Title: ARMSTRONG v. HRABAL

State: wyoming

Issuer: Wyoming Supreme Court

Document:

ARMSTRONG v. HRABAL2004 WY 3987 P.3d 1226Case Number: 03-36Decided: 04/12/2004
APRIL 
TERM, A.D. 2004

 

                                                                                                                                   

 

IVAN 
P. ARMSTRONG, an individual; and

JENNIFER 
ARMSTRONG, an individual,

 

Appellants(Plaintiffs),

 

v.

 

TANYA 
L. HRABAL, M.D., an individual;

and 
EMERGENCY MEDICAL PHYSICIANS, P.C.,

a 
Wyoming professional corporation,

 

Appellees(Defendants).

 

 

Representing 
Appellants:

 

            
Robert G. Pickering of the Pickering Law Firm, P.C., Fort Collins, 
Colorado; and Henry F. Bailey, Jr. of Bailey, Stock & Harmon, P.C., 
Cheyenne, Wyoming.

 

Representing 
Appellees:

 

            
J. Kent Rutledge and James C. Kaste of Lathrop & Rutledge, P.C., 
Cheyenne, Wyoming.

 

Before 
HILL, C.J., and GOLDEN, LEHMAN, KITE, and VOIGT, JJ.

 

VOIGT, 
Justice, delivered the opinion of the Court; 
LEHMAN, 
Justice, filed a dissenting opinion.

 

 

            
VOIGT, Justice.

 

[¶1]      This is a medical 
malpractice case in which the appellants dispute several evidentiary rulings of 
the district court, its denial of their motion for leave to amend their 
complaint, and its denial of their motion for a new trial.  We affirm in part, reverse in part, and 
remand to the district court.

 

ISSUES

 

            
1.         
Did the district court err in precluding the appellants' retained 
emergency medicine expert from offering opinions as to the standard of care for 
treatment?

 

            
2.         
Did the district court err in precluding the appellants' only other 
retained expert from offering opinions as to the standard of 
care?

 

3.         
Did the district court err in precluding the appellants' retained expert 
from offering opinions as to the standard of care for an infectious disease 
consultant?

 

            
4.         
Did the district court err in precluding evidence of appellee Hrabal's 
prior malpractice claims, the suspension of appellee Hrabal's hospital 
privileges, and other matters affecting her credibility?

 

            
5.         
Did the district court err in denying the appellants' motion for leave to 
file an amended complaint to allege negligent 
misrepresentation?

 

FACTS

 

[¶2]      The appellants in 
this case are husband and wife, Ivan and Jennifer Armstrong.  On February 5, 1999, one of their 
children was diagnosed at a private medical clinic as suffering from 
influenza.  As a precautionary 
measure, the Armstrong family members were prescribed an anti-influenza 
medication.  Despite taking a full 
ten-day course of the medication, Ivan Armstrong (Armstrong) awoke on February 
25, 1999, with head and body aches and nausea.  He returned to the medical clinic and 
was prescribed a second dose of the same anti-influenza 
medication.

 

[¶3]      On February 28, 
1999, Armstrong went to the emergency room of the United Medical Center (UMC) in 
Cheyenne, complaining of worsening symptoms.  A nurse noted he had both an elevated 
temperature and an elevated heart rate.  
Armstrong was seen by appellee, Tanya L. Hrabal, M.D., an employee of 
appellee, Emergency Medical Physicians, P.C. (EMP).  Dr. Hrabal obtained Armstrong's medical 
history and did a physical examination.  
After considering numerous potential causes of Armstrong's symptoms, 
including trauma, appendicitis, gallbladder disease, and viral or bacterial 
infection, Dr. Hrabal concluded that the most likely cause was 
influenza.

 

[¶4]      Dr. Hrabal 
ordered the administration of fluids and medication to reduce Armstrong's 
dehydration and high temperature.  
When Armstrong appeared to improve, Dr. Hrabal discharged him from the 
emergency room with instructions to return if he did not continue to improve, to 
take large quantities of clear fluids, to take specified medications, and to 
follow up with his family doctor, Ronald Malm, M.D.

 

[¶5]      On March 2, 1999, 
Armstrong went to see Dr. Malm because he was experiencing dizziness, fever, 
vomiting and diarrhea.  Dr. Malm had 
originally prescribed the anti-influenza medication for the Armstrong 
family.  Dr. Malm diagnosed 
Armstrong as suffering from gastroenteritis, or stomach flu, and dehydration, 
and admitted him to the hospital for observation and rehydration.  Laboratory test results and x-rays were 
sufficiently normal so as not to change Dr. Malm's 
diagnosis.

 

[¶6]      During the 
afternoon of March 3, 1999, Armstrong's condition dramatically worsened.  His attending nurses contacted Dr. 
Malm's on-call partner, Dr. Schiel.  
After examining Armstrong and seeing the abnormal results of new 
laboratory tests, Dr. Schiel suspected that Armstrong might be suffering from a 
bacterial infection, or sepsis.  Dr. 
Schiel ordered blood cultures and requested a consultation from Philip Sharp, 
M.D., an infectious disease specialist.

 

[¶7]      Dr. Sharp saw 
Armstrong on the night of March 3, 1999, and concluded that Armstrong was 
suffering from sepsis, possibly due to an intestinal infection.  Dr. Sharp ordered broad coverage 
antibiotics and body fluid cultures for Armstrong.  The next day, Dr. Sharp noted that the 
cultures were positive for bacterial infection.  He also felt that a heart murmur might 
be present.  Subsequent tests 
revealed that Armstrong had endocarditis, which is an infection of the heart 
valve.  He underwent surgery to 
replace his damaged aortic valve with a prosthetic valve.  The endorcarditis was caused by bacteria 
called staphylococcus aureus.

 

NATURE 
OF THE CASE

 

[¶8]      On February 22, 
2001, the appellants filed a medical malpractice action against the appellees.1  After engaging in discovery, the 
appellants sought leave to file an amended complaint to add an allegation of 
negligent misrepresentation based upon Dr. Hrabal's alleged failure to disclose 
to EMP her involvement in a previous lawsuit in which failure to diagnose a 
progressive bacterial infection had been alleged.  The appellees resisted the motion to 
amend and moved in limine to preclude admission of evidence of any prior 
malpractice claims against Dr. Hrabal.  
The motion to amend was denied and the motion in limine was 
granted.  Those rulings are the 
basis for the fourth and fifth issues in this appeal.

 

[¶9]      In their pretrial 
disclosure of expert witnesses, the appellants named two retained medical 
experts:  Steven M. Tredal, M.D., 
board certified in emergency medicine, and Gary M. Green, M.D., board certified 
in internal medicine and infectious disease.  It was intended that Dr. Tredal would 
establish the standard of care for emergency room physicians and that Dr. Green 
would do the same for emergency room physicians and for infectious disease 
practice in the emergency room setting.  
At trial, the district court sustained objections to questions posed by 
appellants' counsel to Dr. Tredal and Dr. Green concerning the standard of 
care.  Those rulings are the basis 
for the first three issues in this appeal.

 

STANDARD 
OF REVIEW

 

            
Evidentiary Rulings

 

[¶10]   Trial court rulings on the 
admissibility of evidence are reviewed for an abuse of discretion.  Clark v. Gale, 966 P.2d 431, 435 
(Wyo. 1998).  We apply the following 
standard:

 

"Such 
decisions are within the sound discretion of the trial court and will not be 
disturbed absent a clear abuse of discretion.  . . .  Determining whether the trial court 
abused its discretion involves the consideration of whether the court could 
reasonably conclude as it did, and whether it acted in an arbitrary or 
capricious manner.  . . 
.

 

            
A trial court's evidentiary rulings "are entitled to considerable 
deference,"' and will not be reversed on appeal so long as "there exists a 
legitimate basis for the trial court's ruling.  . . ."'"

 

Dysthe 
v. State, 2003 
WY 20, ¶ 16, 63 P.3d 875, 883 (Wyo. 2003) (quoting Lancaster v. State, 2002 
WY 45, ¶ 11, 43 P.3d 80, 87 (Wyo. 2002)).  This standard applies to a trial court's 
exclusion of expert testimony.  
Chapman v. State, 2001 WY 25, ¶ 8, 18 P.3d 1164, 1169 (Wyo. 
2001); 
Bunting v. Jamieson, 984 P.2d 467, 470 (Wyo. 1999).  Expert testimony is admissible if it 
meets the requirements of W.R.E. 702:

 

If 
scientific, technical, or other specialized knowledge will assist the trier of 
fact to understand the evidence or to determine a fact in issue, a witness 
qualified as an expert by knowledge, skill, experience, training, or education, 
may testify thereto in the form of an opinion or 
otherwise.

 

[¶11]   All relevant evidence is 
admissible.  W.R.E. 402.  Even where relevant, however, evidence 
may be excluded if it constitutes the "needless presentation of cumulative 
evidence."  W.R.E. 403.  Furthermore, rulings excluding evidence 
are subject to harmless error analysis and there must be an offer of proof under 
W.R.E. 103:

 

(a)       Effect 
of erroneous ruling.  Error may not be predicated upon a ruling which 
admits or excludes evidence unless a substantial right of the party is affected, 
and

 

            
. . .

 

(2)       Offer of 
Proof.  In case the ruling is one excluding evidence, the substance of the 
evidence was made known to the court by offer or was apparent from the context 
within which questions were asked.

 

Motion 
for Leave to Amend Complaint

 

            
The law in Wyoming is well settled that the decision to allow amendment 
to pleadings is vested within the sound discretion of the district court.  That decision will be reversed only for 
an abuse of discretion shown by clear evidence.

 

Ekberg 
v. Sharp, 2003 
WY 123, ¶ 9, 76 P.3d 1250, 1253 (Wyo. 2003).  Leave to amend pleadings "shall be 
freely given when justice so requires."  
W.R.C.P. 15(a).  We have 
identified the "proper test as to what the trial court should consider when an 
amendment is proffered" to be the following:

 

"* 
* *  If the underlying facts or 
circumstances relied upon by a plaintiff may be a proper subject of relief, he 
ought to be afforded an opportunity to test his claim on the merits.  In the absence of any apparent or 
declared reasonsuch as undue delay, bad faith or dilatory motive on the part of 
the movant, repeated failure to cure deficiencies by amendments previously 
allowed, undue prejudice to the opposing party by virtue of allowance of the 
amendment, futility of amendment, etc.the leave sought should, as the rules 
require, be freely given.'  
* * *"

 

Beaudoin 
v. Taylor, 492 P.2d 966, 970 (Wyo. 1972) (quoting Foman v. Davis, 371 U.S. 178, 182, 83 S. Ct. 227, 230, 9 L. Ed. 2d 222 (1962)).

 

DISCUSSION

 

Did 
the district court err in precluding the appellants' retained emergency medicine 
expert from offering opinions as to the standard of care for 
treatment?

 

[¶12]   As part of his burden of proof in a 
medical malpractice action, the plaintiff must establish the accepted standard 
of medical care or practice.  Wyo. 
Stat. Ann. § 1-12-601 (LexisNexis 2003); Oakden v. Roland, 988 P.2d 1057, 
1059 (Wyo. 1999) (quoting Harris v. Grizzle, 625 P.2d 747, 751 (Wyo. 
1981)).  As with allegations of negligence in 
other professions, the standard of care in a medical malpractice case generally 
must be proven through expert testimony.  
Smyth v. Kaufman, 2003 WY 52, ¶ 27, 67 P.3d 1161, 1169 (Wyo. 
2003); 
Sayer v. Williams, 962 P.2d 165, 167-68 (Wyo. 1998) (quoting Mize v. 
North Big Horn Hosp. Dist., 931 P.2d 229, 233 (Wyo. 1997));  Siebert v. Fowler, 637 P.2d 255, 
257 (Wyo. 1981).  See also Rino v. Mead, 2002 WY 
144, ¶ 17, 55 P.3d 13, 19 (Wyo. 2002).

 

[¶13]   The appellants called Dr. Tredal, 
an emergency medicine specialist, to testify as to the standard of care Dr. 
Hrabal was expected to meet when Armstrong appeared at the UMC emergency 
room.  During the direct examination 
of Dr. Tredal, the following exchange occurred:

 

Q.        And, 
Doctor, did Tanya Hrabal meet the core standard of care in treating Ivan 
Armstrong on the 28th of February?

 

A.        
No.

 

Q.        What 
should she have done?

 

MR. 
RUTLEDGE:      
Your Honor, this has been asked and answered about five 
times.

 

THE 
COURT: Sustained.

 

[¶14]   The appellants' trial counsel made 
no immediate response when the objection was sustained and made no offer of 
proof.  In their appellate brief, 
the appellants contend that their counsel intended to question Dr. Tredal about 
the standard of care in several distinct areasevaluation, testing, 
consultation, treatment, appropriateness of discharge, and aftercare 
instructionsand that only evaluation, testing and consultation had been covered 
when the objection was sustained.  
They argue that it was clear error for the district court to preclude 
them from eliciting testimony on the critical issue of treatment.  They identify prejudice in the fact that 
the jury submitted the following note to the district court during 
deliberations:

 

            
We have a problem with "what is standard of care"[.]  All dr's testified differently  We are 
[to] decide on evidence presented  If we come to an agreement  can we present 
a statement to the attys/plaintiff how we came to -- ??[2]

 

Furthermore, 
in finding against the appellants, the jury concluded that Dr. Hrabal did not 
deviate from the standard of care expected of her as an emergency room 
physician.

 

[¶15]   The appellees' counter-argument is 
that, pursuant to W.R.E. 403, the district court properly exercised its 
discretion in sustaining their objection in order to prevent the "needless 
presentation of cumulative evidence."3  They point to numerous prior questions 
where Dr. Tredal had been asked about the standard of care or about what Dr. 
Hrabal "should have done:"

 

Q.        And 
how do you treat bacterial sepsis generally?

 

                                    
. . .

 

Q.        . . 
.  Could you tell us what things Dr. 
Hrabal failed to do to meet the standard of care?

 

                                    
. . .

 

Q.        And 
what were  what would the standard of care have required for [bacterial sepsis] 
on the differential to be ruled out?

 

                                    
. . .

 

Q.        What 
testing was required by the standard of care?

 

                                    
. . .

 

Q.        Were 
all of these tests required to evaluate  by the standard of care, were they 
required to evaluate Ivan Armstrong on February 28, 1999?

 

                                    
. . .

 

Q.        Now, 
Doctor, in your opinion in this case did the standard of care require objective 
tests to rule out sepsis?

 

                                    
. . .

 

Q.        If a 
doctor is thinking bacterial infection does the standard of care require them to 
do a septic work-up?

 

[¶16]   In the context of all these 
questions and their answers, sustaining the objection was certainly 
understandable.  The appellants' 
counsel did not explain to the district court his plan to pursue the standard of 
care in six sub-categories nor did he make an offer of proof to alert the 
district court to how the proposed testimony would differ from earlier 
testimony.  Further, the record does 
not suggest that such a plan of attack was apparent from the previous 
questions.  In this situation, an 
offer of proof was required by W.R.E. 103(a)(2).  See Contreras By and Through 
Contreras v. Carbon County School Dist. No. 1, 843 P.2d 589, 595-96 (Wyo. 
1992); 
Rudolph v. State, 829 P.2d 269, 274-75 (Wyo. 1992); 
and Pack v. State, 571 P.2d 241, 245 (Wyo. 1977).  The dual purpose of an offer of proof is 
to alert the trial court to the nature of the error in order to allow corrective 
action, and at the same time to create a sufficient record for appellate 
review.  Padilla v. State, 
601 P.2d 189, 194 (Wyo. 1979).  Those purposes were not served in this 
case, and we affirm the district court's decision to sustain the appellees' 
objection.

 

Did 
the district court err in precluding the appellants' only other retained expert 
from offering opinions as to the standard of care?

 

[¶17]   Gary M. Green, M.D., was retained 
by the appellants as an expert to establish the standard of care for infectious 
disease practice in the emergency room setting.  After graduation from Georgetown 
University School of Medicine, Dr. Green did an internship in internal medicine 
at the Medical Center of Delaware.  
He then finished his residency at St. Joseph's Hospital & Medical 
Center in Phoenix, Arizona.  Next, 
he completed a fellowship in infectious disease at U.C.L.A.  He is board-certified by both the 
American Board of Internal Medicine and the American Board of Infectious 
Diseases.  At the time of trial, he 
was Sub-Chief of the Division of Infectious Diseases at Santa Rosa Kaiser 
Permanente Medical Center.

 

[¶18]   Dr. Green's medical residency 
included training in emergency medicine.  
During his infectious disease fellowship at U.C.L.A., Dr. Green also 
worked as an emergency room physician at West Los Angeles Kaiser Hospital.  After working for a time at Cedars Sinai 
Medical Center, also in Los Angeles, Dr. Green was recruited to Casper, where he 
established a private practice and worked at the Wyoming Medical 
Center.

 

[¶19]   In Casper, Dr. Green consulted in 
the emergency room at Wyoming Medical Center "almost daily."  He also taught infectious disease 
recognition and treatment to family practice residents at the University of 
Wyoming Family Practice Residency Program.  
Dr. Green testified as follows in reference to his familiarity while in 
Casper with emergency room treatment of infectious 
diseases:

 

Q.        While 
you were in Casper did you become familiar with the standards of practice for a 
reasonable and prudent board certified emergency physician in connection with 
recognition of infectious diseases?

 

A.        Yes, 
I was.  In fact, it is not much 
different from that for internal medicine and family 
practice.

 

Q.        Is it 
substantially similar?

 

A.        
Yes.

 

[¶20]   Dr. Green moved from Casper to 
Eureka, California, in 1999.  There, 
he was the sole infectious disease specialist in two counties, and he held 
privileges at three area hospitals.  
He attended regularly in the emergency departments of all three 
hospitals.  In doing so, he became 
familiar with the standards of care applied to infectious disease patients in 
those emergency departments, which standards were the same as had been applied 
in Casper.  In his current position 
at Santa Rosa Kaiser Permanente Medical Center, he teaches emergency medicine 
specialists how to evaluate and treat patients with 
sepsis:

 

Q.        Dr. 
Green, do you teach emergency medicine, board-certified emergency medicine 
physicians about sepsis?

 

A.        Yes, 
I do.

 

Q.        When 
was the last time you did that?

 

A.        The 
last lecture I gave to the ER department was within the last six 
months.

 

A.        And 
did you teach emergency medicine physicians about infectious disease at Wyoming 
Medical Center?

 

Q.        Yes, 
I did.

 

A.        Do 
you teach them what standards to apply in approaching  in evaluating, 
diagnosing, and treating patients presenting with fever, tachycardia, of 
potential infectious processes?

 

A.        Yes, 
that's a basic tenant [sic] for the lectures I 
give.

 

Q.        Is 
that part of your job duties as infectious disease chief at Santa Rosa 
Hospital?

 

A.        It 
is.

 

Q.        And 
have you done that  did you do that at Wyoming?

 

A.        I 
did.

 

[¶21]   After establishing Dr. Green's 
qualifications, the appellants' counsel began to inquire directly about the 
standard of care:

 

Q.        Are 
the opinions that you're giving today within a reasonable degree of medical 
probability?

 

A.        Yes, 
they are.

 

Q.        And 
is [sic] the standard of care opinions you're rendering today, are those 
based upon the standard of care for emergency medicine when the questions are in 
that area of focus?

 

A.        Yes, 
they are.

 

Q.        And 
when questions will be in the focus of infectious disease will the standard of 
care then be for that subspecialty?

 

A.        Yes, 
they will be.

 

[¶22]   Counsel then began to ask Dr. Green 
about the process known as "differential diagnosis."  At that point, the appellees' counsel 
interjected the following objection:

 

MR. 
RUTLEDGE:  Your Honor, I'm going to 
object to relevance and also as to qualifications.  If this is intended to be standard of 
care testimony about the standards applicable to an emergency physician, Dr. 
Green does not qualify to give standard of care opinions about emergency 
medicine physicians.  He's not in 
the same line of practice.

 

[¶23]   The district court's initial 
reaction was to overrule this objection on the ground that "he does present some 
evidence that he has some experience in emergency rooms."  The appellees' counsel was granted leave 
to voir dire the witness, however, during which the following exchange 
occurred:

 

Q.        But 
your only experience practicing as an emergency room physician was for about one 
year during your infectious diseases fellowship between '95 and '96; isn't that 
true?

 

A.        
That's correct, sir.

 

. 
. .

 

Q.        And 
your training is considerably different than for a family practice physician 
practicing in the emergency department, isn't it?

 

A.        My 
training is different from a family practice physician, that's 
correct.

 

Q.        And 
your training is considerably different from a board certified person who has 
gone through an emergency medicine residency program?

 

A.        Yes, 
my training is different from an ER trained physician.

 

Q.        
You've never gone through the emergency medicine residency 
program?

 

A.        
That's correct.

 

. 
. .

 

Q.        
You've gone through an internal medicine residency?

 

A.        
That's correct.

 

Q.        And 
that's not required to practice emergency medicine, is it?

 

A.        No, 
it is not.

 

. 
. .

 

Q.        You 
agree that ethically you should have recent and substantive experience in the 
field or line of practice about which you're testifying?

 

A.        
That's correct, I do agree with that.

 

Q.        And 
your recent and substantive experience as an emergency physician is consulting 
only with emergency physicians as an infectious diseases specialist; isn't that 
true?

 

A.        
That's correct.

 

Q.        
Okay.  And when you're 
working in the emergency department and since you've completed your fellowship, 
all the time you've spent working in the emergency department has been as an 
infectious diseases specialist, hasn't it?

 

A.        At 
Kaiser Santa Rosa, sir?

 

Q.        No, 
anywhere.

 

A.        Is 
that what you are asking?

 

Q.        
Anywhere.

 

A.        There 
are times when I've done internal medicine call, but it is fairly minor, I would 
say less than 5 percent of my time.

 

Q.        But 
you haven't worked as an emergency physician in the emergency department 
since?

 

A.        Since 
West Los Angeles Kaiser, that's correct.

 

THE 
COURT: What year was that 
'95?

 

THE 
WITNESS:         
About '95, '96, Your Honor.

 

Q.  (BY MR. RUTLEDGE)  And when you're consulted by emergency 
department physicians in the emergency department you're consulted not as an 
emergency physician but as an infectious diseases specialist, aren't 
you?

 

A.        
That's correct.

 

MR. 
RUTLEDGE:      
Your Honor, I renew my objection to Dr. Green testifying about the 
standard of care.  He is not in the 
same line of practice.

 

[¶24]   At the conclusion of the voir 
dire examination, the district court held a sidebar conference in order to 
rule on the objection:

 

THE 
COURT: Kent, I need to ask you a 
question.  I think you quoted from 
the ethics standards.  What do those 
standards say one more time?  I 
think that 

 

MR. 
RUTLEDGE:      
They say that you should have recent and substantive experience in the 
same line of practice.

 

THE 
COURT: Experience.  So the question is, does teaching from a 
perspective of infectious disease specialist count for emergency room 
experience?  Mr. 
Pickering.

 

MR. 
PICKERING:      
Well, Your Honor, the test is not that.  The test is the statutory test found in 
the Wyoming statutes which requires only that a physician be substantially 
familiar with the standards of care of the area of practice, and he is.  We're bound by the statutory 
requirements of the state legislature.

 

THE 
COURT: I would imagine that the ethics of 
the medical profession have something to do with this decision, wouldn't you 
agree?

 

MR. 
PICKERING:      
It may have.

 

THE 
COURT: Which he would violate if I'm going 
to let someone violate his ethics from the stand.

 

MR. 
PICKERING:      
He's not violating his ethics.

 

THE 
COURT: Sure he is.  He has an opinion that doesn't violate 
the ethical  

 

MR. 
PICKERING:      
He's called to the emergency room three days a week not as an emergency 
room doctor.  They said he's 
observed the same standard of care.

 

THE 
COURT: Is this witness going to give 
opinions on causations [sic]?  
Is he?

 

MR. 
PICKERING:      
Causation, yes.

 

THE 
COURT: I'm going to sustain the objection 
on standard of care.

 

[¶25]   In discussing the first issue in 
this opinion, we noted that the plaintiff in a medical malpractice action must 
establish the applicable standard of care, generally through expert 
testimony.  We also noted that, 
under W.R.E. 702, a witness may be "qualified as an expert by knowledge, skill, 
experience, training, or education . . .."  
In addition to these general directives, Wyo. Stat. Ann. § 1-12-601 
provides a specific burden of proof in medical malpractice 
cases:

 

(a)       In an 
action for injury alleging negligence by a health care provider the plaintiff 
shall have the burden of proving:

 

(i)         
If the defendant is certified by a national certificating board or 
association, that the defendant failed to act in accordance with the standard of 
care adhered to by that national board or association; or

 

(ii)        If 
the defendant is not so certified, that the defendant failed to act in 
accordance with the standard of care adhered to by health care providers in good 
standing performing similar health care services.

 

            
(b)       
In either paragraph (a)(i) or (ii) of this section, variations in theory 
of medical practice or localized circumstances regarding availability of 
equipment, facilities or supplies may be shown to contravene proof offered on 
the applicable standard of care.

 

[¶26]   The appellants find error in the 
district court's ruling on several grounds.  First, they contend that Dr. Hrabal was 
not a board-certified specialist in emergency medicine, so they were not 
required to establish the standard of care adhered to by that national 
board.  Second, they argue that Dr. 
Green, although also not a board-certified specialist in emergency medicine, 
established through his testimony that he was well-qualified to testify as to 
"the standard of care adhered to by health care providers in good standing 
performing similar health care services," namely the diagnosis and treatment of 
bacterial infection in the emergency room setting.  The appellants rely on Beavis ex rel. 
Beavis v. Campbell County Memorial Hosp., 2001 WY 32, ¶ 13, 20 P.3d 508, 513 
(Wyo. 2001), 
where this Court recognized that the standard of care may be the same in certain 
instances across lines of practice.  
They also point out that not only did both Dr. Tredal and Dr. Green 
testify that the standard of care in recognizing infectious disease in the 
emergency room did not differ from one area of practice to another, but the 
appellees' own expert, Dr. Rosen, testified that there was no reason for Dr. 
Hrabal to consult with an infectious disease specialist "because the infectious 
disease specialist has no more information than you do."

 

[¶27]   The appellants' third argument 
against the district court's ruling that Dr. Green could not testify about the 
standard of care is that the district court allowed the appellees' expert, 
Dennis L. Stevens, M.D., to give such testimony even though he had no real 
knowledge of the standard of care that should be applied in the attendant 
circumstances.  The appellees 
designated Dr. Stevens as an expert to testify about the standard of care and to 
give opinions as to Dr. Hrabal's care and treatment of Armstrong.  Like Dr. Green, Dr. Stevens is 
board-certified in internal medicine and in infectious disease.  Dr. Stevens attended medical school and 
did his internship and residency at the University of Utah.  He then completed two years of 
infectious disease training at Brooke Army Medical Center in San Antonio, 
Texas.  He remained at that facility 
for some time as assistant chief of infectious disease.  In 1979, he went to work at the 
Veteran's Affairs Medical Center, in Boise, Idaho.  At the time of trial, Dr. Stevens was 
Chief of the Infectious Disease Service at the V.A. Center.  His current practice involves the 
diagnosis and treatment of patients with a variety of infectious diseases, and 
he lectures on infectious disease to University of Washington medical 
students.  Over the years, Dr. 
Stevens has authored numerous publications dealing with infectious 
disease.

 

[¶28]   Prior to trial, the appellants 
filed a motion in limine seeking to preclude Dr. Stevens from testifying 
about the standard of care.  Citing 
to Dr. Stevens' deposition, they pointed out that the doctor has had no training 
in emergency medicine since his internship, that he has never practiced in a 
private hospital, and that he had not seen and was not familiar with any 
emergency medicine texts.  In short, 
relying on W.R.E. 702 and Wyo. Stat. Ann. § 1-12-601, just as the appellees 
later would do in challenging Dr. Green, the appellants argued in their motion 
that there is no evidence that Dr. Stevens has any familiarity with the standard 
of care owed by emergency room specialists.

 

[¶29]   The motion in limine was 
argued during a pretrial conference.  
Ironically, the positions taken by the parties in regard to the motion 
were, for all intents and purposes, exactly the opposite of the positions they 
later took at trial in regard to Dr. Green.  The appellants raised the following 
points in seeking to keep Dr. Stevens from establishing the standard of 
care:  (1) he has had no training in 
emergency medicine; (2) he is not board-certified in emergency medicine; (3) he 
has no experience in emergency medicine; and (4) he has no familiarity with the 
emergency medicine standard of care, as required by Wyo. Stat. Ann. § 
1-12-601.

 

[¶30]   In response, the appellees raised 
the following points:  (1) Dr. 
Hrabal is not board-certified in emergency medicine, so Wyo. Stat. Ann. § 
1-12-601 does not hold her to the standard of care for such a specialist; (2) 
Dr. Stevens is a preeminent expert in the field of infectious disease; (3) the 
question of causation, about which he can testify, is inextricably interwoven 
with the standard of care; and (4) he works in the emergency department about 
once a week dealing with internal medicine emergencies.

 

[¶31]   The reader will remember that the 
district court's initial reaction during the trial was to overrule the 
appellees' objection and to allow Dr. Green to testify because "he does present 
some evidence that he has some experience in emergency rooms."  This initial ruling is reflective of the 
district court's apparent perception at that time that, by combination of 
training and experience, Dr. Green was qualified under W.R.E. 702 to testify 
about the emergency medicine standard of care, and that Wyo. Stat. Ann. § 
1-12-601 did not require testimony from a board-certified emergency medicine 
physician under the circumstances.  
The district court's pretrial analysis of the same issue as it involved 
Dr. Stevens is consonant with that same perception:

 

THE 
COURT: What does he say?  What does Dr. Stevens 
say?

 

MR. 
PICKERING:      
He's going to say that Dr. Hrabal met the standard of care for an 
emergency physician.  Dr. Stevens 
has never even held privileges at a private hospital.  He's been either at the Army or the VA 
for 20, 30 years.

 

THE 
COURT: He [d]oesn't have any familiarity 
with infectious 

 

MR. 
PICKERING:      
With emergency medicine.

 

THE 
COURT: Now, why does that matter in this 
case?

 

MR. 
PICKERING:      
Well, Your Honor, because he's going to testify about standard of 
care.  And the Wyoming statutes 
require[] that they  since she's board certified, or at least holding herself 
to that standard, that he have familiarity with the standards of 
care.

 

THE 
COURT: What statute is 
that?

 

MR. 
PICKERING:      
That's Wyoming 1-12-601.

 

THE 
COURT: Is it constitutional?  Isn't that a question of evidence for 
the Court?  Is the legislature 
intruding into prerogatives 

 

MR. 
PICKERING:      
It has been held constitutional in other states, been applied by the 
Supreme Court of Wyoming numerous times.  
He didn't even know the names of emergency text authors.  He's never even looked at an emergency 
medicine textbook.  He  so we don't 
think he can offer any opinions on standard of care.  At his deposition I said, are you going 
to talk about 

 

THE 
COURT: So a guy comes in with a broken leg 
in the emergency room, the doctor fails to diagnose it.

 

MR. 
PICKERING:      
Right.

 

THE 
COURT: Your position is that the 
orthopedic surgeon who knows something about broken legs but has no ER 
experience cannot tell us what ought to be done in the face of the broken 
leg?

 

MR. 
PICKERING:      I 
think that's probably true.

 

THE 
COURT: I don't believe it.  I can't believe that the law is so 
irrational.

 

MR. 
PICKERING:      
Well, several cases sided along that way.

 

THE 
COURT: The question is, why do you need a 
medical expert testimony in the first place?  Case law says you need it because the 
jury can't speculate.  They're not 
doctors.  They need to be told what 
the standard of care is.  So when 
faced with a condition of is it viral or is it bacterial, what is the relevance 
of the distinction between an ER doctor and an infectious disease doctor?  I don't understand the 
difference.

 

MR. 
PICKERING:      
Well, Your Honor, the other argument 

 

THE 
COURT: You're trying to hold this ER 
doctor arguably up to standards involving infectious disease 
diagnoses.

 

MR. 
PICKERING:      
No.  We're trying to hold her 
to the standards of an emergency medicine specialist.

 

THE 
COURT: I assume that's lower than an 
infectious disease specialist.

 

MR. 
PICKERING:      I 
would assume so, too.

 

THE 
COURT: So someone who says that even 
though I know about the higher standard, she didn't even violate the higher 
standard.

 

MR. 
PICKERING:      
That may be, but he doesn't even know what the standard of emergency 
medicine is.  He doesn't do 
it.

 

[¶32]   After this exchange with the 
appellants' counsel, and after the appellees' counsel responded, the district 
court denied the appellants' motion to preclude Dr. Stevens' standard of care 
testimony.  Interestingly enough, 
the district court's decision was announced directly upon the heels of the 
following statement from the appellees' counsel:

 

I 
point out that Dr. Green, their infectious diseases expert, who hasn't practiced 
in the emergency room for years as an emergency room physician and has only very 
limited experience practicing in the emergency room, is going to offer standard 
of care opinions about Dr. Hrabal.

 

[¶33]   We are unable to discern from the 
record, for purposes of W.R.E. 702 and Wyo. Stat. Ann. § 1-12-601, any 
meaningful distinction between the qualifications of Dr. Green and the 
qualifications of Dr. Stevens.  Both 
are board-certified in internal medicine and infectious disease, both had some 
training in emergency medicine early in their careers, and both consult weekly 
on infectious disease cases in the emergency room.  While neither is board-certified in 
emergency medicine, the same is true of Dr. Hrabal.  The record contains evidence that both 
are sufficiently familiar with the standard of care in treating infectious 
disease in the emergency room that their testimony would assist the jury in 
determining facts in issue.

 

[¶34]   The district court's reason for 
sustaining the objection to Dr. Green's testimony was that Dr. Green would be 
violating his professional ethics by testifying because he did not have "recent 
and substantive experience in the field or line of practice" about which he 
intended to testify.  This 
justification fails for several reasons.  
First, the source of that ethical standard is not identified in the 
record.  Second, there was no 
testimony from any medical professional that such testimony would violate the 
ethical standard.  Third, Dr. 
Green's qualifications are such that he did have "recent and substantive 
experience in the field or line of practice."  Fourth, a medical expert's 
qualifications are determined under W.R.E. 702 and Wyo. Stat. Ann. § 1-12-601, 
not under some unidentified code of professional conduct.  And finally, it goes without saying that 
if Dr. Green's testimony was, indeed, violative of his code of ethics, so 
likewise would have been the testimony of Dr. Stevens.

 

[¶35]   We hold that it was an abuse of 
discretion for the district court to preclude Dr. Green's standard of care 
testimony.  No formal offer of proof 
was required to apprise the district court of the nature of the error and to 
preserve the issue for appeal because the substance of the precluded testimony 
was apparent from the circumstances.  
Further, the appellants were unfairly prejudiced by the ruling because 
the appellees' infectious disease expert was allowed to give standard of care 
testimony while the appellants' was not.  
This is especially troublesome in light of the jury's obvious difficulty 
in determining the standard of care by which they were to measure Dr. Hrabal's 
conduct.

 

Did 
the district court err in precluding the appellants' retained expert from 
offering opinions as to the standard of care for an infectious disease 
consultant?

 

[¶36]   Dr. Tredal, the appellants' 
emergency medicine expert, testified that the standard of care required Dr. 
Hrabal to consult with an infectious disease specialist:

 

Q.        Do 
you consult with infectious disease consultants in the emergency 
room?

 

A.        
Yes.

 

Q.        
Often?

 

A.        
Reasonably  relatively frequently, yes.

 

Q.        On 
cases like this?

 

A.        
Sure.

 

Q.        And 
in this presentation would that have been reasonable and 
appropriate?

 

A.        Yes, 
particularly if you weren't sure, if you hadn't been able to reasonably evaluate 
the patient yourself, sure.

 

In 
later following up on this line of inquiry with Dr. Green, the appellants' 
counsel attempted to establish what the infectious disease consultant would do 
when brought into the case:

 

Q.        Now, 
if you had been called to the emergency room that day for a consultation, would 
a reasonable and prudent infectious disease consultant have been required to 
rule out a differential diagnosis of primary or secondary bacterial 
infection?

 

A.        
Yes.  An infectious disease 
specialist would have done that.  
But I think it is also important to know that any medical physician 

 

MR. 
RUTLEDGE:      
Excuse me, Your Honor.  I'm 
going to object to the last part of the answer as being 
nonresponsive.

 

THE 
WITNESS:         
I'm sorry, Your Honor.

 

THE 
COURT: Restate your question.  Let's hear the answer one more 
time.

 

Q. 
(BY MR. PICKERING):    
Well, would an infectious disease consultant having been called to the 
emergency department be required to rule out in the differential diagnosis in 
Mr. Armstrong?

 

THE 
COURT: That calls for a yes or 
no.

 

THE 
WITNESS:         
Yes.

 

Q.  (BY MR. PICKERING):  And that would have been on February 28, 
'99?

 

A.        
That's correct.

 

Q.        And 
what would a reasonable infectious disease consultant, reasonable and prudent 
infectious disease consultant would have had to do to rule it out?  I mean what  tell me what they should 
have done?

 

MR. 
RUTLEDGE:      I 
don't know what the relevance is of what an infectious disease specialist would 
have done, Your Honor.

 

MR. 
PICKERING:      
It is relevant, Your Honor, because 

 

THE 
COURT: Just a minute.  Sustained.

 

MR. 
PICKERING:      
May I make an argument, please?

 

THE 
COURT: Just a minute.  Don't make arguments before the 
jury.

 

(Whereupon 
the following proceedings were had at the bench.)

 

THE 
COURT: Okay.  Lower your voice.

 

MR. 
PICKERING:      
Dr. Tredal testified that consultation would have been appropriate with 
an infectious disease consultant and required by the standard of care.  If that had happened and one had been 
called, then I think he's entitled to testify what would have 
occurred.

 

THE 
COURT: Kent?

 

MR. 
RUTLEDGE:      I 
don't think it makes any difference.  
In this case they did call an infectious disease specialist later on in 
the course of the case.  And we know 
what did occur.

 

THE 
COURT: I'm going to sustain the 
objection.

 

[¶37]   During the pretrial hearing upon 
the appellants' motion in limine directed at Dr. Stevens' standard of 
care testimony, the appellees argued that the question of causation and the 
question of standard of care were "inextricably interwoven."  That same concept leads to the 
conclusion that the district court erred in sustaining the appellees' objection 
to Dr. Green's testimony as to what an infectious disease consultant would do if 
called into the emergency room.  Dr. 
Tredal testified that the standard of care required Dr. Hrabal to consult with 
an infectious disease specialist.  
It would be impossible for the jury to decide whether or not Dr. Hrabal's 
failure to seek such consultation played any part in causing the appellants' 
damages without knowing what the infectious disease specialist would do.  If, for instance, the infectious disease 
experts agreed that a reasonable and prudent specialist in their field would do 
nothing more than what Dr. Hrabal had already done, then the failure to seek a 
consultation would have no causative effect.

 

[¶38]   The appellants did not make an 
offer of proof when the appellees' objection to Dr. Green's testimony was 
sustained.  In this Court, they 
contend that Dr. Green would have testified as follows in accordance with his 
disclosure:

 

[T]hat 
a reasonable and prudent infectious disease specialist "should have, at a 
minimum, ordered the tests identified above, including blood cultures with gram 
stains, if not already obtained.  It 
is likely that culture results would have been returned within 12 hours, if not 
earlier, and would have been positive.  
Gram stains could have provided earlier important information.  Mr. Armstrong should have then been 
immediately treated with IV antibiotics appropriate to the results of the gram 
stain and appropriate to a patient with his allergies."

 

[¶39]   Despite the district court's abuse 
of discretion in sustaining the appellees' motion, we will affirm the decision 
of the district court because there was no resultant prejudice to the 
appellants.  Dr. Green's testimony 
takes up 227 pages of trial transcript.  
During the course of his testimony, he answered numerous questions about 
the matters quoted above from his disclosure, and his testimony contained 
detailed information about what tests should have been performed when Armstrong 
entered the emergency room, what antibiotics he should have been given, and the 
likelihood that those antibiotics would have prevented the endocarditis.  The clear impact of Dr. Green's 
testimony was a statement of what an infectious disease specialist would have 
done had he or she been called in for a consultation.

 

Did 
the district court err in precluding evidence of appellee Hrabal's prior 
malpractice claims, the suspension of Hrabal's hospital privileges, and other 
matters affecting her credibility?

 

[¶40]   The appellants' complaint in this 
case alleged that Dr. Hrabal was negligent in her care of Armstrong.  During discovery, the appellants learned 
of a previous lawsuit against Dr. Hrabal, with similar allegations of 
negligence.  The appellants moved 
for leave to amend their complaint to add an allegation of negligent 
misrepresentation based upon Dr. Hrabal's failure to disclose this prior lawsuit 
to her employer, EMP, and to UMC.  
The appellees resisted this motion and moved in limine to preclude 
the admission of any evidence of the prior claim.

 

[¶41]   In the memorandum written in 
support of their motion in limine, the appellees argued first that the 
gist of a medical malpractice case is proof of the standard of care and proof 
that the defendant doctor violated that standard on a particular occasion.  Proof that the defendant has been sued 
before, even under similar circumstances, does not tend to make the existence of 
these necessary elements any more probable, so the evidence is irrelevant.  Second, the appellees argued that, even 
if such evidence is marginally relevant, it should be excluded under W.R.E. 403 
because its probative value is substantially outweighed by the danger of unfair 
prejudice, because its introduction would tend to mislead and confuse the jury, 
and because the trial would be unduly lengthened by the need for Dr. Hrabal to 
defend herself against the earlier accusations.4  Specifically, the appellees contended 
that introduction of evidence about the prior lawsuit undoubtedly would lead the 
jury to impermissible conclusionsthat Dr. Hrabal was a bad doctor because she 
had been sued before, that Dr. Hrabal violated the standard of care once, so she 
probably did so again in this case, and that the standard of care established by 
the expert witnesses in the first case was the standard of care in this case, 
even though those experts were not witnesses in this case.

 

[¶42]   The appellants' response to the 
motion in limine emphasized two points:  first, that the appellees' experts were 
not aware of this information when they formulated their opinions that Dr. 
Hrabal was qualified to work in the emergency department, and second, that Dr. 
Hrabal's withholding of the information was relevant to her credibility and was 
therefore admissible under W.R.E. 608(b).5  In a separate further response, the 
appellants contended that, if the appellees' expert, Dr. Rosen, was aware of the 
prior lawsuit when he rendered his opinion that Dr. Hrabal was qualified to 
serve in the emergency room, then the evidence of the prior lawsuit should be 
admissible during his cross-examination because the expert who testified against 
Dr. Hrabal in the prior case was Roger L. Barkin, M.D., who happens to be Dr. 
Rosen's primary professional collaborator.

 

[¶43]   The motion for leave to amend the 
complaint was heard on July 2, 2002, and was denied by an order filed August 8, 
2002.  The order does not indicate 
whether counsel also argued the motion in limine at that time, and no 
transcript of the hearing appears in the record.  The motion in limine was later 
mentioned during the final pretrial conference, at which time the district court 
indicated that it had already ruled on the motion.  The order granting the motion in 
limine, which order was filed on the first day of trial, gave no reasons for 
it  having been 
granted.

 

[¶44]   In their appellate brief, the 
appellants broaden their attack upon the district court's liminal order to 
include complaints that the district court also prevented them from 
cross-examining Dr. Hrabal or otherwise presenting evidence that Dr. Hrabal's 
privileges were suspended at a hospital in Georgia and that she was also sued in 
New Mexico.  As at trial, they 
contend that the order prevented them from effectively cross-examining Dr. 
Hrabal as to her credibility, and prevented them from effectively 
cross-examining Dr. Hrabal's expert witnesses as to the bases of their opinions, 
particularly as to what they knew about her "fund of knowledge" regarding 
infectious disease.  The appellants 
rely heavily on Dysthe, 2003 WY 20, ¶¶ 19-20, 63 P.3d at 
883-84 and Chrysler Corp. v. Todorovich, 
580 P.2d 1123, 1133 (Wyo. 1978), 
for the proposition that wide latitude should be allowed in the 
cross-examination of experts to determine the basis of an opinion.  They also cite several cases from other 
jurisdictions where cross-examination of experts about prior specific instances 
of conduct was allowed.6

 

[¶45]   In their appellate brief, the 
appellees support the district court's grant of their motion in limine 
with several arguments.  After 
reminding this Court that the standard of review is abuse of discretion, they 
contend (1) that the proscribed evidence was not relevant; (2) that its 
foundation was unreliable; (3) that it was an attempt to impeach with extrinsic 
evidence in violation of W.R.E. 608(b); (4) that it was unfairly prejudicial, 
confusing, and misleading in violation of W.R.E. 403; (5) that the appellants 
failed to preserve the issue for review because they did not make an appropriate 
offer of proof; and (6) that the cases relied upon by the appellants are 
inapposite because, unlike the expert witnesses in those cases, Dr. Hrabal did 
not offer expert testimony related to causation and the standard of 
care.

 

[¶46]   The appellees' focal position is 
that Dr. Hrabal's "fund of knowledge"her training and past experiencewas 
irrelevant because the issue was not whether she was qualified to treat 
Armstrong, the question was whether, at a particular point in time, she met the 
applicable standard of care.  The 
appellees point to Beavis ex rel. Beavis, 2001 WY 32, ¶¶ 11-16, 20 P.3d  
at 512-14, 
where we affirmed the district court's preclusion of qualification evidence.7

 

[¶47]   This Court is at a considerable 
disadvantage in attempting to review the district court's grant of the 
appellees' motion in limine because we do not know the district court's 
precise reasoning.  The record 
contains neither a transcript of the July 2, 2002, hearing during which the 
matter apparently was decided nor a decision letter.  The order, itself, is devoid of 
explanation.  The best we can do is 
to glean from the trial transcript a hint as to the basis for the district 
court's decision.  During the 
cross-examination of Dr. Hrabal, the following exchange 
occurred:

 

Q.        Have 
you failed to diagnosis sepsis in 14-year-old boys with 
meningococcemia?

 

A.        No, 
sir.

 

Q.        Do 
you know who Roger Barkin is?

 

A.        Yes, 
sir.

 

Q.        Is he 
co-author of the Rosen book?

 

A.        
Correct.

 

Q.        Has 
he ever been critical of you for not diagnosing meningococcemia in a 14-year-old 
boy?

 

A.        No, 
sir.

 

Q.        Have 
you ever read a written affidavit of his where he was critical of you for not 
diagnosing meningococcemia in a 14-year-old boy?

 

A.        No, 
sir.

 

MR. 
RUTLEDGE:      
Your Honor, I would object on the grounds of relevance to 
this line of questioning.  We're not 
talking about a 14-year-old boy.  We 
don't have Dr. Barkin here to testify.

 

THE 
COURT: Sustained, sustained, Mr. 
Pickering.

 

. 
. .

 

MR. 
PICKERING:      
Your Honor, I think this is important for two reasons and relevant.  One is, she was served with a copy of 
the affidavit of Dr. Barkin; and he was critical of her care.  So it directly goes to whether she's an 
honest and credible witness.

 

THE 
COURT: Okay.  Thank you.

 

MR. 
BAILEY:  It also goes to her clinical 

 

MR. 
PICKERING:      
Her fund of knowledge and theories.  
The reasons why I think it ought to be allowed 

 

THE 
COURT: I'm at the verge right now, Mr. 
Pickering, of declaring a mistrial if this thing continues, you know.  You don't open the door by putting an 
adverse witness on the stand and asking all of these questions.  I've given you quite a bit of leeway, 
but with the understanding that you're not going to violate my order in 
limine.  You're the one that is 
forcing the issue on this doctor.  I 
don't believe that this is the way doors are opened in my 
opinion.

 

Even 
if it is opened, Rule 403 prevents you from doing this.  If you were going to do this, 
from day one then we would have to have this other case tried, this other 
issue of this youngster tried in this case.  It's a complete surprise in a 
sense.  Now, do you want to have it 
this way, or do you want me to declare a mistrial?  I will declare a 
mistrial.

 

(Emphasis 
added.)

 

[¶48]   From the entire record, we can 
assume that the district court sustained the appellees' relevance objection on 
the ground that Dr. Hrabal's prior experience and qualifications were not 
relevant to the question of whether she met the standard of care in regard to 
Armstrong.  In context, the district 
court's reference to W.R.E. 403 suggests an additional concern with either the 
danger of confusing the issues or the danger of undue delay, or both.8  We cannot say that the district court 
abused its discretion in reaching these conclusions, and we note that the 
relevancy consideration is consistent with Beavis ex rel. Beavis, 2001 WY 
32, ¶¶ 11-16, 20 P.3d  at 512-14.  Evidentiary decisions of this nature are 
left to the sound discretion of the trial court and will not be overturned where 
the record reveals a legitimate basis for the ruling.  Dysthe, 2003 WY 20, ¶ 16, 63 P.3d  
at 883 (quoting Lancaster, 2002 WY 45, ¶ 11, 43 P.3d at 87).  Here, the district court reasonably 
could have concluded that any probative value of the earlier alleged incident 
was outweighed by the spectre of a "trial within a trial" as the appellants 
tried to prove Dr. Hrabal's negligence in that incident.  We affirm the district court's rulings 
on the motion in limine and the objection.

 

Did 
the district court err in denying the appellants' motion for leave to file an 
amended complaint to allege negligent 
misrepresentation?

 

[¶49]   The Complaint in this case was 
filed on February 22, 2001.  The 
jury trial began on August 19, 2002.  
Less than two months before trial, and more than sixteen months after the 
Complaint was filed, the appellants filed a Motion for Leave to File First 
Amended Complaint.  Both the motion 
and the proposed amended complaint attached to it raised a second claim against 
Dr. Hrabal characterized as "negligent misrepresentation."  The focus of this new claim was Dr. 
Hrabal's alleged failure to disclose to her employer, EMP, a prior lawsuit 
against her for failure properly to diagnose a progressive bacterial 
infection.

 

[¶50]   Although the appellants referred in 
both their district court motion and their appellate brief to "negligent 
misrepresentation," and although they cited in both courts to Husman, Inc. v. 
Triton Coal Co., 809 P.2d 796 (Wyo. 1991), 
which is a negligent misrepresentation case, their specific reference to 
Restatement (Second) of Torts § 551 (1977) suggests that their proposed claim was 
actually based in nondisclosure.9  See Birt v. Wells Fargo Home Mortg., 
Inc., 2003 WY 102, ¶ 43, 75 P.3d 640, 656-57 (Wyo. 2003).  To date, Wyoming has not adopted the 
tort of nondisclosure, although neither has the tort directly been 
rejected.  See Lee v. LPP Mortg. 
Ltd., 2003 WY 92, ¶ 33, 74 P.3d 152, 163-64 (Wyo. 2003).

 

[¶51]   In a legal memorandum filed in the 
district court in support of their motion, the appellants "shrugged off" both 
the distinction between the two torts and the fact that this Court had never 
adopted nondisclosure with the following comments:

 

Defendant 
Hrabal agrees that, if faced with the question, the Supreme Court of Wyoming 
would adopt the Restatement of Torts (Second) § 551.  In any event, Dr. Hrabal undertook a 
duty to supply truthful and accurate facts as part of the employment screening 
process and as part of her application for temporary and permanent UMC medical 
privileges.

 

Throughout 
their appellate brief, the appellants continue to blur the distinction between 
the torts by referring alternatively to Dr. Hrabal's alleged misconduct as a 
failure to disclose or a misrepresentation.  Furthermore, the appellants presented no 
legal or factual argument suggesting why this Court should adopt Restatement 
(Second) of Torts, supra, § 551.

 

[¶52]   The appellees presented before the 
district court and in this Court several contentions in opposition to the 
appellants' motion.  First, citing 
Beaudoin, 492 P.2d  at 970, 
they argued that the proposed amendment was futile because it failed to state a 
claim upon which relief can be granted, inasmuch as EMP is the party to whom any 
duty of disclosure would be owed.  
Further, citing Restatement (Second) of Torts, supra, § 551, cmt. 
f, 
the appellees contend that Dr. Hrabal owed no such duty to EMP, because their 
employee-employer relationship was not a fiduciary relationship as contemplated 
by Restatement (Second) of Torts, supra, § 551.10  Finally, the appellees argued that the 
prior lawsuit was not a fact basic to the transaction and that, therefore, any 
failure to disclose that lawsuit's existence could not form the basis for a 
cause of action under Restatement (Second) of Torts, supra, § 
551.11

 

[¶53]   The appellees' second 
counter-argument is that the motion for leave to amend was untimely.  Noting that the appellants' counsel had 
known of the prior lawsuit at least since October 29, 2001, noting that 
additional discovery would have been required if the motion was granted, and 
noting that no experts had been designated to testify about the matter, the 
appellees argued that adding a new cause of action would have "inject[ed] a host 
of new factual and legal issues into this litigation at this late 
date."

 

[¶54]   Next, the appellees argued that the 
motion to amend was made for an improper purpose in that it was made to enable 
the appellants to suggest to the jury that Dr. Hrabal is a "bad doctor" who 
previously breached the standard of care so she must have done so again, and to 
attempt to establish the standard of care in the present case through 
incompetent expert testimony.  This 
argument, of course, complemented the appellees' position in regard to their own 
motion in limine.

 

[¶55]   The Order Denying Plaintiffs' 
Motion for Leave to File First Amended Complaint was filed on August 8, 2002, 
only a few days before trial.  The 
order indicates that the motion was heard on July 2, 2002.  As with the appellees' motion in 
limine, the record contains neither a hearing transcript nor a decision 
letter, and the order, itself, contains no justification for its 
conclusion.  Thus, we are left again 
to surmise as to the reasons for the district court's 
ruling.

 

[¶56]   "This court must affirm the 
district court's action on appeal if it is sustainable on any legal ground 
appearing in the record . . .."  
Heilig v. Wyoming Game and Fish Com'n, 2003 WY 27, ¶ 8, 64 P.3d 734, 737 (Wyo. 2003).  This rule holds true even where the 
district court has not articulated on the record the reasons for its 
action:

 

            
This court must affirm the district court's action on appeal if the 
judgment is sustainable on any legal ground appearing in the record.  Deisch v. Jay, 790 P.2d 1273, 
1278 (Wyo. 1990).  Although the 
orders denying the motions to intervene in these cases do not set out the 
grounds the district court specifically relied upon, we conclude sufficient 
bases exist in the records to warrant denial of the motions to 
intervene.

 

Masinter 
v. Markstein, 2002 
WY 64, ¶ 8, 45 P.3d 237, 241 (Wyo. 2002).

 

[¶57]   We will affirm the district court's 
denial of the appellants' motion for leave to amend their complaint.  The appellants have not adequately 
distinguished between the torts of negligent misrepresentation and 
nondisclosure, they have not adequately advocated for the adoption of the latter 
tort, and they have not adequately supported their contention that, under either 
tort, the alleged tortfeasor owes a duty to a third person not party to the 
transaction.  Furthermore, the 
record supports denial of the motion on the ground that it was 
untimely.

 

CONCLUSION

 

[¶58]   The district court did not abuse 
its discretion in precluding the appellants' retained emergency medicine expert 
from offering opinions as to the standard of care for treatment, or in 
precluding the appellants' retained expert from offering opinions as to the 
standard of care for an infectious disease consultant, or in precluding evidence 
of Dr. Hrabal's prior malpractice claim, or in denying the appellants' motion to 
amend their complaint.  Nor was it 
an abuse of discretion to deny the motion for a new trial, where that motion 
simply reiterated earlier arguments.  
It was error, however, for the district court to preclude Dr. Green's 
standard of care testimony while allowing Dr. Stevens' similar testimony.  And we cannot find such error to have 
been harmless, given the jury's stated confusion as to the standard of 
care.

 

[¶59]   We affirm in part, reverse in part, 
and remand to the district court for a new trial.

 

LEHMAN, 
Justice, dissenting.

 

[¶60]   I 
respectfully dissent.  I agree with 
the portions of the majority's opinion that affirm the district court's 
decisions and find no abuse of discretion.  
I likewise agree that it was improper for the district court to exclude 
Dr. Green's standard-of-care testimony.  
As the majority discussed in ¶33, there does not appear to be a 
meaningful distinction between the qualifications of Dr. Green and Dr. Stevens, 
and both doctors are sufficiently familiar with the standard of care that their 
testimony would assist the jury in determining the facts at issue.  However, I would find that the district 
court's error was not prejudicial to the appellants and would therefore affirm 
this case in its entirety.  

 

[¶61]   An error warrants reversal only 
when it is prejudicial and it affects the appellants' substantial rights. 
Robinson v. Hamblin, 914 P.2d 152, 155 (Wyo. 1996) (quoting  Candelaria v. State, 895 P.2d 434, 439-40 (Wyo. 1995)).  
Generally, to be prejudicial an error must "cause a miscarriage of 
justice or result in damage to the integrity, reputation, and fairness of the 
judicial process . . . [or possess] a clear capacity to bring about an 
unjust result."  Natural Gas 
Processing Co. v. Hull, 886 P.2d 1181, 1188 (Wyo. 1994) (citations 
omitted).  In this case, I cannot 
conclude that the error caused a miscarriage of justice or compromised the 
fairness of the proceedings, and I consequently do not believe the error 
requires reversal.

 

[¶62]   My review of Dr. Stevens' testimony 
shows that, although it was determined at the pretrial hearing that Dr. Stevens 
could testify about the standard of care, he never expressly testified on that 
subject.  Dr. Steven's testimony, as 
a whole, centered on causation.  He 
mainly testified as to when he believed Mr. Armstrong contracted the infection 
and why he believed that.  Dr. 
Stevens' conclusions in this area were based on the history of the events from 
February 28 to March 3.  As a 
result, Dr. Stevens discussed some of the tests performed and the care given to 
Mr. Armstrong during this time.  
Because such a discussion is intertwined to some extent with the standard 
of care, Dr. Stevens' testimony certainly danced around the standard of care 
topic.  However, the ultimate point 
of Dr. Stevens' testimony was that of causation.  The defendant did not elicit standard of 
care opinions from Dr. Stevens, and it appears he never expressly offered such 
opinions.    

 

[¶63]   A review of Dr. Green's testimony 
shows that although the district court ruled that Dr. Green could not testify 
about the standard of care, he did continue to testify about his conclusions 
regarding Mr. Armstrong's infection.  
Similar to Dr. Stevens, Dr. Green did not expressly offer a standard of 
care opinion.  Nevertheless, Dr. 
Green did offer extensive testimony.  
Included in this testimony was his opinion as to whether Mr. Armstrong 
had the infection on February 28 and why he concluded this.  Dr. Green's testimony in this area 
similarly included elements of the standard of care but to a much greater extent 
than the testimony of Dr. Stevens.  
In fact, Dr. Green testified about what questions should have been asked 
of Mr. Armstrong, about what symptoms should have raised a red flag that there 
was an infection, that a blood test would have shown abnormalities, that 
antibiotics would have helped, and that Dr. Hrabal had the "golden moment" to 
prevent Mr. Armstrong's infection.  
While this testimony was not an express opinion on the standard of care 
either, it was significantly closer to such testimony than that of Dr. 
Stevens.  I would consider this 
testimony, combined with the testimony of Dr. Tredal, sufficient to counter the 
testimony offered by Dr. Rosen, the appellee's standard of care expert.   

 

[¶64]   Thus, considering the trial as a 
whole, I cannot conclude that there was a miscarriage of justice or that the 
appellants were denied a fair trial due to the district court's error.  I would therefore hold that the district 
court's error was not prejudicial to the appellants.  As a result, I would affirm this case in 
its entirety.  

 

 

FOOTNOTES

 

  1Appellee EMP has conceded that 
appellee Hrabal was its employee and that she was acting within the course and 
scope of that employment during all relevant times.

 

  2No issue is presented in this appeal 
as to how this question was answered.

 

  3See also W.R.E. 611(a), where 
the trial court is instructed to "exercise reasonable control over the mode and 
order of interrogating witnesses . . . so as to . . . avoid needless consumption 
of time . . .."

 

  4W.R.E. 403 states:  "Although relevant, evidence may be 
excluded if its probative value is substantially outweighed by the danger of 
unfair prejudice, confusion of the issues, or misleading the jury, or by 
considerations of undue delay, waste of time, or needless presentation of 
cumulative evidence."

 

  5W.R.E. 608(b) states, in pertinent 
part:

 

Specific 
instances of the conduct of a witness, for the purpose of attacking or 
supporting his credibility, other than conviction of crime as provided in Rule 
609, may not be proved by extrinsic evidence.  They may, however, in the discretion of 
the court, if probative of truthfulness or untruthfulness, be inquired into on 
cross-examination of the witness (1) concerning his character for truthfulness 
or untruthfulness, or (2) concerning the character for truthfulness or 
untruthfulness of another witness as to which character the witness being 
cross-examined has testified.

 

  6Navarro de Cosme v. Hospital 
Pavia, 922 F.2d 926, 932-33 (1st Cir. 1991) (evidence of prior malpractice claims and 
suspension of license admissible as relevant to expert witness' credibility); 
Hock v. New York Life Ins. Co., 876 P.2d 1242, 1257 (Colo. 
1994) (evidence of prior lawsuit against expert 
witness alleging inadequate testing methods admissible as relevant to witness' 
credibility and accuracy of his testimony); Raybeck v. Danbury Orthopedic 
Associates, P.C., 72 Conn.App. 359, 805 A.2d 130, 141-42 (2002) (evidence that expert witness treated his 
own wife's wrist fracture with cast admissible where he asserted the standard of 
care was to use pins); Hayes v. Manchester Memorial Hosp., 38 Conn.App. 
471, 661 A.2d 123, 125 (1995) (evidence of similar prior lawsuit 
against expert witness admissible as relevant to credibility, motive and bias); 
Underhill v. Stephensen, 756 S.W.2d 459, 461 (Ky. 1988) (evidence of prior lawsuit against expert 
witness admissible as relevant to bias); Irish v. Gimbel, 1997 ME 50, 691 A.2d 664, 674 (Mass. 1997) (evidence of prior lawsuit admissible to 
impeach expert witness as to interest or bias); Wischmeyer v. Schanz, 449 
Mich. 469, 536 N.W.2d 760, 764-65 (1995) (evidence of prior "botched" surgeries 
performed by expert witness admissible to show witness' lack of competency); 
Willoughby v. Wilkins, 65 N.C.App. 626, 310 S.E.2d 90, 97-98 
(1983) (evidence of prior lawsuit against expert 
witness admissible as relevant to bias or interest).

 

  7Beavis involved an injection 
of allergy medication.  We held 
that, where the standard of care for giving such an injection is the same for 
all medical professionals, the district court did not abuse its discretion in 
excluding evidence of the qualifications of the medical assistant who 
administered the injection.  
Beavis ex rel. Beavis, 2001 WY 32, ¶ 15, 20 P.3d  at 
514.

 

  8The comment that "[w]e don't have 
Dr. Barkin here to testify[]," also indicates the district court had concerns 
with hearsay testimony as to this extrinsic issue.  In its Order Denying Motion for New 
Trial, the district court emphasized W.R.E. 403 in finding evidence of the prior 
lawsuit vastly more prejudicial than probative, and in commenting on the danger 
of a "full-blown trial" of the Georgia case within the present 
trial.

 

  9Restatement (Second) of Torts, 
supra, § 551 at 119 reads as follows:

 

(1)        One 
who fails to disclose to another a fact that he knows may justifiably induce the 
other to act or refrain from acting in a business transaction is subject to the 
same liability to the other as though he had represented the nonexistence of the 
matter that he has failed to disclose, if, but only if, he is under a duty to 
the other to exercise reasonable care to disclose the matter in 
question.

 

(2)        One 
party to a business transaction is under a duty to exercise reasonable care to 
disclose to the other before the transaction is 
consummated,

 

(a)        
matters known to him that the other is entitled to know because of a 
fiduciary or other similar relation of trust and confidence between them;  and

 

(b)        
matters known to him that he knows to be necessary to prevent his partial 
or ambiguous statement of the facts from being misleading;  and

 

(c)        
subsequently acquired information that he knows will make untrue or 
misleading a previous representation that when made was true or believed to be 
so;  and

 

(d)        the 
falsity of a representation not made with the expectation that it would be acted 
upon, if he subsequently learns that the other is about to act in reliance upon 
it in a transaction with him;  
and

 

(e)        facts 
basic to the transaction, if he knows that the other is about to enter into it 
under a mistake as to them, and that the other, because of the relationship 
between them, the customs of the trade or other objective circumstances, would 
reasonably expect a disclosure of those facts.

 

Restatement 
(Second) of Torts, supra, § 552 at 126-27 reads as 
follows:

 

(1)        One 
who, in the course of his business, profession or employment, or in any other 
transaction in which he has a pecuniary interest, supplies false information for 
the guidance of others in their business transactions, is subject to liability 
for pecuniary loss caused to them by their justifiable reliance upon the 
information, if he fails to exercise reasonable care or competence in obtaining 
or communicating the information.

 

(2)        
Except as stated in Subsection (3), the liability stated in Subsection 
(1) is limited to loss suffered

 

(a)        by 
the person or one of a limited group of persons for whose benefit and guidance 
he intends to supply the information or knows that the recipient intends to 
supply it;  
and

 

(b)        
through reliance upon it in a transaction that he intends the information 
to influence or knows that the recipient so intends or in a substantially 
similar transaction.

 

(3)        The 
liability of one who is under a public duty to give the information extends to 
loss suffered by any of the class of persons for whose benefit the duty is 
created, in any of the transactions in which it is intended to protect 
them.

 

  10Restatement (Second) of Torts, 
supra, § 551, cmt. f at 121 reads as follows:

 

Other 
relations of trust and confidence [in addition to trustees, agents and corporate 
directors] include those of the executor of an estate and its beneficiary, a 
bank and an investing depositor, and those of physician and patient, attorney 
and client, priest and parishioner, partners, tenants in common and guardian and 
ward.  Members of the same family 
normally stand in a fiduciary relation to one another, although it is of course 
obvious that the fact that two men are brothers does not establish relation of 
trust and confidence when they have become estranged and have not spoken to one 
another for many years.  In 
addition, certain types of contracts, such as those of suretyship or guaranty, 
insurance and joint adventure, are recognized as creating in themselves a 
confidential relation and hence as requiring the utmost good faith and full and 
fair disclosure of all material facts.

 

  11Restatement (Second) of Torts, 
supra, § 551, cmt. j at 123 reads as follows:

 

"Facts 
basic to the transaction."  The 
word "basic" is used in this Clause in the same sense in which it is used in 
Comment c under § 16 of the Restatement of Restitution.  A basic fact is a fact that is assumed 
by the parties as a basis for the transaction itself.  It is a fact that goes to the basis, or 
essence, of the transaction, and is an important part of the substance of what 
is bargained for or dealt with.  
Other facts may serve as important and persuasive inducements to enter 
into the transaction, but not go to its essence.  These facts may be material, but they 
are not basic.  If the parties 
expressly or impliedly place the risk as to the existence of a fact on one party 
or if the law places it there by custom or otherwise the other party has no duty 
of disclosure.  (Compare 
Restatement, Second, Contracts § 296).