procedure was not fully explained by the evidence.
51 50

Id. at 104.
8

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 31. 30. 29. 28. 27. 26.

surgery,52 although it can be done in the hospital on the day of the surgery.53 PTT and pro-time are coagulation profiles used to determine whether a patient has a tendency to bleed longer than normal, necessitating certain medications.54 Like vein mapping, blood tests, chest x-rays, and EKG's are typically performed a few days before surgery.55 On January 13, 2006, Dr. Yokoyama's office ordered the preoperative testing that needed to be performed prior to Mr. Aramyan's surgery on January 19.56 By January 19, 2006, most of the tests had been completed. Vein mapping had not been done, but, as noted, could have been completed at the hospital. Plaintiffs' expert, Dr. Randolph Noble, noted after reviewing Mr. Aramyan's records that blood typing and cross-matching had not occurred. There was no specific testimony that PTT and pro-time had been completed, although it is possible that these were encompassed in, or were simply different terms for, some of the procedures that the testimony indicated had been completed: i.e., lab studies, a chemistry panel, and a complete blood count.57 In addition to having pre-operative tests, Mr. Aramyan needed to stop taking aspirin before the surgery.58 Most relevant in this case, it was necessary to secure the participation of a cardiologist prior to surgery. Although the parties agree that Dr. Yokoyama wanted a cardiologist involved in Mr. Aramyan's treatment in some manner, they dispute the role he intended

52 53 54 55 56 57 58

Id. at 167. Id. at 245. Id. at 108. Id. at 270-71. Id. at 116. Id. at 271. Id. at 161, Exh. 41 at 46.
9

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 34. 33. 32.

the cardiologist to play.

Defendant contends that Dr. Yokoyama envisioned that a

cardiologist would see Mr. Aramyan prior to surgery and would address cardiac issues that arose during and after the operation. Plaintiffs counter that Dr. Yokoyama only wanted to identify a cardiologist who would care for Mr. Aramyan post-operatively; they maintain he did not want a preoperative consultation. Testimony regarding this issue focused on a note recorded by Dr. Yokoyama after his December 14, 2006 consultation with Mr. Aramyan. In the note, Dr. Yokoyama wrote, among other things, "we need cardiologist."59 The testimony regarding what Dr. Yokoyama intended by the notation "we need cardiologist" was conflicting.60 Dr. Yokoyama explained that a cardiologist generally handles the non-surgical medical aspects of a patient's care, because the surgeon handles only the surgery.61 The cardiologist follows up with the patient after surgery to deal with post-operative problems, and the same cardiologist may see the patient before surgery, although this is not necessarily the case in every situation.62 Dr. Yokoyama stated that there was no rigid practice regarding pre-operative consultations with a cardiologist prior to surgery. At his deposition, however, Dr. Yokoyama testified that he was referring both to preoperative care at the hospital and post-operative care when he wrote "we need cardiologist."63 He seemed to confirm this statement at trial, stating that he wanted to have a discussion before the operation with the cardiologist who was going to follow Mr.

Exh. 41 at 46. Dr. Yokoyama also noted "we need pulmonologist." Apparently, this was due to Mr. Aramyan's history of smoking, although the pulmonologist's role in treatment was not discussed in detail at trial.
60 61 62 63

59

RT at 163-65. Id. at 163. Id. at 163-64. Id. at 163.
10

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Aramyan after the surgery,64 that he wanted to have a cardiologist with whom he was familiar review the case pre-operatively,65 and that he envisioned the review would occur before the surgery took place.66 This was consistent with Dr. Yokoyama's deposition testimony that a patient in Mr. Aramyan's position would usually see the cardiologist who was going to care for him post-operatively prior to undergoing surgery.67 Nonetheless, he appeared to back away from these statements to some extent when he testified at trial that speaking with a cardiologist was merely a "formality" necessary to secure a cardiologist's participation during the post-operative period.68 Overall, Dr. Yokoyama's testimony did not provide a clear picture as to whether he intended for Mr. Aramyan to have a pre-operative consultation with a cardiologist. Dr. Yokoyama indicated generally, however, that there was no set practice as to whether a CABG surgery patient sees a cardiologist pre-operatively.69 Mrs. Yokoyama testified that Dr. Yokoyama's note referred only to the need for a cardiologist to follow Mr. Aramyan post-operatively.70 She stated that it was not normal for a patient to be seen pre-operatively by the cardiologist who was going to care for him post-operatively. This, however, contradicted Dr. Yokoyama's deposition testimony.71 Plaintiffs' expert Dr. Noble also expressed an opinion regarding the need for a cardiologist, as discussed in the separate section regarding his testimony below.

64 65 66 67 68

Id. at 165. Id. Id. at 166. 171. Id. at 174. Id. at 164 ("It's not a rigid situation"). Id. at 106. Mrs. Yokoyama is both Dr. Yokoyama's wife and his nurse. (Id. at 86, 88.) Id.
11

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69 70 71

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38.

Dr. Yokoyama's notes indicate that he initially contemplated that a cardiologist named Dr. Sroujie at St. Joseph's Medical Center would participate in Mr. Aramyan's care.72 This was before Mr. Aramyan switched medical groups, however. Once Mr. Aramyan

switched groups, the cardiologist had to be someone contracted with the new group.73 39. Before a cardiologist could perform services for Mr. Aramyan, an authorization from the IPA was required.74 The role of the primary care provider in securing this authorization is to refer the patient to a cardiologist and fill out the paperwork required by the IPA.75 The rules of the IPA required that Mr. Aramyan's primary care physician at APHV see him before referring him to a cardiologist for pre-operative or post-operative care.76 F. 40. Communications Between the Aramyans, APHV and Dr. Yokoyama's Office

Mr. Aramyan was first seen at APHV on January 18, 2006 by Dr. Pakdaman, and was seen a second time on January 19, 2006 by Dr. Hoh. On the days of these appointments, and the days preceding them, there were a variety of communications between staff at APHV and staff at Dr. Yokoyama's office. In addition, there were several The court describes these

communications between APHV and the Aramyans.

communications before turning to the appointments themselves. 41. The earliest conversations between APHV staff and Dr. Yokoyama's office described at trial were conversations in early January to which Mrs. Yokoyama testified. She stated that the Aramyans called APHV several times beginning January 3, 2006 to schedule an appointment and were told that no appointment was available for two or three weeks.77

72 73 74

Id. at 174-75. Id. at 167. Id. at 399-400. Id. at 398. Id. at 399. Id. at 90-91.
12

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75 76 77

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 42.

She said that, on January 3 or 4, the Aramyans contacted Dr. Yokoyama's office and enlisted her help in securing an appointment with APHV. Mrs. Yokoyama reported that she called APHV and spoke with Teresita Towner, a licensed vocational nurse employed by APHV,78 who stated that the clinic was "very busy." Mrs. Yokoyama testified that she then asked to speak with the director and was connected to Dr. Hoh. She stated that Dr. Hoh simply said, "Well, we're busy, but we'll see what we can do," and there was no further conversation.79 Mrs. Yokoyama's testimony regarding these early January contacts with APHV was contradicted by Mrs. Aramyan's testimony. When asked whether she had had any interaction with APHV staff prior to January 16, 2006, Mrs. Aramyan testified that her only contact with the clinic was a telephone call that occurred between January 5 and January 16, 2006.80 Mrs. Aramyan stated that she received a call from a woman at APHV who asked her to schedule an appointment for Mr. Aramyan to be seen at the clinic; she said she replied that she would schedule the appointment after Mr. Aramyan's surgery.81 This testimony was corroborated by Ms. Towner's testimony. Ms. Towner testified that on January 12, 2006, she called the Aramyans and left a message, noting that surgery had been authorized and asking them to call to make an appointment at APHV, as APHV was Mr. Aramyan's new primary care provider.82 Ms. Towner stated that Mrs. Aramyan called back and said she would schedule an appointment after Mr. Aramyan's surgery.83 Based on Ms. Towner's testimony, the conversation described by Mrs. Aramyan occurred

78 79 80

Id. at 328. Id. at 91-92. Id. at 43-44. Id. at 44. Id. at 335-37. Id. at 337
13

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81 82 83

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 43.

on January 12; this is consistent with Mrs. Aramyan's testimony that the conversation occurred sometime between January 5 and January 16. Mrs. Yokoyama testified that her initial contact with Ms. Towner and Dr. Hoh on January 3 or 4 was compelled by the Aramyans' unsuccessful efforts to schedule an appointment beginning January 3. Mrs. Aramyan's testimony, however, as well as that of Ms. Towner, indicates that, as of January 12, Mrs. Aramyan had not attempted to schedule an appointment with APHV for Mr. Aramyan, and in fact did not believe it was necessary to do so. Mrs. Yokoyama's testimony that she began attempting to contact APHV in response to the Aramyan's unsuccessful attempts to schedule an appointment is inconsistent with this version of events. Neither Ms. Towner nor Dr. Hoh testified to the conversations described by Mrs. Yokoyama. In fact, Dr. Hoh testified that he did not speak with Mrs. Yokoyama or deal with Dr. Yokoyama's office prior to January 16, 2006.84 Mrs. Aramyan also testified that her first interaction with Mrs. Yokoyama occurred when she called Dr. Yokoyama's office to obtain an address for the facility Mr. Aramyan had to visit to have a chest x-ray taken.85 According to Mrs. Aramyan, Mrs. Yokoyama told her that Mr. Aramyan should not go for the x-ray because the surgery had been cancelled, and that she should schedule an appointment to see Dr. Hoh.86 Mrs. Aramyan also testified that she spoke with someone at APHV on January 17, 2006 to schedule an appointment for the next day. This was consistent with Ms. Towner's testimony; she stated that on January 17, she set an appointment for Mr. Aramyan to come into APHV on January 18, 2006.87 Ms. Towner said that she called the Aramyans to inform them of this and spoke with Mrs. Aramyan. When Ms. Towner advised Mrs. Aramyan that she had scheduled an appointment, Mrs. Aramyan responded that Mr. Aramyan would see
84

25 26 27 28
85 86 87

Id. at 385. Id. at 43. Id. Id. at 338-40; see also Exh. 25.
14

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 45. 44.

APHV after the surgery.88 Ms. Towner called Dr. Yokoyama's office to ask Mrs. Yokoyama to encourage Mr. Aramyan to keep the appointment.89 Although she was unable to speak with Mrs. Yokoyama, Ms. Towner left a message with Tony in Dr. Yokoyama's office, indicating that Mrs. Aramyan had again stated that her husband would see APHV after the surgery.90 Mrs. Aramyan subsequently called APHV; when Ms. Towner returned the call at 5:30 p.m. on January 17, she was unable to speak with Mrs. Aramyan, but left a message confirming the appointment in January 18.91 This chronology ­ documented in contemporaneous notes that Ms. Towner created ­ gives rise to an inference that the conversation with Mrs. Yokoyama to which Mrs. Aramyan testified occurred on January 17, 2006, after Ms. Towner called Dr. Yokoyama's office to explain that Mr. Aramyan needed to come into APHV for an appointment. The fact the conversation took place on January 17, 2006 indicates that as of that date, it was not clear to Mrs. Aramyan that she needed to schedule an appointment for Mr. Aramyan at APHV prior to the surgery. This contradicts Mrs. Yokoyama's testimony that, commencing January 3, 2006, the Aramyans tried numerous times to schedule an appointment for Mr. Aramyan at APHV. Mrs. Aramyan's description of the January 17 call as her first interaction with Mrs. Yokoyama further contradicts Mrs. Yokoyama's version of the events. For these reasons, the court finds that the conversations on January 3 and 4 between the Aramyans and APHV, the Aramyans and Mrs. Yokoyama, and Mrs. Yokoyama and Ms. Towner and Dr. Hoh that Mrs. Yokoyama described did not occur.92
88 89 90 91 92

RT at 339-40; 56-57; Exh. 25. RT at 340; Exh. 25. Id. RT at 341; Exh. 25.

This conclusion is also supported by notes that APHV nurse, Karen Hathaway, made on January 19, 2006 of a conversation with Mrs. Yokoyama. The notes reflect that Mrs. Yokoyama 15

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

46.

Rather, the court finds that APHV and Dr. Yokoyama's office first interacted on January 10, 2006, when APHV forwarded to Dr. Yokoyama's office a copy of the authorization it had received for Mr. Aramyan's surgery from the IPA on January 9, 2006.93 Ms. Towner first saw the authorization form on her desk on January 10, 2006.94 At all times relevant to this case, Ms. Towner's duties included handling referrals to specialists.95 Ms. Towner checked APHV's computers and learned that Mr. Aramyan had never been seen at the clinic. She mailed a copy of the form to Mr. Aramyan and faxed a copy to Dr. Yokoyama's office.96

47.

As previously discussed, Ms. Towner and Mrs. Aramyan had a conversation on January 12, in which Ms. Towner invited Mrs. Aramyan to schedule an appointment for Mr. Aramyan, as APHV was his new primary care provider. Mrs. Aramyan stated she would schedule an appointment after the surgery.

48.

Mrs. Yokoyama testified that on January 13, 2006, someone at APHV told her to bypass the requirement that Mr. Aramyan be seen at APHV before seeking authorization for the surgery.97 At that point, however, Dr. Yokoyama's request for authorization had already been submitted and approved, and a copy of the authorization had been sent to APHV.98

told Ms. Hathaway that she began to attempt to "facilitate arranging [Mr. Aramyan's] surgery" after the Aramyans called Dr. Yokoyama's office and reported that Mr. Aramyan was experiencing episodes of angina. (Deposition of Karen Gale Hathaway ("Hathaway Depo."), Exh. 27.)
93 94 95 96 97

Id. at 418, Exh. 24; Exh. 25. Id. at 333. Id. at 330-31. Id. at 333-34. Id. at 95.

26 27 28
98

Although Mrs. Yokoyama acknowledged that she had earlier submitted an application for approval of the surgery to the IPA in order to "get [some]body's attention" (id. at 96), this does not explain why she would have had a conversation with someone at APHV on January 13 ­ four 16

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

49.

Mrs. Yokoyama also testified that on January 13, 2006, she spoke with Ms. Towner, who requested that she fax Mr. Aramyan's medical records to APHV.99 Ms. Towner did not testify to this conversation, and no record of a facsimile transmission for January 13 was offered at trial. Finally, Mrs. Yokoyama stated that on January 13, 2006, someone at APHV gave her the names of facilities that were contracted with the IPA where Mr. Aramyan's pre-operative testing could be performed.100 A facsimile transmission sheet bearing a date and time of January 16, 2006 at 8:53 a.m. from Dr. Yokoyama's office to Quest Diagnostics indicates that Mrs. Yokoyama knew by this date that Quest was contracted with the IPA. There is also a facsimile transmission sheet directed to Burbank Advanced Imaging that was dated January 13 and transmitted on that same day at 6:45 p.m.101 There is no specific indication in Dr. Yokoyama's patient file that this information was obtained from APHV as opposed to the IPA or some other source, however. Mrs. Yokoyama's suggestion, moreover, that she was required to use the test facilities the clinic typically used is contradicted by Ms. Towner's contemporaneous note of a conversation with Mrs. Yokoyama on January 18, in which Mrs. Yokoyama told Ms. Towner that APHV should not perform any blood tests, as she had arranged to have such tests completed by Quest. Because Ms. Towner's contemporaneous notes contain no reference to a conversation with Mrs. Yokoyama on January 13, however, and because there is no documentary evidence of a fax transmission from Dr. Yokoyama's office to APHV on January 13, the court concludes that not all of the January 13 conversations to which she

days after the approval had been received ­ in which she was told to bypass the requirement that Mr. Aramyan establish a relationship with his primary care physician as a prerequisite to obtaining approval for the surgery.
99

Id. at 111-12. Id. at 112-14. Exh. 41 at 8, 14, 23, 29.
17

100 101

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 52. 51. 50.

testified occurred.102 Mrs. Yokoyama called Dr. Hoh on January 16, 2009. January 16 was Martin Luther King, Jr. Day, so APHV was closed, and Dr. Hoh was on call.103 Mrs. Yokoyama and Dr. Hoh testified to two different versions of the conversation. Mrs. Yokoyama testified that the purpose of the call was to identify a cardiologist contracted with the IPA who could care for Mr. Aramyan post-operatively.104 She also stated that she raised "issues with having [Mr. Aramyan] appropriately processed through the medical group."105 She said that Dr. Hoh told her he had never seen the patient; she responded that the Aramyans had been trying unsuccessfully to arrange an appointment, and that she had faxed Mr. Aramyan's records to APHV twice.106 The court has already found that the facts do not support Mrs. Yokoyama's testimony regarding the Aramyans' attempts to schedule an appointment and noted the absence of any documentary evidence supporting Mrs. Yokoyama's assertion that records were faxed prior to January 16. Mrs. Yokoyama also testified that she told Dr. Hoh Mr. Aramyan's surgery was scheduled for January 19.107 Dr. Hoh testified that January 16 was the first occasion on which he had spoken with Mrs. Yokoyama. According to Dr. Hoh, Mrs. Yokoyama told him that Mr. Aramyan was scheduled for surgery on January 19.108 He testified that he was surprised to receive a call regarding a patient whom APHV had not seen who was scheduled to undergo surgery in

102 103 104 105

See Exh. 25. Id. at 394. Id. at 115. Id. Id. at 118. Id. at 119. Id.
18

25 26 27 28
106 107 108

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 53.

three days.109 Dr. Hoh reported that Mrs. Yokoyama advised that, because Mr. Aramyan had switched medical groups, the surgery could no longer be performed at Glendale Hospital as originally scheduled, and Mr. Aramyan needed to be seen by a cardiologist who could care for him peri-operatively at St. Vincent's.110 Dr. Hoh stated that Mrs. Yokoyama wanted APHV to "basically give a form clearance" for surgery.111 Dr. Hoh said he felt uncomfortable doing so without seeing and establishing a relationship with Mr. Aramyan first. He told Mrs. Yokoyama that Dr. Yokoyama should proceed with the surgery if Mr. Aramyan's condition was emergent.112 Aramyan's records be faxed to APHV.113 After his conversation with Ms. Yokoyama, Dr. Hoh sent an email to various APHV employees regarding the conversation.114 In the email, Dr. Hoh stated that Ms. Yokoyama had requested "cardiology clearance" for the patient, and reported that he had told her APHV was not familiar with Mr. Aramyan and needed to assess him and refer him to a cardiologist before surgery. Dr. Hoh's email suggests that he was unaware that the IPA had already authorized surgery for Mr. Aramyan; it states that APHV could not authorize the surgery prior to seeing Mr. Aramyan unless his medical condition was unstable and emergent. Dr. Hoh asked staff to schedule an appointment for Mr. Aramyan no later than January 19. He directed that the appointment be made with him or Dr. Mehrdad He also requested that Mr.

Pakdaman if Mr. Aramyan had not yet been assigned a primary care physician at APHV. He further directed that Mr. Aramyan be given an urgent referral to a cardiologist by

109 110 111

Id. at 395. Id. at 396-97. Id. at 383-84, 427. Id. Id. at 396. Exh. 28.
19

25 26 27 28
112 113 114

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 57. 56. 55. 54.

January 18.115 Mrs. Yokoyama faxed Mr. Aramyan's medical records to APHV on the afternoon of January 16, 2009.116 It is uncertain what became of the records after they were faxed to APHV. As previously noted, on January 17, 2006, Ms. Towner called Mrs. Aramyan to attempt to schedule an appointment for January 18, 2006. Mrs. Aramyan did not agree to schedule an appointment, so Ms. Towner contacted Dr. Yokoyama's office. Thereafter, Mrs. Yokoyama communicated to Mrs. Aramyan that it was necessary for Mr. Aramyan to be seen at APHV before the surgery could go forward. During this conversation, Mrs. Yokoyama also told Mrs. Aramyan that the surgery would not take place on January 19. Mrs. Aramyan subsequently contacted Ms. Towner to confirm her husband's appointment at APHV for January 18. On the morning of January 18, 2006, Ms. Towner was unable to locate Mr. Aramyan's medical records. She therefore called Dr. Yokoyama's office and requested that the records be faxed to APHV.117 At approximately midday on January 18, Ms. Towner had a further telephone conversation with Mrs. Yokoyama.118 Mrs. Yokoyama stated that Mr. Aramyan's surgery had been rescheduled for one week later.119 She stated that APHV should not perform blood tests, as Mr. Aramyan would have blood tests performed at Quest Diagnostic three days before

115 116 117 118

Id. Id. at 366; Exh. 40, Section D at 8-19. Id. at 342-43.

It is unclear whether this conversation occurred before or after Mr. Aramyan's appointment at APHV on January 18. Dr. Pakdaman was unaware of Mrs. Yokoyama's instructions at the time of the appointment, however. Id. at 345. Ms. Hathaway's notes of her January 19 conversation with Mrs. Yokoyama indicate that Mrs. Yokoyama had ascertained that there was a surgical opening for January 24 if Mr. Aramyan could be seen by a cardiologist by that date. (Hathaway Depo., Exh. 27.) 20
119

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 58.

the surgery.120 Mrs. Yokoyama also stated that Mr. Aramyan could have an EKG at the hospital but that, if APHV performed an EKG, it should send a copy EKG directly to Mrs. Yokoyama.121 Ms. Towner testified that Mrs. Yokoyama said she simply wanted APHV to establish a relationship with Mr. Aramyan and indicate that he needed surgery.122 During this conversation, Mrs. Yokoyama asked if Ms. Towner had a list of cardiologists who were contracted with the IPA. Ms. Towner read names from the list, and Mrs. Yokoyama indicated that she was familiar with two of the names, Dr. Mayeda, and Dr. Matthews. 1 2 3 Mrs. Yokoyama testified that on January 18, Dr. Hoh called and told her that the surgery could not go forward on January 19, because he wanted to see Mr. Aramyan himself and could not do so until January 19.124 The court does not find this testimony credible. Although Mrs. Yokoyama initially intended to have Mr. Aramyan's blood work performed at APHV, she told Ms. Towner during a conversation that commenced at 12:30 p.m. on January 18 that Quest Laboratories would perform the tests the following week.125 This strongly suggests that as of midday on January 18, Mrs. Yokoyama had already rescheduled the surgery. The evidence was also undisputed that Dr. Hoh was not at

Mrs. Aramyan testified that her husband had blood work performed on January 16. Records contained in Dr. Yokoyama's patient file indicate that the tests actually occurred on January 17. (See Ex. 41 at 61.) The laboratory did not send the results of the tests to Dr. Yokoyama's office until January 20, the day after Mr. Aramyan died. (Id.) Id. In a subsequent note that Ms. Towner left for Dr. Hoh, she reported that Mrs. Yokoyama wanted any EKG done by APHV to be given to Mr. Aramyan. (See Exh. 26.) She testified that Mrs. Yokoyama wanted Mr. Aramyan to take the EKG film with him to another appointment. (RT at 353.)
122 123 124 125 121

120

Id. at 352. Id. at 353. See also Exh. 40, Section G at 9. Id. at 121. See Exh. 25.
21

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 59.

APHV on January 18 because he was attending a countywide training session that day.126 Indeed, Mrs. Aramyan testified that Dr. Mehrdad Pakdaman, the doctor who saw Mr. Aramyan on January 18, tried to reach Dr. Hoh on his cell phone while she and her husband were at APHV and that he was unable to do so.127 The court thus concludes that Mrs. Yokoyama rescheduled the surgery from January 19 to the following week in recognition of the fact that several necessary pre-operative steps could not be completed by January 19. Specifically, on the afternoon of January 18, Mr. Aramyan saw Dr. Pakdaman, who referred him to a radiology clinic for a chest X-ray that afternoon, and told him to return to APHV in the morning, after fasting, for blood work.128 Dr. Pakdaman also referred Mr. Aramyan to a cardiologist and told him to see Dr. Hoh the next day when he came in for blood work, because Dr. Hoh could facilitate or expedite the cardiologist referral.129 At 10:12 a.m. on January 19, Karen Hathaway, an RN and associated manager of APHV's nursing department, answered a telephone call from Mrs. Aramyan.130 Mrs. Aramyan

126 127 128

RT at 291, 401. Id. at 46.

Id. at 293. It appears that both APHV and Mrs. Yokoyama believed, as of January 18, that Mr. Aramyan still needed to have blood tests taken, as Dr. Pakdaman told Mr. Aramyan to return to APHV for the tests the following day after he had been fasting, and Mrs. Yokoyama told both Ms. Towner on January 18 and Ms. Hathaway on January 19 that Mr. Aramyan could have the tests done at Quest Diagnostics. (See Exh. 40, Section F at 13-14; Hathaway Depo., Exh. 27.) Id. at 311. See also Exh. 19, 20. Other pre-operative tests ­ vein mapping and type and cross-matching of blood ­ were required as well and had not been performed. There was testimony, however, that both vein mapping and type and cross-matching could have been done in the hospital on the day of surgery if Mr. Aramyan's condition was emergent. (See RT at 141, 245, 270-71.) Ms. Hathaway's responsibilities generally involved managing the pharmaceutical dispensary. She also worked approximately once a week in the triage department, answering phone calls from patients. (Hathaway Depo. at 12-13, 17, 25-26.) 22
130 129

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 62. 61. 60.

stated that she was the wife of a patient who was scheduled to have surgery that day, and was upset that the surgery had been postponed.131 Ms. Hathaway told Mrs. Aramyan that she would attempt to answer her questions. She pulled up Mr. Aramyan's information in her computer and learned that he had been seen by Dr. Pakdaman the previous day.132 Dr. Pakdaman told Ms. Hathaway that the surgery had already been postponed at the time he saw Mr. Aramyan.133 After speaking with Dr. Pakdaman, Ms. Hathaway contacted Mrs. Yokoyama.134 Mrs. Yokoyama told her that the surgery had been postponed because Dr. Hoh could not clear Mr. Aramyan for surgery until the January 18 appointment.135 Mrs. Azoyan testified that on January 18, she called Dr. Hoh and asked him why the surgery was cancelled, and he told her she was overreacting.136 As Dr. Hoh was not in the office on January 18, the court does not find this testimony credible. Dr. Hoh spoke with Rita Yokoyama after he saw Mr. Aramyan.137 The two recounted different versions of the conversation. Mrs. Yokoyama asserted that Dr. Hoh told her he was sending Mr. Aramyan to see a cardiologist for a second opinion.138 Dr. Hoh stated that he informed Mrs. Yokoyama he had arranged an appointment with a cardiologist, but did not state that the purpose of the visit was for a second opinion.139 The court does not

131 132 133 134 135 136

Id. at 29-30. Id. at 58-59. Id. at 49. Id. at 59. Id. at 63-64. RT at 182. Id. at 407-08. Id. at 119. Id. at 408.
23

25 26 27 28
137 138 139

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 65. 64. 63.

find Mrs. Yokoyama's testimony regarding the conversation credible. Specifically, the court not believe that Dr. Hoh stated the purpose of the cardiology appointment was to obtain a second opinion. Rather, the purpose of the appointment was to arrange for Mr. Aramyan to be seen preoperatively by a cardiologist who could care for him intraoperatively and post-operatively. This is what Dr. Hoh understood Mrs. Yokoyama requested on January 16, 2006.140 G. Mr. Aramyan's January 18 Appointment

Mr. Aramyan was seen at APHV on the afternoon of January 18, 2006 by Dr. Pakdaman as Dr. Hoh was not in the office.141 Mrs. Aramyan accompanied Mr. Aramyan on the visit.142 Dr. Pakdaman attended medical school at Melli University in Iran, which he described as the best medical school in Iran. He passed the California boards in 2001, and did his residency and internship at Harbor UCLA.143 He is board certified in family medicine.144 In January 2006, he was a clinician at APHV.145 His practice consisted primarily of assisting patients with chronic diseases, including cardiac diseases.146 Typically, a chart for a new patient at APHV is prepared on the date of the patient's first visit. The patient fills out an intake form and then sees a "financial screener." The financial screener prepares the patient's chart.147

140 141 142 143 144

See Exh. 40, Section E at 1. RT at 290. Id. at 284. Id. at 305. Id. at 281. Id. at 282. Id. at 305. Id. at 361-62.
24

25 26 27 28
145 146 147

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

66.

The only information in the chart given to Dr. Pakdaman were answers to patient questionnaires and Mr. Aramyan's vital signs.148 Dr. Pakdaman did not speak with Dr. Hoh prior to the consultation.149 He could not recall whether he had seen Dr. Hoh's January 16, 2006 email before the consultation.150 Dr. Pakdaman testified that all he knew about the purpose of the visit was that Mr. Aramyan was scheduled for CABG surgery and needed a pre-operative consultation. He obtained this information from Mr. and Mrs. A r a m y a n .1 5 1

67.

Mrs. Aramyan told Dr. Pakdaman that "everything had been done" that was necessary for Mr. Aramyan to proceed with surgery.152 Dr. Pakdaman interpreted this statement to mean that Mr. Aramyan had already had an angiogram.153 He believed the purpose of the visit was pre-operative evaluation, which he described as encompassing blood work and chest x-rays. Essentially, Dr. Pakdaman believed his role was to collect information to provide to the surgeon.154

68.

Mr. Aramyan told Dr. Pakdaman that he was able to swim one mile without chest pain or shortness of breath, and that he could walk three miles before experiencing chest pain.155

69.

Dr. Pakdaman performed an EKG.156 In Dr. Pakdaman's opinion, the EKG was "bad" and indicated considerable ischemia. Based on the EKG, he considered Mr. Aramyan's

148 149 150 151 152 153

Id. at 286. Id. at 285. Id. at 287. Id. Id. at 289. Id. at 289-90. Id. at 296-97. Id. at 310. Id. at 291.
25

25 26 27 28
154 155 156

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 72. 71. 70.

condition urgent, and believed Mr. Aramyan should have surgery as soon as possible.157 Dr. Pakdaman referred Mr. Aramyan to a radiology clinic to have a chest x-ray performed that day.158 He also told Mr. Aramyan to fast and return to the clinic the next day for blood tests.159 He did not refer Mr. Aramyan for vein mapping, as that was something that could be done at the hospital.160 In order for Mr. Aramyan to see a cardiologist, it was necessary to complete a referral form and obtain authorization from the IPA.161 There was no way to bypass this process in a non-emergent situation.162 Dr. Pakdaman filled out a referral form for a cardiologist appointment, and gave the form to Ms. Towner.163 The referral filled out by Dr.

Pakdaman was a direct referral form.164 Dr. Pakdaman told Mr. Aramyan to see Dr. Hoh when he returned the next day, so that Dr. Hoh could expedite or facilitate the cardiology c o n s u l t a t i o n .1 6 5 Although Dr. Pakdaman filled out a cardiologist referral form on January 18, he testified that he wanted Mr. Aramyan to see Dr. Hoh on January 19 so that Dr. Hoh could facilitate
157 158 159 160 161 162 163 164

Id. at 292. Id. at 292-93. Id. at 293. Id. at 302. Id. at 315. Id. at 316. Id. at 322.

Dr. Hoh explained that "[a] direct referral [of the type Dr. Pakdaman prepared] is a quick referral to initiate processes, in order to be able to help a patient, to be able to see the cardiologist or other specialist," while "a full authorization is what is required for on-going care as well as potential care in the hospital by the specialist." (Id. at 413.) A full authorization allows the specialist to perform procedures on the patient, while a direct referral merely authorizes an office visit. (Id.)
165

Id. at 292-93.
26

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 74. 73.

the referral.166 He appeared to suggest that because Mr. Aramyan had to return for blood tests in any event, he should see Dr. Hoh when he came because Dr. Hoh could expedite the cardiology referral.167 Dr. Hoh testified that it was not normal procedure for Dr. Pakdaman to ask Mr. Aramyan to see Dr. Hoh after he had already been seen by Dr. Pakdaman. Dr. Hoh was "not entirely sure" why Dr. Pakdaman arranged for him to see Mr. Aramyan a second time on January 19; he testified, however, that he believed Dr. Pakdaman may have wanted Dr. Hoh to see Mr. Aramyan to make sure everything had been done properly, as Dr. Pakdaman was relatively new to the clinic, and Mr. Aramyan was going to return for blood tests in any event.168 Dr. Hoh testified that the cardiology referral Dr. Pakdaman initiated on January 18 resulted in an appointment with Dr. Matthews for Monday, January 23. The following day, as described in more detail below, Dr. Hoh was able to contact Dr. Matthews' office and arrange for the appointment to be moved up to January 20.169 Dr. Pakdaman also instructed Mr. Aramyan to stop taking aspirin, and told Mr. and Mrs. Aramyan to call 911 if Mr. Aramyan experienced any shortness of breath or chest pains.170 H. January 19, 2009

Mr. Aramyan's appointment with Dr. Hoh was scheduled for the afternoon of January 19,

166 167

Id. at 293, 324.

Id. at 292-93 ("Q. You also told the patient that he had to come back the next day to see Dr. Hoh in order to facilitate that cardiology. Is that true? A. Yes. And also for follow-up of the lab results. . . I told him go to the X ray today. Come for the blood test tomorrow morning fasting, and then have a follow-up with Dr. Hoh to facilitate the process").
168 169 170

Id. at 457-58. Id. at 406, 409. Id. at 313.
27

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 77. 76. 75.

at approximately 12 noon or 1 p.m.,171 and lasted approximately forty-five minutes.172 Gary Azoyan accompanied Mr. Aramyan to the appointment.173 By the time Dr. Hoh saw Mr. Aramyan, Dr. Yokoyama's medical records regarding Mr. Aramyan had been added to his chart at APHV, and were available to Dr. Hoh.174 The EKG taken by Dr. Pakdaman was also included in the chart.175 Mr. Aramyan did not tell Dr. Hoh that he was in pain at the time of the appointment.176 Dr. Hoh did not believe that Mr. Aramyan was in imminent danger of having a heart attack, as he did not complain of chest pain, was not short of breath, and was not sweating.177 Dr. Hoh did not believe Mr. Aramyan's condition was emergent.178 He considered the EKG taken by Dr. Pakdaman abnormal; even after comparing it with the prior EKG that Mr. Aramyan had had taken, however, his opinion was that the EKGs did not indicate Mr. Aramyan would suffer a heart attack immediately.179 Dr. Hoh checked Mr. Aramyan's blood pressure and found it to be abnormally high; he prescribed a higher dose of a medication called Norvasc to address this issue.180 He also prescribed Isosorbide to open Mr. Aramyan's blood vessels, Zantac for dyspepsia, and

171 172 173 174 175 176 177

Id. at 193. Id. at 413. Id. at 190. Id. at 455. Id. Id. at 404. Id. at 412. Id. at 434. Id. at 458. Id. at 402, 407.
28

25 26 27 28
178 179 180

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 80. 79. 78.

refilled Mr. Aramyan's prescription for Atenolol, a beta blocker.181 Finally, Dr. Hoh prescribed nitroglycerine, as Mr. Aramyan's current supply had gone stale and was ineffective.182 Dr. Hoh telephoned the office of Dr. Ray Matthews, a cardiologist, and arranged for Mr. Aramyan to be seen the next day.183 He explained to Mr. Aramyan and Gary Azoyan that the appointment with Dr. Matthews was necessary and was at Dr. Yokoyama's request.184 Dr. Hoh prepared an authorization for Mr. Aramyan to see Dr. Matthews; unlike the form Dr. Pakdaman prepared, the form Dr. Hoh completed was a full authorization.185 Dr. Hoh advised Mr. Aramyan to go to the emergency room if he experienced chest pain.1 8 6 Mr. Aramyan began to experience chest pain after dinner that evening, and Mrs. Aramyan drove him to St. Joseph's Hospital.187 He was admitted to the emergency room, and passed away that evening, at age 47.188

181 182

Id. at 407, 472.

Id. at 402-03. Mr. Azoyan testified that Dr. Hoh said Mr. Aramyan's condition could be cured by medicine rather than surgery. (Id. at 191.) Given Dr. Hoh's testimony, the court believes Mr. Azoyan simply misunderstood Dr. Hoh, and finds that Dr. Hoh did not make such a statement. Mr. Azoyan stated that he asked Dr. Hoh why Mr. Aramyan needed to see him that day, and that Dr. Hoh simply ignored the question. (Id. at 191-92.) The court similarly does not credit this testimony, as Mr. Azoyan later testified that he could not remember well, and that it may have been the case that Dr. Hoh answered the question, and he simply did not remember the response. (Id. at 200.)
183 184 185

Id. at 409. Id. at 411-12.

Id. at 413-14. The IPA approved the authorization on January 20, 2006. (Id. at 416, Exh. 20.)
186 187 188

Id. at 411-12. Id. at 48. Id.
29

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 85. 84. 83. 82. 81.

I.

Dr. Noble's Testimony 1. Dr. Noble's Background

Dr. Randolph Noble testified as an expert witness for plaintiffs. Dr. Noble is currently a primary care physician. He graduated from UCLA Medical School in 1973 and completed an internship in internal medicine at USC Medical Center in 1974. He did his residency in internal medicine at West Los Angeles Veterans Administration Hospital ("WLAVAH"), which included rotations in cardiology. From 1977 to 1979, Dr. Noble had a fellowship in pulmonary diseases at WLAVAH, focusing on cardiopulmonary problems in the intensive care unit and in the laboratory. Dr. Noble is board-certified in internal medicine, pulmonary diseases, psychiatry and hyperbaric medicine, and is a fellow of the American College of Chest Physicians. He estimates that he has performed more than a thousand pre-operative consultations for patients with cardiopulmonary problems, including in excess of one hundred consultations prior to CABG procedures.189 Dr. Noble testified that, in his opinion, two breaches of the standard of care occurred in this case. 2. First Breach: Inadequate Chart Provided to Dr. Pakdaman

First, Dr. Noble stated that APHV's failure to provide Dr. Pakdaman with a complete chart at the time of Mr. Aramyan's January 18 appointment breached the standard of care. 1 9 0 Dr. Noble testified that the records provided to Dr. Pakdaman should have included the authorization for the CABG surgery received by APHV on January 9, 2006, the records from Dr. Yokoyama's office, and Dr. Hoh's email regarding his January 16, 2006 conversation with Rita Yokoyama.191 Dr. Noble conceded, however, that the authorization would not have provided Dr.
189 190 191

Id. at 215-21. Id. at 231. Id. at 231-33, 237.
30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 86.

Pakdaman with any information beyond that which Mr. and Mrs. Aramyan gave him on January 18, 2006.192 He also testified that in his opinion, the EKG that Dr. Pakdaman performed was sufficient to indicate that Mr. Aramyan needed surgery. Dr. Noble stated, however, that the results of the 2005 EKG would have "been extremely helpful in appreciating the urgency of the situation."193 Additionally, Dr. Noble felt that, had Dr. Pakdaman been able to review them, the records of Mr. Aramyan's December 14, 2005 consultation with Dr. Yokoyama would have indicated "the severity of [Mr. Aramyan's] multi-vessel coronary artery disease[,] as well as his . . . primary problem with his heart as a pump with decreased ejection fraction."194 Finally, Dr. Noble noted that Dr. Hoh's email indicated that Dr. Yokoyama contemplated surgery on January 19, 2006.195 Dr. Noble opined that Dr. Pakdaman should have known that the EKG he performed on January 18, 2006 "could represent an impending heart attack."196 He based this opinion on the fact that certain waves in the EKG, known as T waves, were deeply inverted. This indicated "acute ischemia."197 Dr. Noble concluded that the EKG indicated "an impending anterolateral wall myocardial infraction."198 He opined that if Dr. Pakdaman had been able to compare the January 18 EKG with the December 9, 2005 EKG, he would have concluded that Mr. Aramyan "was moving toward a heart attack."199 He testified,
192 193 194

Id. at 273. Id. at 276. Id. at 233.

Id. at 236. Dr. Hoh, who was designated as an expert witness, also testified that, ideally, the medical records and authorization should have been provided to Dr. Pakdaman. (Id. at 437-38.)
196 197 198 199

195

Id. at 241. Id. at 240-41. Ischemia is lack of blood supply. (Id. at 242.) Id. at 244. Id. at 245.
31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 89. 88. 87.

however, that in his opinion the January 18 EKG did not require the immediate hospitalization of Mr. Aramyan.200 Dr. Noble conceded that Mr. Aramyan's condition at the time he saw Dr. Pakdaman was not emergent, i.e., he did not need immediate surgery.201 Dr. Noble testified that in his opinion, to a reasonable medical probability, the exclusion of materials from the chart given to Dr. Pakdaman delayed Mr. Aramyan's surgery.202 He did not, however, identify any action Dr. Pakdaman would have taken had the material omitted from the chart been available to him.203 Dr. Noble did not believe that Dr. Pakdaman breached the standard of care given the materials available to him.204 Rather, he found that the breach was APHV's failure to prepare an adequate chart for Dr. Pakdaman. 3. Second Breach: Requiring an Appointment

Dr. Noble also testified that, in his opinion, Dr. Hoh breached the standard of care by requiring that Mr. Aramyan be seen at APHV prior to surgery, and by requiring that Mr. Aramyan be seen by a cardiologist before the surgery.205 He testified that this breach "contributed directly" to Mr. Aramyan's death by delaying the surgery, and that he had

Id. at 247. At trial, Dr. Noble expressed the opinion that, on January 18, 2006, Mr. Aramyan had a "twenty-four hour window" in which to have surgery. The court struck this testimony, however, because Dr. Noble's opinion regarding a twenty-four window was not included in his expert report or deposition. (Id. at 264-66.) As a result, the court has not considered this aspect of Dr. Noble's testimony in making findings of fact and conclusions of law.
201 202 203

200

Id. at 260. Id. at 231.

Similarly, Dr. Hoh testified that in his opinion Dr. Pakdaman would not have done anything differently had the material in question been provided to him. (Id. at 463.)
204 205

Id. at 257. Id. at 248.
32

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 93. 92. 91. 90.

reached these opinions to a reasonable degree of medical probability.206 Dr. Noble did not believe Mr. Aramyan's condition was emergent on January 19, 2006, when Dr. Hoh saw him.207 4. Opinions Regarding Role of Cardiologist

Dr. Noble opined that in mid-January, it was "not absolutely necessary" for Mr. Aramyan to be seen pre-operatively by a cardiologist.208 He agreed, however, that it was necessary for Mr. Aramyan to be seen post-operatively by a cardiologist.209 He also agreed that preoperative tests are generally done a few days before the surgery.210 5. Opinion Regarding Life Expectancy

Dr. Noble opined that Mr. Aramyan "would be alive today" if he had undergone CABG surgery on January 19.211 He testified that Mr. Aramyan's life expectancy would have been ten to fifteen years, based on various risk factors, including his smoking, history of hypertension, multiple vessel coronary artery disease, and decreased ejection fraction.212 This opinion, however, was based on the assumption that Mr. Aramyan would successfully have stopped smoking.213 Had Mr. Aramyan not quit smoking, Dr. Noble believed his life expectancy would have decreased by three years.214 Dr. Noble testified that, in general, the likelihood that a smoker could successfully quit

206 207 208 209 210 211

Id. Id. at 260. Id. at 270. Id. Id. at 271. Id. at 249. Id. at 250-51. Id. at 251. Id.
33

25 26 27 28
212 213 214

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 96. 95. 94.

was less than ten percent, or twenty percent if medicines were used.215 He testified that he believed CABG surgery patients were more likely to quit smoking, but could not cite any authority to support this opinion.216 J. Dr. Bleifer's Opinions 1. Dr. Bleifer's Background

Dr. Selvyn Burton Bleifer testified as an expert for defendant. Dr. Bleifer is a specialist in cardiovascular disease. He attended medical school at the University of California, San Francisco, and interned at the University of California Medical Center in San Francisco. He completed a two-year residency in internal medicine at the Veterans Administration Hospital in Boston and a one-year residency in cardiology at Mt. Sinai Hospital in New York. Dr. Bleifer is board-certified in internal medicine and cardiovascular disease.217 He is presently in private practice in Beverly Hills, focusing on cardiovascular disease, and has authored or co-authored approximately 65 articles concerning cardiovascular medicine that have appeared in peer-reviewed journals.218 In his current practice, Dr. Bleifer sees patients contemplating CABG surgery. He testified that he typically sees patients both pre-operatively and post-operatively; he stated that this is the standard of care in the field.219 Dr. Bleifer was critical of the treatment provided to Mr. Aramyan by doctors at Glendale Adventist Hospital in 2008. He opined that the physicians should have recommended to Mr. Aramyan an implanatable cardiac defibrillator, because patients with reduced ejection fractions, such as Mr. Aramyan, have a high risk of ventricle arrhythmias and sudden

215 216

Id. at 254. Id. at 254. Id. at 465-66. Id. at 466-67. Id. at 469.
34

25 26 27 28
217 218 219

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 99. 98. 97.

death.220 Although Dr. Bleifer believed that Mr. Aramyan might have benefitted from CABG surgery, he opined that the implantable defibrillator would have been the most advantageous procedure for Mr. Aramyan to have undergone.221 He also believed the doctors should have prescribed Carbetalol or Coreg as a beta blocker rather than atenolol, although he did not elaborate on this opinion.222 Dr. Bleifer testified that when APHV received the approval for Mr. Aramyan's surgery on January 9, 2006, the standard of care did not require that APHV do anything other than fax the form to Dr. Yokoyama and send it to the Aramyans.223 Dr. Bleifer opined that APHV did not breach the standard of care in its preparation of Mr. Aramyan's chart prior to his appointment with Dr. Pakdaman. Dr. Bleifer based this opinion on the fact that APHV had not yet received medical records from Dr. Yokoyama's office.224 Dr. Bleifer also testified that, had the information in the records been available to Dr. Pakdaman, Dr. Pakdaman would not have acted differently, because, in his opinion, Mr. Aramyan's condition was not emergent at the time of the appointment. Dr. Bleifer conceded, however, that having the earlier EKG available for comparison would have been of benefit to Dr. Pakdaman.225 Based on Mr. Aramyan's statements regarding his ability to exercise, Dr. Bleifer concluded that Mr. Aramyan had stable angina pectoralis, or chest pain that occurs after exertion and is relieved by rest. This, Dr. Bleifer stated, indicates

220 221 222 223 224

Id. at 472. Id. at 473. Id. at 472. Id. at 474-75.

Id. at 475-76 (stating that the medical records were not received from Dr. Yokoyama's office until January 18).
225

Id. at 493.
35

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 103. 102. 101. 100.

a non-emergent condition.226 Based on Mr. Aramyan's ability to exercise, his history, and the results of the EKG taken by Dr. Pakdaman, Dr. Bleifer opined that there was no emergent need for Mr. Aramyan to have CABG surgery within "the next day or so" on January 18, 2006.227 In Dr. Bleifer's opinion, the EKG performed by Dr. Pakdaman did not indicate that Mr. Aramyan was in danger of having an imminent heart attack.228 He did not believe that Dr. Pakdaman should have done anything differently than he did to meet the standard of care. 2 2 9 Dr. Bleifer also found that Dr. Hoh's treatment of Mr. Aramyan was well within the standard of care. He noted that Dr. Hoh had arranged for Mr. Aramyan to see Dr. Matthews the day after he saw Dr. Hoh, and that Mr. Aramyan's condition was stable as of January 19, 2006.230 Dr. Bleifer also opined that Dr. Hoh's actions in response to his conversation with Ms. Yokoyama on January 16, 2006 were within the standard of care. Specifically, he stated that Mr. Aramyan declined to come into APHV on January 17, and that APHV prevailed on Dr. Yokoyama's office to convince him to come in on January 18. Because Dr. Hoh was not in the office that day, Mr. Aramyan saw Dr. Pakdaman.231 Dr. Bleifer stated that in his opinion, Dr. Hoh did not breach the standard of care at any time either before or

226 227 228 229 230

Id. at 476-77. Id. at 477. Id. at 479-80. Id. at 480-81. Id. at 481-82.

Id. at 482-83. Dr. Bleifer's belief that Mr. Aramyan was offered an appointment on January 17 does not square with the records in APHV's files. Ms. Towner's notes, as well as her testimony, indicate that she called the Aramyans on January 17 to offer an appointment on January 18. See RT at 338-40; Exh. 25.) 36

231

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1. 106. 105. 104.

after January 16.232 He also opined that Dr. Hoh did not do anything that breached the standard of care prior to the time he spoke with Mrs. Yokoyama on January 16.233 According to Dr. Bleifer, Mr. Aramyan died due to sudden cardiac death. Sudden cardiac death occurs when the heart fibrillates and fails to pump blood; the fibrillation is caused either by an occlusion or ischemia. Dr. Bleifer opined th