## Facts

- Roberto Romero Lama, living in Puerto Rico, developed severe back pain and was referred by his family physician to neurosurgeon Dr. Pedro Borrás.
- Dr. Borrás diagnosed a herniated lumbar disc and scheduled surgery.
- Before surgery, Dr. Borrás did not implement a conservative, non-surgical regimen (e.g., strict bed rest, traction, or similar measures) described by plaintiffs’ experts as customary before operating.
- On April 9, 1986, Dr. Borrás performed lumbar surgery; Romero’s original symptoms returned shortly afterward, supporting an inference (with expert testimony) of an inadequate decompression or operating at the wrong level.
- Dr. Borrás elected to perform a second surgery on May 15, 1986.
- No prophylactic antibiotics were ordered in connection with the second operation.
- Postoperatively, nursing notes recorded Romero’s bandages as “very bloody” and later “soiled again,” but the hospital’s charting was minimal and, according to plaintiffs’ evidence, inadequate for postoperative monitoring.
- Romero developed discitis (infection of the intervertebral disc space), resulting in prolonged hospitalization and significant pain and impairment.
- Romero and his wife sued Dr. Borrás and the hospital in a federal diversity action alleging negligent diagnosis, treatment, discharge, and postoperative infection management.

## Issues

1. Whether the trial evidence was sufficient under Puerto Rico medical-malpractice law to establish standard of care, breach, and causation against Dr. Borrás and the hospital.
2. Whether the district court erred in denying defendants’ post-verdict motions for judgment as a matter of law (Rule 50(b)) and for a new trial (Rule 59) based on asserted evidentiary insufficiency.

## Decision

- The First Circuit affirmed the judgment for plaintiffs and the $600,000 jury award.
- The court held that, viewing the record in the light most favorable to the verdict, a reasonable jury could find Dr. Borrás deviated from the applicable standard of care and that the hospital was independently negligent in postoperative monitoring and recordkeeping.
- The court further held that the evidence, including expert testimony and the clinical sequence, permitted a jury finding that defendants’ departures were the “most probable” cause of Romero’s discitis and damages.
- Accordingly, the district court properly denied Rule 50(b) and Rule 59 relief.

## Legal Principles

- Under Puerto Rico malpractice law, a plaintiff must prove: (1) the applicable medical standard of care, (2) breach of that standard, and (3) a causal relation between the breach and the injury.
- Causation requires proof by a preponderance that the defendant’s act or omission was the factor “most probable” in producing the harm, not merely a possible cause.
- Because medical diagnosis, treatment, and causation are technical matters, expert testimony is ordinarily required to establish the standard of care, breach, and causation.
- On appellate review of a jury verdict challenged for insufficiency, the evidence is viewed in the light most favorable to the prevailing party, and credibility choices and weight-of-evidence determinations are for the jury.

## Conclusion

The First Circuit upheld the malpractice verdict because plaintiffs’ expert-driven proof allowed a reasonable jury to find that both the surgeon’s treatment choices and the hospital’s postoperative monitoring failures fell below the Puerto Rico standard of care and were more likely than not the cause of Romero’s discitis and resulting damages.


Lama v. Borrás, 16 F.3d 473 (1st Cir. 1994)