Case Title: Reynolds v. Mario D. Gonzalez, M.D.

Citation: 

Docket Number: a-9-01

State: new-jersey

Court: New Jersey Supreme Court

Date: 2002-06-11T00:00:00Z

Document:
In this matter, the Court determines whether it should eliminate the substantial factor test in increased-risk medical malpractice cases. In September 1992, plaintiff sustained serious injuries to his left leg in a dirt-bike accident. He was transported to the emergency room at Meadowlands Hospital in Secaucus. The emergency room physician made an initial diagnosis of tibial plateau fracture of the leg with possible compartment syndrome, a painful condition that occurs when there is swelling inside an enclosed compartment in the body. Generally, if the syndrome is suspected, the proper course of treatment is to check intracompartmental pressure and perform a fasciotomy (an incision) to relieve the pressure. Plaintiff's treating doctor at Meadowlands Hospital was Dr. Gonzalez ("defendant"). Two days after plaintiff was admitted to the hospital, defendant operated on plaintiff's leg to repair his fracture. After the surgery, plaintiff noticed that his foot was numb and that he had some loss of control, an inability to flex the foot, and a burning sensation. Approximately two weeks later, plaintiff was placed in a leg cast and discharged. After two more weeks, defendant changed the cast because plaintiff complained of pain. The pain persisted with the changed cast, however, and plaintiff testified that he could not move his foot and it was flopping around. Defendant removed the second cast in December 1992. At that time, plaintiff was still unable to move his foot and it was numb with a tingling sensation. Plaintiff had slight mobility in his toes, however. Late in December 1992, plaintiff fell outside his residence. Defendant examined plaintiff's leg and advised him that he needed additional surgery. Defendant sought a second opinion at the University of Medicine and Dentistry of New Jersey (UMDNJ). When UMDNJ accepted him as a patient, plaintiff's foot was paralyzed and curled. The surgeons at UMDNJ inserted a rod from the lower leg to the foot to keep the foot flat. Plaintiff sought further treatment in August 1994 when he became a patient at the Hospital for Special Surgery in New York. There, surgeons operated on plaintiff's foot, resulting in the fusion of the foot into a permanent 90-degree angle. Plaintiff testified that he suffers from excruciating pain, loss of sensation and a severely affected gait. In September 1994, plaintiff filed a medical malpractice action against defendant. The case was tried twice to a jury. Plaintiff argued at both trials that defendant was negligent for failing to properly monitor him for compartment syndrome, for failing to perform intracompartmental pressure measurements, and in casting the fractured leg when the compartment pressures were elevated. In addition, he argued that the nerve damage he sustained that resulted in his paralysis developed because of the undiagnosed and untreated compartment syndrome. Defendant argued that plaintiff did not have compartment syndrome while under his care and that the foot problems were caused by nerve damage sustained in the dirt-bike accident. Defendant explained also that it was his normal practice to perform a fasciotomy immediately when he suspected compartment syndrome, rather than to rely on diagnostic tests to confirm or rule it out. Both juries determined that defendant deviated from accepted standards of medical care by failing to test for compartment syndrome and that the deviation increased the risk of ultimate harm. However, both juries also concluded that the increased risk was not a substantial factor in producing plaintiff's paralysis and related complications. Following the first trial, the court granted plaintiff's motion for a new trial, concluding that the testimony of defendant and his expert either had misled or confused the jury. After the second trial, plaintiff filed a second motion for a new trial, and the trial court denied the motion without opinion. Before the Appellate Division, plaintiff argued that the substantial factor test should be abolished or modified because it is confusing and misleading. The Appellate Division affirmed the denial of plaintiff's motion for a new trial, observing that it had no authority to modify or eliminate the substantial factor test. HELD : In a medical malpractice case involving a claim that the negligence increased the risk of harm posed by a pre-existing condition, the Court reaffirms the need for a plaintiff to prove that the increased risk was a substantial factor in causing the ultimate harm. 1. New Jersey courts apply the substantial factor test in medical malpractice cases involving preexisting conditions. The first inquiry in the substantial factor analysis is whether there is evidence demonstrating, within a reasonable degree of medical probability, that negligent treatment increased the risk of harm posed by a preexistent condition. Once that requirement has been satisfied, the jury must determine whether the increased risk was a substantial factor in causing the ultimate harm. If the jury determines that the plaintiff has satisfied the two-prong inquiry, it next must address the appropriate apportionment of damages. The damages awarded should be adjusted to reflect the extent to which the ultimate result would have occurred in the absence of defendant's negligence or solely by virtue of a preexistent condition. (Pp. 15 to 21). 2. The issue of a defendant's liability cannot be presented to the jury simply because there is some evidence of negligence. There must be evidence or reasonable inferences therefrom showing a proximate causal relation between defendant's negligence, if found by the jury, and the resulting injury. This Court has found that the application of a standard of causation that is more flexible than that used in conventional tort claims is appropriate in medical malpractice cases involving preexistent conditions. The two-prong increased risk, substantial factor test was adopted to address a plaintiff's different burden of proof because of the inapplicability of "but for" causation. The facts of this case illustrate the soundness of the two-part test. The Court rejects plaintiff's argument that the test is unnecessary. (Pp. 21 to 25). 3. Here, however, the jury's verdict may have resulted from some confusion about plaintiff's burden under the substantial factor causation test. The Court is persuaded that a clearer instruction on the substantial factor test would have been preferable, and remands for a new trial in this case with a modified substantial factor charge explaining to the jury the legal significance of the word "substantial." The Court refers the issue to the Committee on Model Civil Jury Charges, recommending modification of the substantial factor test in increased-risk medical malpractice cases and in the general instructions on proximate cause. Pending such modification, the Court instructs the trial court about explanations that it must provide to the jury on remand. (Pp. 25 to 28). 4. The trial court's failure to tailor its instructions to the theories and facts presented in this case also supports a remand for a new trial. Specifically, there was an absence of any explanation about plaintiff's burden of proving an increased risk based on defendant's failure to test for compartment syndrome. The jury may have determined that defendant's failure to perform the required diagnostic tests insulated him from liability. (Pp. 29-31). 5. Finally, there was a complete lack of any cross-reference in the jury charge on the law to the underlying evidence and plaintiff's theory of recovery. No attempt was made to relate the legal principles to the underlying factual allegations or to the parties' respective contentions. While not an independent source of reversible error, the abstractness of the trial court's instruction on the law increases the Court's concern that the second jury may not have understood adequately how to apply the legal principles that were to guide its decision. (Pp. 32-33). The judgment of the Appellate Division is REVERSED and the matter is remanded to the Law Division for a new trial. JUSTICES VERNIERO and LaVECCHIA, concurring in part, dissenting in part, concur in that part of the Court's opinion modifying the instruction on substantial factor causation in increased risk cases, but do not believe that a third trial is warranted in this case. CHIEF JUSTICE PORITZ and JUSTICES COLEMAN, LONG and ZAZZALI join in JUSTICE STEIN's opinion. JUSTICES VERNIERO and LaVECCHIA filed a separate opinion concurring in part and dissenting in part. Plaintiff-Appellant, v. MARIO D. GONZALEZ, M.D., a licensed physician of the State of New Jersey, Defendant-Respondent, and MEADOWLANDS HOSPITAL MEDICAL CENTER, a Hospital Corporation of the State of New Jersey, its servants, agents or employees, JOHN DOE AND MARY ROE #1-5 (fictitious names intending to designate nurses and health care professionals who participated in the care, management, post surgical management and care of Plaintiff), and each of them jointly, severally or in the alternative, Defendants. Argued February 25, 2002 Decided June 11, 2002 On certification to the Superior Court, Appellate Division. Douglas D. Burgess argued the cause for appellant (Cary & Icaza, attorneys; Robert R. Cary, on the brief). Judith A. Wahrenberger argued the cause for respondent (Wahrenberger & O'Brien, attorneys). E. Drew Britcher argued the cause for amicus curiae, Association of Trial Lawyers-New Jersey (Britcher, Leone & Roth, attorneys). The opinion of the Court was delivered by STEIN, J. In this appeal, plaintiff contends that the Court should eliminate the substantial factor test in increased-risk medical malpractice cases. See Scafidi v. Seiler, 119 N.J. 93 (1990); Evers v. Dollinger, 95 N.J. 399 (1984). We decline to do so. Instead, we modify the instructions on substantial factor causation in increased-risk cases to clarify plaintiff s burden of proof. [W. Page Keeton et. al., Prosser & Keeton on the Law of Torts, 41, at 269 (5th ed. 1984) (Prosser & Keeton).] [119 N.J. at 101 (quoting Model Jury Charges (Civil) 7.11 (1999).] Consistent with our decision in Evers, we also noted that in cases in which the defendant's negligence combines with a preexistent condition to cause an injury, the standard charge on proximate cause could confuse or mislead a jury. The language of the standard charge assumes that the defendant's negligence began a chain of events leading to the plaintiff's injury. If a plaintiff has a preexistent injury or disability and is then adversely affected by a defendant's negligence, the standard by which the jury evaluates causation must be expressed in terms consistent with the operative facts. [Scafidi, supra, 119 N.J. at 108-09 (citations omitted).] Plaintiff asserts that the substantial factor test, in addition to being confusing, is unnecessary in light of our decision in Fosgate, supra, limiting a plaintiff s recovery to that portion of the harm caused by a defendant s negligence. 66 N.J. at 272-73. According to plaintiff, the jury should be allowed to apportion damages once it determines that a defendant s negligence has increased the risk of harm posed by the preexisting condition. We reject that contention because plaintiff s formulation dispenses with the need for proof of any causal connection between defendant s negligence and the resultant harm. The facts of this case illustrate the soundness of the two-part substantial factor test. The jury determined that the failure to test increased the risk of harm because the symptoms plaintiff exhibited made it medically appropriate to perform the intracompartmental tests. Even accepting that finding, the next inquiry was whether the failure to test was a factor in causing plaintiff s ultimate injury. If, as defendant contends, there was no compartment syndrome, then defendant s failure to test although a deviation from accepted medical standards would not have contributed at all to plaintiff s injury and thus would not have satisfied the substantial factor test. Accordingly, we reject plaintiff s argument that the substantial factor test is unnecessary. FRANK REYNOLDS, Plaintiff-Appellant, v. MARIO D. GONZALEZ, M.D., a licensed physician of the State of New Jersey, Defendant-Respondent, and MEADOWLANDS HOSPITAL MEDICAL CENTER, a Hospital Corporation of the State of New Jersey, its, servants, agents or employees, JOHN DOE AND MARY ROE #1-5 (fictitious names intending to designate nurses and health care professionals who participated in the care, management, post surgical management and care of Plaintiff), and each of them jointly, severally or in the alternative, Defendants. VERNIERO, LaVECCHIA JJ., concurring in part, dissenting in part. We concur in that part of the Court s opinion modifying the instructions on substantial-factor causation in increased-risk cases. Unlike the majority, however, we would apply the modified instruction prospectively and do not believe that a third trial is warranted in this case. Plaintiff commenced this action in September 1994. Defendant twice defended himself, and on both occasions the jury agreed that the risk of harm generated by defendant s deviation from acceptable medical practice was not a substantial factor in producing the ultimate injury. Although not perfect, the charge given in the second trial is sustainable under applicable standards. See Fischer v. Canario, 143 N.J. 235, 254 (1996) (instructing that no reversible error is found where the charge, considered as a whole, adequately conveys the law and is unlikely to confuse or mislead the jury, even though part of the charge, standing alone, might be incorrect ). In our view, the jury s verdict was based not on confusion, but on the simple fact that jurors found defendant s expert more persuasive on the relevant issues. After nearly eight years of litigation and two separate trials, we should not trespass on that finding. The judgment of the Appellate Division should be affirmed. NO. A-9 SEPTEMBER TERM 2001 ON CERTIFICATION TO Appellate Division, Superior Court FRANK REYNOLDS, Plaintiff-Appellant, v. MARIO D. GONZALEZ, M.D., a Licensed physician of the State of New Jersey, Defendant-Respondent. DECIDED June 11, 2002 Chief Justice Poritz PRESIDING OPINION BY Justice Stein CONCURRING/DISSENTING OPINION BY JUSTICES VERNIERO AND LaVECCHIA Converted by Andrew Scriven