MOORE et al. v. SINGH et al.
This appeal arises from the grant of a motion for directed verdict in favor of Sonu G. Singh, M. D., and Peach State Nephrology, Inc., in a medical malpractice action filed by Herbert Moore, individually and as the administrator of the Estate of Rosemary Moore. For the reasons that follow, we reverse.
A directed verdict is authorized only when there is no conflict in the evidence as to any material issue and the evidence introduced, with all reasonable deductions therefrom, shall demand a particular verdict. A grant of directed verdict is a ruling that the evidence and all reasonable deductions therefrom demand a particular verdict. It is illogical to say such a finding will be upheld if there is any evidence to support it. A grant of directed verdict can be upheld only where we determine that all the evidence demands that verdict. This requires a de novo review․ It is correct to say that a directed verdict cannot be granted if there is any evidence to support a contrary verdict, but there cannot be “some evidence” that all the evidence demands a particular verdict .1
Viewed in this light, the evidence presented at trial showed that on December 23, 2008, after a fall in her home during which she hit her left knee on a door frame, Rosemary Moore, who as a result of her diabetes had end-stage renal disease, was transported by ambulance to Henry Medical Center Emergency Department (“Henry Medical”). Rosemary complained that she was unable to put weight on her leg, and she feared that her ankle was sprained; she also had a contusion on her knee, which was x-rayed, but did not appear to have a fracture per the radiologist's report. During Rosemary's stay, Dr. Singh, who is a nephrologist who treats patients with diabetes, diagnosed Rosemary with a left ankle sprain and left knee contusion. Dr. Singh discharged Rosemary from the hospital that same day, but Rosemary was not able to stand or walk at that time.
The following morning, December 24, 2008, Moore found Rosemary unresponsive in their bed, and she was again transported to Henry Medical, where Dr. Singh treated her until she was discharged on January 5, 2009. Rosemary regained consciousness on December 26, and she again complained of pain in her left leg. Over the course of the hospital stay, Rosemary was assessed for various other ailments related to her diabetes, and a physical therapist assessed her left leg, finding that her pain in that leg was centered on her knee and tibial tuberosity,2 but Dr. Singh did not follow up on the physical therapist's findings and did not order further x-rays, a CT scan, an MRI, or consult with an orthopedist regarding the issue.
Rosemary continued to experience issues with her leg and was unable to bear weight on it. She regularly saw doctors for the other ailments she experienced as a result of her diabetes, but in late February 2009, she sought assistance from Dr. Brice Choi about her leg.3 Dr. Choi determined that Rosemary had sustained a fracture in her tibia that had at some point displaced4 and healed in the displaced position, and he referred her to orthopedist Dr. Daniel Orcutt for treatment. On April 2, 2009, Dr. Orcutt performed surgery on Rosemary's leg, which surgery included breaking the partially healed bone in order to set it with pins for healing in the correct position.
At trial, Dr. Stephan Borkan provided expert testimony that a nephrologist examining Rosemary on December 23 would have been concentrating on the status of her bones, which could be affected by end-stage renal disease and the length of time she had been on dialysis, circulatory problems, and peripheral neuropathy, which is the decreased perception of pain and normal stimuli in the extremities. Borkan testified that doctors are taught specifically to describe and localize particular portions of the lower extremities to which they are referring when assessing a patient and describing symptoms in a chart. He explained that the upper leg is the area below the pelvis and above but not including the knee, the knee is the knee joint, the lower leg is the area below but not including the knee to the ankle joint, and below the ankle joint is the foot.
Dr. Borkan testified that Dr. Singh's December 27 notes failed to meet the standard of care by adequately describing and localizing Rosemary's pain to a specific portion of Rosemary's left leg, instead, noting that she had “severe pain in the [left] leg” and contained a notation that the “[left] leg is tender [and] swelling.” Dr. Borkan further testified that Dr. Singh should have explained to a more precise degree where on the leg the pain and swelling was, the appearance of that particular portion of the leg-swelling, tenderness, bruising-Rosemary's ambulation ability, and the failure to so specify was a breach of the standard of care.
Dr. Borkan testified that there was evidence Dr. Singh was examining the leg because she noted deep vein thrombosis and cellulitus as possible issues, but contrary to the standard of care, Dr. Singh failed to note the area of the leg where the symptoms were that may indicate such issues. Dr. Borkan explained that a chart should be able to stand alone so that any other medical providers could step in and easily assess what the other doctor had found with regard to symptoms and what other possibilities had been ruled out; Borkan stated that he had “not seen such a superficial and inadequate record in” his career, and the damage that it can lead to is misdiagnosis. Dr. Borkan testified that by December 27, with Rosemary still complaining of pain in her left leg, trauma leaving a contusion and swelling at the knee merely four days prior to that, and redness and pain in the leg as evidenced by the differential diagnosis's inclusion of deep vein thrombosis and cellulitus, Dr. Singh's differential diagnosis also should have included a fracture as a possible diagnosis, and she should have ordered a CT scan, an MRI, or an orthopedic consult.
By December 29, Rosemary still was experiencing pain in her leg and could not bear weight on it, and Dr. Singh ordered a physical therapy consult, which consult localized the pain in Rosemary's leg to the top of the tibial tuberosity and kneecap area; Dr. Singh, however, failed to follow up on that report with any further investigative tests, such as a CT scan, an MRI, or an orthopedic consult between that time and Rosemary's discharge on January 5, 2009, which Dr. Borkan testified was a breach of the standard of care for an attending nephrologist.
Dr. Orcutt testified that when he first saw Rosemary in late March 2009, the fracture was at the least six weeks old, which he estimated based on the appearance of the fracture and the partial healing that had occurred, and he postulated that it had not existed for more than a year. According to Dr. Orcutt, because Rosemary did not have issues walking prior to her December 23 injury, it was unlikely that the fracture existed prior to the incident and was most likely not displaced until sometime after December 23 because the x-ray performed on that day did not show the existence of a fracture, which could have been occult, i.e., not visible on an x-ray, at that point. Dr. Orcutt stated that without some other trauma than that which reportedly occurred on December 23, “[t]he only explanation [for the displaced and re-healed fracture] was [Rosemary] had a nondisplaced fracture after the fall in December that was not diagnosed.”
Dr. Orcutt testified that although the fracture could have been an occult fracture on December 23, it could have been detected at that point using a CT scan or MRI scan. Dr. Orcutt testified that if the fracture had been detected while it was non-displaced, then it could have been treated without surgical intervention, which treatment would have included orders not to bear weight and the use of a brace.
At the close of Moore's case, the Defendants moved for a directed verdict, which the trial court granted. In its order granting the motion for directed verdict, the trial court found that
[a]fter considering the testimony presented by Plaintiffs, the Court finds Plaintiff failed to present adequate testimony from a qualified expert any violation of the standard of care on the part of the Defendants proximately caused the injuries for which Plaintiffs w[ere] seeking recovery. Specifically, Plaintiffs presented neither testimony to a reasonable degree of medical probability any violation of the standard of care caused injury to Rosemary Moore, nor did they present testimony to a reasonable degree of medical probability Ms. Moore's injuries for which Plaintiffs were seeking damages at trial could have been avoided.
1. Moore argues that the trial court erred by granting a directed verdict on the basis that he failed to present evidence of causation of any damage to Rosemary. Specifically, Moore contends that he presented evidence of damages, and the trial court erroneously limited its view of damages as the necessity of surgery, and its grant of the directed verdict on this basis is therefore erroneous.
To recover in a medical malpractice case, a plaintiff must show not only a violation of the applicable medical standard of care but also that the purported violation or deviation from the proper standard of care is the proximate cause of the injury sustained. In other words, a plaintiff must prove that the defendants' negligence was both the cause in fact and the proximate cause of his injury.5
In some instances where the question of causation is outside the ken of the normal juror, this showing must be based on expert testimony that is sufficient to support a finding that the deviation from the standard of care to a reasonable degree of medical certainty caused the injury.6 “Causation may be established by linking the testimony of several different experts.”7 “Questions regarding causation are peculiarly questions for the jury except in clear, plain, palpable and undisputed cases.”8 Although “[a] plaintiff must introduce evidence which affords a reasonable basis for the conclusion that it is more likely than not that the conduct of the defendant was a cause in fact of the result. A mere possibility of such causation is not enough․”9
Based on the combined expert testimony, we conclude that Moore presented evidence creating a jury issue as to whether Dr. Singh would have discovered the fracture if she had properly complied with the standard of care during the examination of Rosemary in the ER, and moreover, whether the failure to diagnose the fracture at that time led to further complications with the break such that surgery was required or made more complicated as a result of approximately two months of lack of treatment.10
To the extent that the Defendants contend that Rosemary was not complaining about pain in her leg that would trigger Dr. Singh to assess it for a fracture, there is ample testimony from Moore and Dr. Borkan that the issue was presented to her and that the signs of a potential fracture were apparent. Moreover, Dr. Borkan's testimony that Dr. Singh's notes included a differential diagnosis for left leg pain and swelling including deep vein thrombosis and cellulitus, neither of which would manifest in the ankle, support the conclusion that material issues of fact exist as to whether Dr. Singh's breach of the standard of care resulted in a failure to diagnose the fracture prior to its displacement or prior to its healing out of position.11 To the extent that there are questions regarding these issues, those were for the jury to decide and did not demand the grant of the Defendants' motion for new trial.12
Dr. Orcutt testified that he believed Rosemary fractured her leg during her fall on December 23 and that it displaced sometime later based on the fact that the x-ray from that day did not show a fracture. His failure to state that he believed this to be the case “to a reasonable degree of medical certainty” does not require a finding that Moore failed to present evidence of causation—Moore's “experts were not required to use these magic words in rendering their opinions.”13
Based on the testimony outlined above it was possible for the jury to find that Dr. Singh's breach of the standard of care resulted in a missed diagnosis of a nondisplaced fracture of Rosemary's left knee, which later displaced requiring surgery.14 The jury also could have found that while surgery could have been required in any event, the failure to diagnose resulted in approximately two months of lack of treatment and a more complicated surgery or recovery period.
Accordingly, the trial court erred by granting the motion for directed verdict.15
2. Next, Moore argues that the trial court erred by excluding the following testimony of Dr. Orcutt:16
QUESTION: Can you tell me in terms of probabilities how probable it might be for a nondisplaced fracture to develop into a displaced fracture in a patient like [Rosemary], assuming that the fracture is diagnosed and you placed them on nonweight-bearing restriction?
[ORCUTT]: I'm not sure I can give you a probability of that.
QUESTION: Do you think its 50–50?․
[ORCUTT]: I would say 20 percent, 30 percent, something like that, likely that it would displace.
QUESTION: So 20 to 30 percent of the patients who have comorbid conditions like [Rosemary] had, even when they're placed on nonweight-bearing restriction, 20 to 30 percent of those patients who have nondisplaced fractures can develop into displaced fractures; correct?
[ORCUTT]: That would be my best estimate.
Moore also argues that the trial court erred by allowing testimony from Dr. Orcutt:
QUESTION: In [Rosemary's] case, can you say that it is more likely than not that even if she had ․ a nondisplaced fracture that was being treated conservatively, that ultimately she would have progressed to a displaced fracture?
[ORCUTT]: I cannot say that․
QUESTION: You can't say one way or the other; is that correct?
[ORCUTT]: That's correct.
The trial court excluded Dr. Orcutt's testimony that approximately 20 to 30 percent of patients like Rosemary who presented with a nondisplaced fracture and were treated with a brace and instructions not to bear weight on the leg would eventually need surgery because their fractures would displace. The trial court determined that the testimony was speculative; but Dr. Orcutt, although he was “unsure” he could provide a response at first, was able to do so without hesitation after the Defendants' provided an example of the type of response they were asking for.17 Because the trial court allowed the later testimony by Dr. Orcutt on the same matter, it abused its discretion by disallowing the testimony as to percentages. “[C]ontradictions go solely to the expert's credibility, and are to be assessed by the jury when weighing the expert's testimony.”18 Accordingly, the trial court erred by excluding the testimony.
DOYLE, Presiding Judge.
McFADDEN and BOGGS, JJ., concur.