for two years mr anthony suffered severe daily abdominal pain and near daily rectal bleeding as a result of his radiation poisoning mr anthony saw for cruel and unusual punishment when the defendant's decided to only treat mr anthony conservatively for two years not only did they not provide the colossally that was recommend it but for two years day that nothing other than a little more than tylenol hormones and medically ends the defendants knew of mr anthony severe medical condition and continue to prescribe more of the same and adequate treatment this is more of the same and adequate treatment that was prescribed by the defendants did not alleviate mr anthony's pain and suffering and the question before us today is whether verified medical evidence is need it to tell a jury what has already obvious which is that the conservative treatment of tylenol medically ends and her moles was not enough and adequate for mr anthony's chronic abdominal pain and nearly daily rectal bleeding is inadequate the same as deliberately indifferent and does that satisfy the subjective element of the requirement for medical denial of medical treatment no other words treatment how do you get from there to deliberate indifference and this and the subjective element knowing and believing that it was inadequate your honor the fact that it went on for two years and there was no change in the dosage or anything gets to that deliberate indifferen problem here no your honor it's the fact that for two years a defendants did nothing more or try anything difference once they realized that their prescription of tylenol the medical lanes and the hormones which worse not only in adequate but maybe was grossly inadequate since you're a green you know deliberate indifference no your honor and that's because mr anthony's severe medical condition was obvious and when it's obvious that there is no need for verifying medical affidavit chronic abdominal pain and near daily rectal bleeding is obvious and once it is obvious that eliminates the need for verify medical usually we get the obviousness question when the doctors have done nothing and you say well would it have been obvious that there was a problem here they clearly understood there was a problem and you didn't like the treatment you didn't like the treatment that he got at least some of the time but i did and if you have cases help me that obviousness meets what judge cla said where you have medical evidence on one side and none on the other i thought obviousness went to did the doctors know anything at all you know you have somebody who's having heart palpitations and it should have been obvious that they should do something for him and then they just ignored it so can you help me there in that distinction do you have a case that addresses obviousness as a matter of the medical accuracy of their  of their actions your honor there is no bright line rule for why is obvious however the fact that it was the two years of the chronic a domino pain and the bleeding that goes to show that what they were doing was not working it was not adequate and therefore for them not to even suggest increase in his dosage of the tylenol or any of the other hormones  tylenol or whatever that is because you sort of first say really should have done something but the specific of what he wanted was a collage to me your honor it's not even that they could have done the colossally they didn't offer anything the only option on the more tylenol or that sort of thing your honor that he did request something to alleviate his pain however throughout the rocker it shows that why they did try to prescribe  more tylenol and they didn't give it to him or you were just saying that was something that they might have done that they could have trite something more than what they did and they did not do the surgery and one reason i would have thought you'd need a medical expert is all surgeries come with risks i mean there's some risk it won't go well and things will get worse and then there are some risks that solve the problem but it will come with these other symptoms don't don't you need an expert to compare the before the problems  had with the risks associated with the surgery and some of the problems you're still going to have after the surgery why would she need an expert for that your honor because for two years this was going on there proved that what they were doing was not adequate and then they for them not it was the first part but we have to compare it to the nirvana solution and we have to confirm it really is nevada lost the reserve in most cases people don't want them there's a of problems with the don't you need the expert to talk about how this works and it's a pain for sure it can go wrong whatever ounce and the record shows that they did the  procedure of a colossal me with mr anthony and that he understood the risk he understood the procedure and according to the defendant he defendant's wants and he did not he rejected the colossus to me however that goes to show that  point that the doctors did in fact recommended or suggest that he take that procedure and that within the cell as a genuine issue of material fact for one of the defendants to say that yes he he rejected the and then to have mr anthony saying that it was never even an option for him but he did understand the rest and everything that comes with the colossi me and after two years of his pain and suffering he would rather go t not just his choice it has to be the objective side of you have to have objective evidence really would have alleviated the cruel and unusual punishment that is correct while the we do not look to the preferred treatment some treatment should have been done more than what was prescribed for two years months two years is a long time to go on with the same treatment with al differentiating and the dosage or anything like that two years of the exact same thing with no alleviation of the pain is a much morning i'm nicholas de sade and i'm arguing today on behalf of believe dr daniel cherry this court is very carefully identified and distinguished two types of claims alleging deliberate indifference to medical care on the one hand there are those claims that allege the denial or delay of any medical treatment like in blackmore versus kalamazoo can you what the inmate was complaining about abdominal pain for two days before anybody did anything about it in those cases the constitutional violation is the denial or delay of any treatment and that can be proven by showing that the condition was so obvious that even a layperson could have identified it but then there is another subset of cases those claims allege the denial or delay of a specific type of treatment or that generally allege that the treatment provided was inadequate like in blosser versus gilbert santiago versus ringle and most recently in king versus alexander in those types of complications the constitutional violation is the effect of the denial or delay in not receiving the specific or different treatment to make that showing this court has repeatedly held that a plaintiff must come forth with expert medical testimony that it's stablish is the detrimental effect of not receiving the specific or alternative treatment here mr anthony's claims fall in the second category he alleges he was denied a specific type of treatment a colossal me and as a result his preexisting condition his claim therefore falls right in line with the case with blosser santiago and king and because it does he was required to put forth expert medical testimony that established the failure to give the specific treatment he wanted the cost to me and show that it had a detrimental effect on his condition he didn't for that reason the district or properly dismissed the claim this all involves the objective component of the constitutional claim here and what plaintiffs are trying what mr anthony is trying to do is use wanting to choose the standard the obvious to a standard and then allow that to dictate his claim that's what the plaintiff tried to do in the king case in this course rejected it what you're supposed to do is identify the type of claim whether it is a black or king type claim and if it is the latter then you apply the appropriate standard and here the standard requires that they come forth with expert medical testimony we are not arguing that the effect of the delay of was detrimental to mr anthony we are arguing that two years of pain and suffering is enough blackmore states that pain is enough not that  his condition got worse just that the two years of the pain was enough we are arguing that mr anthony's chronic pain and near daily back to bleeding for two years is obvious so there's no need for medical experts and we're not arguing that his condition got worse because he was not  didn't get any treatment and the problem is that it's not cruel and unusual punishment to have pain even for two years it's cruel and unusual punishment for them to be deliberately indifferent to that pain and not offer treatment isn't that really the problem yes and we're arguing that the treatment provided by the defend this was so will fully in adequate that amount to no treatment at all