Title: Dagner v. Anderson

State: virginia

Issuer: Virginia Supreme Court

Document:

Present:  Hassell, C.J., Keenan, Koontz, Kinser, Lemons, and 
Agee, JJ., and Russell, S.J. 
 
KEISHA DAGNER, ADMINISTRATRIX OF THE 
 ESTATE OF CAROLINE DAGNER, DECEASED 
 
 
                                OPINION BY 
v.  Record No. 062134 
JUSTICE LAWRENCE L. KOONTZ, JR. 
 
 
 
November 2, 2007 
CHARLES ANDERSON, M.D. 
 
FROM THE CIRCUIT COURT OF PRINCE EDWARD COUNTY 
Richard S. Blanton, Judge 
 
 
This appeal arises from a jury verdict in favor of an 
emergency room physician in a wrongful death medical 
malpractice action.  The dispositive issue presented is 
whether the circuit court erred in permitting the jury to 
consider the testimony of the physician’s expert medical 
witness who had expressed an opinion that an alcohol 
withdrawal seizure rather than a diabetic seizure was the 
cause of the decedent’s injury and death.  To resolve that 
issue, we consider whether such testimony was relevant to the 
question of the physician’s alleged negligence in discharging 
the decedent from the emergency department of the hospital 
where she was being treated, and if so, whether the expert was 
qualified to express that opinion. 
BACKGROUND 
Because our consideration of this appeal is limited to 
discrete questions concerning the relevance and admissibility 
of expert witness testimony, we need recite only those facts 
 
2
necessary to our resolution of the appeal.  See, e.g., Budd v. 
Punyanitya, 273 Va. 583, 587, 643 S.E.2d 180, 181 (2007); 
Molchon v. Tyler, 262 Va. 175, 180, 546 S.E.2d 691, 695 
(2001).  We will recite the evidence in the light most 
favorable to the defendant, Charles C. Anderson, M.D., the 
prevailing party in the circuit court.  See, e.g., Smith v. 
Irving, 268 Va. 496, 498, 604 S.E.2d 62, 63 (2004). 
On the evening of September 22, 2000, Caroline A. Dagner 
(Dagner), a 52-year-old insulin-dependant diabetic, was 
transported to the emergency department of Southside Community 
Hospital in Farmville after being found unconscious in her 
apartment by her adult daughter, Keisha R. Dagner.  It is not 
disputed that Dagner had taken her daily doses of insulin, had 
not eaten any solid food, and had consumed a considerable 
quantity of beer.1  While en route to the hospital, emergency 
                     
1 There is no dispute among the parties in this case that 
insulin is a naturally occurring substance normally produced 
in the pancreas that triggers the conversion of glucose in the 
bloodstream into glycogen, which is stored in the liver and 
muscle tissue, in order to reduce blood sugar levels.  Dagner 
suffered from a form of diabetes mellitus, commonly referred 
to as diabetes, a chronic condition in which the body fails to 
produce adequate amounts of insulin to properly regulate blood 
sugar levels.  Supplemental insulin, taken orally or by 
injections, is a standard treatment for diabetes.  If a 
diabetic patient takes an insulin supplement, but does not 
consume food, the patient’s blood sugar level will fall 
causing a hypoglycemic episode in which the patient may lose 
consciousness.  Consumption of alcoholic beverages can 
exacerbate the effect of a hypoglycemic episode. 
 
3
medical personnel determined that Dagner was likely suffering 
from hypoglycemia, that is, an abnormally low blood sugar 
level, and gave Dagner an injection of glucagon in an effort 
to stabilize her condition.2  Dagner responded positively to 
the glucagon treatment and began to regain consciousness. 
Upon arrival at the emergency department of the hospital 
at 8:35 p.m., Dagner was evaluated by Kim Brown, R.N., a 
triage nurse, and was then examined by Dr. Anderson.  Both 
Nurse Brown and Dr. Anderson concurred that Dagner’s condition 
was the result of diabetic hypoglycemia.  They also detected a 
smell of alcohol on Dagner’s person and suspected that she 
might be intoxicated, a factor which would interfere with her 
body’s ability to recover from the hypoglycemic episode.  Dr. 
Anderson ordered various laboratory tests to be conducted 
including a determination of Dagner’s blood alcohol level  
(BAL).  He further directed that she be given a meal, and that 
she receive 50 milligrams of dextrose.3 
                     
2 There is no dispute among the parties in this case that 
glucagon is a naturally occurring substance in the body that 
triggers the release of stored glycogen into the bloodstream 
and the production of glucose in the liver, thus raising blood 
sugar level.  An intramuscular injection of glucagon is a 
standard treatment for diabetic hypoglycemia when the patient 
is unable to take glucose orally. 
3 There is no dispute among the parties in this case that 
dextrose is a form of glucose and is frequently given to 
diabetic patients orally or by injection following a 
 
 
4
While Dagner ate the meal, Dr. Anderson spoke with her 
about her routine for managing her diabetes.  During this 
conversation, Dagner, who then appeared to be fully alert and 
responding normally, conceded that she had in the past 
encountered complications in managing her blood sugar level 
when consuming alcoholic beverages.  Dr. Anderson warned her 
that she “should never drink [alcohol] again.”  After the 
laboratory tests were completed, which among other things 
showed that Dagner had a BAL of .24, Dr. Anderson discussed a 
management plan with Dagner, directing her to return home, 
measure her blood sugar level, eat a snack, and rest.  He then 
discharged Dagner from the emergency department shortly after 
10:00 p.m. 
At Dagner’s request, Nurse Brown called Keisha Dagner to 
advise her that Dagner would be discharged from the hospital 
and needed to be taken home.  Keisha Dagner advised Nurse 
Brown that she would be unable to leave work and come to the 
hospital until the next morning.  Dr. Anderson was not advised 
that Dagner would not be able to return home and follow the 
management plan as he had advised her. 
                                                                
hypoglycemic episode in order to speed the natural recovery to 
a normal blood sugar level. 
 
 
5
Dagner remained in the waiting area of the emergency 
department, unattended, for over eight hours after she was 
discharged by Dr. Anderson.  When hospital personnel next 
checked Dagner on the morning of September 23, she had a blood 
sugar level of 17 and was comatose and unresponsive.4  Dagner 
was admitted to the hospital and died on December 20, 2000 
without regaining consciousness. 
On September 18, 2002, Keisha Dagner, who had qualified 
as administratrix of her mother’s estate, filed a motion for 
judgment in the Circuit Court of Prince Edward County alleging 
that Dagner’s death was caused by the medically negligent acts 
of Dr. Anderson and Southside Community Hospital.  The action 
named Dr. Anderson, his employer Emergency Physicians of 
Farmville, P.C. (collectively, “Dr. Anderson”), and Southside 
Community Hospital as defendants.5  Dr. Anderson responded to 
the action by asserting, among other things, that his 
treatment of Dagner, and specifically his decision to 
discharge her, was not a breach of the applicable standard of 
care. 
                     
4 Dr. Anderson does not contest that when a person’s blood 
sugar level declines below 20 milligrams per deciliter of 
blood and remains so for a prolonged period of time that brain 
damage and death are the likely result. 
5 The estate subsequently accepted a settlement from the 
hospital, which was dismissed from the action. 
 
6
At trial, during the opening statement by counsel for Dr. 
Anderson, a computerized slideshow media presentation was 
shown to the jury that outlined Dr. Anderson’s anticipated 
defense and included references to an alcohol withdrawal 
syndrome (AWS) seizure as the cause of Dagner’s coma, brain 
injury, and death.  The substance of Dr. Anderson’s defense as 
outlined in this presentation was that his discharge of Dagner 
from the emergency department did not violate the standard of 
medical care because he could not have known that Dagner was 
subject to seizures as a result of AWS, and that it was just 
such a seizure that caused her coma, brain injury, and death. 
During their direct testimony, counsel for the estate 
asked its expert witnesses, Dean Williams, M.D. and Anthony 
McCall, M.D., their opinions as to whether Dagner’s coma, 
brain injury, and death were the result of an AWS seizure, 
rather than a diabetic seizure.  Both experts opined that 
there was no evidence to support a diagnosis that Dagner had 
suffered an AWS seizure.  Both experts further opined that Dr. 
Anderson had failed to comply with the standard of care that 
required him to protect Dagner from the consequences of her 
low blood sugar in combination with her intoxication from 
alcohol in making the decision to discharge Dagner from the 
emergency department.  Dr. McCall explained that the 
combination of insulin and alcohol can be a “lethal 
 
7
combination” for a diabetic such as Dagner.  In general terms, 
insulin lowers the blood sugar level and excessive alcohol in 
the bloodstream prevents the blood sugar from being stabilized 
because alcohol prevents the liver from producing more sugar, 
and the brain requires a constant supply of sugar to remain 
healthy. 
In voir dire by Dr. Anderson’s counsel, David L. Shank, 
M.D., who was Dr. Anderson’s only expert witness, testified 
that he was “board certified in emergency medicine” and that 
he had “been . . . in the practice of full time emergency 
medicine since [1980].”  Dr. Shank further testified that he 
was “familiar with the standard of care for the care and 
treatment of diabetes and hypoglycemia.”  Dr. Shank agreed 
that he was “familiar with something called alcohol withdrawal 
seizure” and that he would be concerned about the occurrence 
of such a seizure “[i]f someone who has been consuming 
significant alcohol stops consuming alcohol.”  In the course 
of his practice of emergency medicine, Dr. Shank stated that 
“[i]t wouldn’t be unusual . . . to see 5, 10, maybe 15 of 
those patients [suffering AWS seizures] in a year’s time.”  
Over the objection of the estate, the circuit court qualified 
Dr. Shank “as an expert on the standard of care for an 
emergency room physician or emergency medicine physician” and, 
 
8
after being prompted by counsel for Dr. Anderson, added that 
Dr. Shank was “qualified to speak as to causation.” 
During direct examination, counsel for Dr. Anderson asked 
Dr. Shank to “explain what caused [Dagner’s] unresponsiveness” 
when she was found in the waiting area of the emergency 
department on September 23, 2000.  Dr. Shank stated that 
“[t]here are several things that we have to think about that 
could be the cause,” but expressed the opinion that “the most 
likely cause was that she had an alcoholic withdrawal 
seizure.”  Dr. Shank further opined that Dagner’s alcohol 
withdrawal seizure was an “unforeseeable, unpredictable event” 
based on everything Dr. Anderson knew during his treatment of 
Dagner and at the time he discharged her from the emergency 
department. 
During cross-examination, Dr. Shank conceded that only 
three to five percent of the people who have alcohol 
withdrawal also have seizures, and that such seizures are 
“readily treatable.”  Dr. Shank acknowledged that if Dagner 
had been admitted to the hospital and been observed he would 
have expected her to survive.  Dr. Shank further acknowledged 
that Dagner’s insulin level “was a significant factor” in 
causing her brain injury following her seizure, that the 
seizure could have had a “multifactorial cause,” and that he 
was not an expert in such cases.  Dr. Shank stated that while 
 
9
he did not “have a neurologist’s perspective” on the causation 
of seizures, he maintained that he had “a reasonable 
physician’s opinion since I’m in emergency medicine and see 
seizures.”  At the conclusion of his testimony, the estate 
moved to strike Dr. Shank’s testimony as to causation on the 
ground that he was not qualified to offer an opinion on a 
seizure with multifactorial causes.  The circuit court 
overruled the motion. 
At the conclusion of all the evidence, the jury returned 
its verdict in favor of Dr. Anderson, and the circuit court 
entered judgment in accord with that verdict.  We awarded the 
estate this appeal. 
DISCUSSION 
The estate contends that the circuit court erred in 
allowing the jury to consider evidence that Dagner’s brain 
injury and subsequent death were caused by an AWS seizure.  
Specifically, the estate contends that the circuit court 
should not have permitted any testimony concerning AWS because 
it was not relevant to the standard of care required of Dr. 
Anderson in treating Dagner for hypoglycemia and in making the 
determination to discharge her from the emergency department.  
The estate also contends that evidence of alcohol use by 
Dagner was highly prejudicial and outweighed its probative 
value, if any.  Even if the possibility that Dagner suffered 
 
10
an AWS seizure was relevant and admissible, the estate further 
contends that Dr. Shank’s opinion that Dagner had suffered 
such a seizure was inadmissible because Dr. Shank lacked the 
necessary qualifications to express that opinion. 
Well established principles govern our consideration of 
the issues raised in this appeal.  “A trial court’s exercise 
of its discretion in determining whether to admit or exclude 
evidence will not be overturned on appeal absent evidence that 
the trial court abused that discretion.”  May v. Caruso, 264 
Va. 358, 362, 568 S.E.2d 690, 692 (2002) (citing John v. Im, 
263 Va. 315, 320, 559 S.E.2d 694, 696 (2002)).  Likewise, 
“whether a witness is qualified to testify as an expert is 
‘largely within the sound discretion of the trial court.’ ”  
Perdieu v. Blackstone Family Practice Center, Inc., 264 Va. 
408, 418, 568 S.E.2d 703, 709 (2002) (quoting Noll v. Rahal, 
219 Va. 795, 800, 250 S.E.2d 741, 744 (1979)); see also 
Swersky v. Higgins, 194 Va. 983, 985, 76 S.E.2d 200, 202 
(1953). 
The issue before the jury in this case was whether Dr. 
Anderson’s treatment of Dagner, and specifically his decision 
to discharge her from the emergency department rather than to 
delay discharge for further observation of her or to admit her 
to the hospital, fell within the applicable standard of care 
for a physician providing treatment to a patient suffering 
 
11
from diabetes-related hypoglycemia in an emergency department 
setting.  In this context, evidence as to the actual cause of 
Dagner’s subsequent coma, brain injury, and death was clearly 
relevant to determining whether that standard of care was 
violated.  Dagner’s estate had the burden of showing that a 
reasonable emergency care physician, under the factual 
circumstances known to Dr. Anderson, would have recognized 
that Dagner’s condition might worsen with respect to the 
actual cause of her subsequent brain injury and death, whether 
from a diabetes-related trauma or some other cause.  If the 
cause of her brain injury and death resulted from, or was 
contributed to by, an AWS seizure as the defense maintained, 
then the estate would have been required to show that Dr. 
Anderson should have foreseen that possibility prior to 
discharging Dagner.  Accordingly, we hold that the circuit 
court did not err in overruling the estate’s motion to exclude 
evidence that Dagner may have suffered an AWS seizure.6 
                     
6 The estate’s reliance on Hemming v. Hutchinson, 221 Va. 
1143, 1146, 277 S.E.2d 230, 232-33 (1981) and DeWald v. King, 
233 Va. 140, 146, 354 S.E.2d 60, 63 (1987), for the 
proposition that evidence of Dagner’s use or abuse of alcohol 
should have been excluded because the prejudice it was likely 
to engender in the jury outweighed its probative value is 
misplaced.  As those cases make clear, evidence of alcohol use 
or abuse is not admissible unless it is relevant to an issue 
in the case.  Here, the question whether Dagner’s alleged 
abuse of alcohol contributed to her death by causing an AWS 
 
 
12
We now turn to the question whether Dr. Shank should have 
been permitted to express an opinion that Dagner’s brain 
injury and death were caused, at least in part, by an AWS 
seizure.  With respect to this issue, it is important to 
distinguish between the two areas in which Dr. Anderson sought 
to qualify Dr. Shank as an expert witness.  Dr. Anderson 
sought to qualify Dr. Shank as an expert on the standard of 
care owed by an emergency room physician providing treatment 
to a patient, such as Dagner, suffering from diabetes-related 
hypoglycemia in an emergency department setting.  Dr. Shank 
was clearly qualified to render such an opinion, and the 
estate does not contest his qualification on that ground.  
However, Dr. Anderson also sought to have Dr. Shank qualified 
as an expert on the causation of a brain injury by seizures, 
and specifically as an expert capable of offering an opinion 
that Dagner had suffered an AWS seizure that was the cause, at 
least in part, of the brain injury that resulted in her death. 
The estate contends that Dr. Shank was not qualified to 
offer such an opinion because he lacked the necessary 
background, training, and experience to offer an opinion as to 
the cause of Dagner’s brain injury.  Specifically, the estate 
                                                                
seizure was clearly relevant to the defense’s theory of the 
case. 
 
 
13
notes that Dr. Shank conceded that he was not qualified to 
speak about the cause of seizures that may be multifactorial 
in nature.  Dr. Anderson responds that Dr. Shank was qualified 
to give an opinion that Dagner suffered an AWS seizure based 
upon Dr. Shank’s testimony that in his practice of emergency 
medicine he treats between 5 and 15 patients each year who 
suffer such seizures. 
Generally, to qualify as an expert a witness needs only 
to have a degree of knowledge of a subject matter beyond that 
of persons of common intelligence and ordinary experience so 
that the witness’ opinion will have value in assisting the 
trier of fact in understanding the evidence or determining a 
fact in issue.  See Velazquez v. Commonwealth, 263 Va. 95, 
103, 557 S.E.2d 213, 218 (2002); see also Sami v. Varn, 260 
Va. 280, 284, 535 S.E.2d 172, 174 (2000).  We are of opinion, 
however, that in this case Dr. Shank’s stated familiarity with 
AWS in the context of treating patients in an emergency 
department setting is not a sufficient basis for the circuit 
court to have qualified him as an expert on the issue whether 
Dagner suffered an AWS seizure which was the cause of Dagner’s 
brain injury and death. 
Dr. Shank’s own testimony established that the role of a 
physician providing emergency medical care was to assess the 
patient’s condition and administer the necessary treatment to 
 
14
stabilize the patient, not to provide long term care.  While 
Dr. Shank noted that in this context emergency medicine 
“overlaps” with a number of medical specialties, he also 
acknowledged that, as a practitioner of emergency medicine, he 
did not have the requisite expertise to offer an opinion on 
whether there was a multifactorial cause to Dagner’s brain 
injury, even though he was of opinion that complications from 
her diabetes would have contributed to that injury.  
Accordingly, we hold that the circuit court erred in finding 
that Dr. Shank was qualified to testify regarding his opinion 
that Dagner’s brain injury was caused by an AWS seizure. 
CONCLUSION 
As we have previously noted, the thrust of Dr. Anderson’s 
defense was that his discharge of Dagner from the emergency 
department when he did so did not violate a reasonable 
standard of medical care because it was not foreseeable that 
Dagner would suffer an AWS seizure after her diabetes-induced 
hypoglycemia had been treated and stabilized.  We therefore 
must conclude that the improper admission of Dr. Shank’s 
opinion testimony that Dagner had in fact suffered an AWS 
seizure, which was the only evidence offered to rebut the 
estate’s evidence to the contrary, could have influenced the 
jury’s determination that Dr. Anderson was not negligent.  
Accordingly, we will reverse the judgment of the circuit court 
 
15
and remand the case for a new trial on all issues consistent 
with the views expressed in this opinion.7 
Reversed and remanded. 
                     
7 Because the evidence adduced in the new trial will 
likely be of a different quality and nature, we will not 
address the further contention of the estate that the evidence 
in Dagner’s medical records provided an insufficient 
foundation to support Dr. Shank’s opinion that Dagner had 
suffered an AWS seizure.  For the same reason, we need not 
address the estate’s two remaining assignments of error 
concerning the admission of evidence of Dagner’s alleged prior 
noncompliance with treatment plans for her diabetes and the 
alleged admission of uncorroborated hearsay statements by 
Dagner through the testimony of Dr. Anderson in violation of 
Code § 8.01-397.