Title: Funke v. Fieldman

State: kansas

Issuer: Kansas Supreme Court

Document:

212 Kan. 524 (1973)
512 P.2d 539
LILLIAN M. FUNKE, Appellant,
v.
E. JAY FIELDMAN, Appellee.
No. 46,798

Supreme Court of Kansas.
Opinion filed July 14, 1973.
Gerald L. Michaud, of Michaud, Cranmer, Syrios and Post, of Wichita, argued the cause, and Ronald D. Heck, of the same firm, was with him on the brief for the appellant.
William Tinker, of McDonald, Tinker, Skaer, Quinn & Herrington, of Wichita, argued the cause, and Norman I. Cooley, of the same firm, was with him on the brief for the appellee.
The opinion of the court was delivered by
SCHROEDER, J.:
This is an action for malpractice against a physician anesthesiologist to recover for injuries sustained as the result of the administration of a spinal anesthetic alleged to have been negligently performed.
The plaintiff (appellant), Lillian M. Funke, had experienced a *526 dull ache in her side for several years prior to 1967. The ache got much worse prior to her menstrual periods. Because of the ache the appellant consulted Dr. Gordon T. Cowles and was placed on birth control pills as a result of the consultation. However, Mrs. Funke subsequently became pregnant and gave birth to her sixth child in August, 1967.
Unforeseen complications prior to the birth of the child resulted in Dr. Cowles' recommending and subsequently administering a caudal anesthesia to Mrs. Funke for the birth. Mrs. Funke had no reaction to the caudal anesthesia and thought it was "marvelous". She continued treatment with Dr. Cowles and eventually was advised to have a hysterectomy. Arrangements were made, and Mrs. Funke entered Wesley Medical Center in Wichita, Kansas, on November 12, 1967, for the scheduled hysterectomy on November 13.
On the evening of November 12, 1967, Dr. Cowles visited Mrs. Funke in her room and advised her that Dr. E. Jay Fieldman (defendant-appellee) was her anesthesiologist and would be in to see her.
Dr. Fieldman visited the plaintiff that same evening. The plaintiff testified that he walked into her room and introduced himself, but only stayed approximately three to four minutes. Dr. Fieldman gave the plaintiff no physical examination but did ask her what kind of anesthetic she wanted. She replied that Dr. Cowles had recommended a spinal to which Dr. Fieldman replied "well, those are the best".
Dr. Fieldman went on to state that he liked to give those and that the most you could get from them is a headache and that "we have medicine for that now".
Before continuing with the facts, a brief discussion of the anatomy and the details of the procedure involved is in order.
The spinal cord runs the length of the back from the brain to approximately the first lumbar vertebra. Below that area the nerves flare out into what is termed the cauda equina (horse's tail). In a caudal anesthetic the anesthetic solution is not placed within the spinal column or subarachnoid space, while in a spinal anesthetic the solution is placed within the subarachnoid space. There is a lateral approach or method of giving a spinal anesthetic which consists of the insertion of the needle through the skin lateral to the midline of the patient's back. The aim in the performance of the spinal anesthetic using the lateral approach is to place the *527 needle within the midline or the center of the intervertebral canal.
The cauda equina nerves are hanging free and are bathed in spinal fluids. The spinal cord which ends in a bulbous mass (conus medullaris) normally ends opposite the first lumbar vertebra.
The Anatomical Record, volume 88, published April, 1944, (defendant's exhibit No. 6.), states that termination of the spinal cord ranges from the level of the lower third of the twelfth thoracic vertebra to that of the middle third of the third lumbar vertebra.
Dr. William H.L. Dornette, called as a witness upon behalf of the defendant, testified the purpose of spinal anesthesia is to produce a block of the spinal nerves which will relieve pain and will produce muscular relaxation. Dr. Dornette explained the subarachnoid space is occupied by the spinal cord and other nerves and is filled with spinal fluid which is watery like substance. The nerves leave the spinal cord and transverse varying lengths of the subarachnoid space. Dr. Dornette continued to testify in detail about this part of the anatomy, stating in part that,
As for the actual procedure involved, Dr. E. Jay Fieldman was called as a witness on behalf of the plaintiff and on direct examination he testified to the following:
..............
Dr. Fieldman went on to state that while he was not taught at the Mayo Clinic to aspirate, in many instances it is important to aspirate before starting an injection and in some instances it is dangerous. Dr. Fieldman agreed that if the plunger rotates freely but spinal fluid cannot be aspirated freely, the needle is not in the right place. The purpose of aspiration is to ascertain if you are getting a free flow of spinal fluid which indicates the needle is in the subarachnoid space rather than up against or inside a nerve, in which case a free flow of spinal fluid would not be present.
Mrs. Funke testified she was sleepy and drowsy from the pre-operative medication when she arrived at the operating room and was placed on the operating table. She was awake when she was set up but did not see Dr. Fieldman. She does remember hearing his voice when he gave instruction on the anesthetic.
The plaintiff was in a sitting position with her legs straight out and held in a position which caused her to lean over with her head very low.
The plaintiff testified when the needle was first inserted she felt a terrible pain down her leg; that her leg jerked; and she said "Oh". The plaintiff testified that Dr. Fieldman then said "Sit still" and soon thereafter the plaintiff felt another pain and remarked to Dr. Fieldman that, "Something's wrong, my legs aren't going to sleep". Dr. Fieldman then said, "Well, maybe we had better remove the needle". He then reinserted the needle at the L3-4 interspace. Plaintiff then remembers nothing after her legs went to sleep.
Evidence disclosed that about two tenths of a cubic centimeter of anesthetic solution was injected through the needle at the place of its initial insertion before the needle was reinserted at the lower interspace.
Testimony disclosed that when the anesthesia disappeared, paralysis remained on the left side with total anesthesia to pain as well as temperature with reduced sensitivity to touch. Testimony *529 also showed that the plaintiff's left leg was so sensitive that doctors could hardly examine it and that a problem with control of bladder and bowels existed.
The plaintiff contends the trial court erred (1) in finding that the defendant was not negligent and in finding generally for the defendant when the evidence was not sufficient to support said findings; (2) in finding plaintiff gave an informed consent to the spinal anesthesia prior to its administration; and (3) in finding that the doctrine of res ipsa loquitur was not applicable to this case.
Under K.S.A. 60-252 (a) where trial is to the court, as here, the trial judge shall find the controlling facts, and on appellate review the findings of fact made by the trial judge shall not be set aside unless clearly erroneous, and due regard shall be given to the opportunity of the trial court to judge of the credibility of the witnesses. (Short v. Sunflower Plastic Pipe, Inc., 210 Kan. 68, 500 P.2d 39.)
The appellant first contends the appellee was negligent in proceeding to start the injection of the solution after she experienced the sudden severe pain down her leg, rather than removing the needle and repositioning it before injection of the solution; and that the appellee was negligent in not heeding the warning of the first pain, and in waiting until she cried out a second time before removing the needle and repositioning it in the next lower interspace.
The appellant's nerves which were adversely affected are described as L-5, L-4, S-1 and S-2. Dr. Dornette, during his direct examination on behalf of the defendant, stated that in his opinion, "There's just no possible way that you can injure four nerves on one side without an injection into the substance of the conus." Dr. Dornette was cross-examined with the assistance of a work called Neurological Complications after Spinal Anesthesia and Results from Two Thousand Four Hundred Ninety Three Follow Up Cases, by Gunnar Thorsen, Stockholm, 1947. The cross-examination began with a paragraph entitled "Injuries via an Assumed Endroneural Injection". An endroneural injection is an injection into a nerve root or into a nerve. When counsel for the appellant began comparison between the plaintiff's case and the case reported by Thorsen, the defendant objected and the court ruled that the plaintiff could finish her cross-examination relative to the reported case but would not be allowed to cross examine Dr. Dornette on any other cases reported in Thorsen's work. Plaintiff *530 sought to proffer other similar cases to compare the complaints and residuals of the plaintiff but was not allowed to proffer the information by the court. There was also evidence introduced that 1.8 percent of the population, or one in every fifty-five persons, has a low lying conus medullaris which extends down to the L2-3 interspace.
Suffice it to say evidence in the record establishes there is a possibility of nerve damage from a spinal injection, such as the appellant sustained in the instant case.
The appellant argues that even if her conus medullaris actually does extend down to the L2-3 interspace, if she had a complaint of pain when the defendant put the needle in followed by an injection without repositioning the needle, he departed from standard approved medical practice, which departure caused her injury.
The long standing general rule, consistently adhered to by this court in malpractice cases of this character, is that expert medical testimony is ordinarily required to establish negligence or lack of skill on the part of a physician or surgeon in his medical diagnosis, his performance of surgical procedures and his care and treatment of the patients. (Collins v. Meeker, 198 Kan. 390, 394, 424 P.2d 488 and cases cited therein.) An exception to the general rule exists where the results of medical treatment are so patently bad as to be manifest to lay persons or as to come within the common knowledge and experience of mankind generally. (Collins v. Meeker, supra, and cases cited there.)
Without belaboring the point further we hold the record does contain substantial competent evidence in the form of expert medical testimony to support the trial court's finding that the appellee was not negligent in the performance of the spinal anesthetic injection.
We now turn to the appellant's second point  that the trial court erred in finding that she gave an informed consent to the spinal anesthesia prior to its administration.
This court was squarely confronted with the question of a patient's informed consent to a method or a course of treatment by medical personnel in Natanson v. Kline, 186 Kan. 393, 350 P.2d 1093. That was an action for malpractice against a hospital and a physician in charge of its radiology department to recover for injuries sustained as a result of radiation therapy with radioactive cobalt, allegedly given in an excessive dosage. One of the plaintiff's contentions in Natanson was that while she consented to the treatment, the treating *531 physician failed to warn her the course of treatment he undertook to administer involved great risk of bodily injury or death.
After an extended review of cases from foreign jurisdictions most nearly in point, this court concluded the proper rule of law to determine whether a patient has given an intelligent consent to a purposed form of treatment by a physician was the rule stated and applied in Salgo v. Leland Stanford Etc. Bd. Trustees [1957], 154 Cal. App. 2d 560, 317 P.2d 170. The trial court in Salgo gave a rather broad instruction on the duty of the physician to disclose to the patient "all the facts which mutually affect his rights and interests and of the surgical risk, hazard and danger if any". In holding the instruction to be overly broad, the California appellate court stated:
This court commented further on the doctrine of informed consent in Williams v. Menehan, 191 Kan. 6, 379 P.2d 292. There it was held the parents of a small child who died while a team of physicians was performing a cardiac catheterization had given an informed consent to the procedure. In commenting on the rule as laid down in Natanson, supra, it was said:
Summarizing the rule in Tatro v. Lueken, 212 Kan. 606, 512 P.2d 528, the court said in Syllabi 3 and 4:
Against this historical background of the rule the question now posed is whether or not a reasonable disclosure of the nature and probable consequences of the recommended spinal anesthesia was made to Mrs. Funke, and whether or not a reasonable disclosure was made to Mrs. Funke of the dangers, within the knowledge of Dr. Fieldman, which were incident or possible in the spinal anesthesia he proposed to administer.
At the time of trial the appellant testified:
On direct examination Mrs. Funke testified concerning the time Dr. Fieldman came into her hospital room on the evening of November 12, 1967, as follows:
"A. Yes, sir.
"A. No, sir.
"A. No. Not that I recall he didn't.
..............
"Q. Tell the Court what you said and what he said.
"A. That was about it.
"A. No, sir."
Dr. Fieldman takes the position, as the trial court found, that he was entitled to rely on the explanation given the patient by Dr. Cowles.
Dr. Cowles in his testimony was evasive as to what he told Mrs. Funke concerning a spinal anesthetic.
Did Dr. Cowles, the physician in charge, or Dr. Fieldman the anesthesiologist, have a duty to make a reasonable disclosure of the dangers of the proposed spinal anesthetic? We do not find it necessary to answer this question because the record clearly shows *534 Dr. Fieldman went to see Mrs. Funke in her hospital room the evening prior to her scheduled operation and undertook to tell Mrs. Funkee that "the most you can get from them [spinal anesthetic] is a headache; and we have medicine for that now".
This testimony was never refuted by Dr. Fieldman.
A careful examination of the record affirmatively shows there were other risks associated with the administration of a spinal anesthetic, and that one out of 55 people does have an abnormally low lying conus medullaris which makes such patient vulnerable to nerve injury if a spinal needle is inserted at L2-L3 interspace, rather than at the next lower interspace.
Dr. Fieldman recognized in his testimony, previously quoted, that if the initial tap is done higher than the L2-3 interspace there is danger of traumatizing the spinal cord which could cause nerve or spinal cord damage. With a low lying conus medullaris the same would be true of an initial tap made at L2-3. On the facts in this case the needle was withdrawn from the L2-3 interspace, where it was first inserted and some anesthetic solution injected after the patient twice indicated pain, and reinserted at the L3-4 interspace where the spinal anesthetic was finally administered.
Albert Faulconer, M.D., chairman of the Department of Anesthesiology at the Mayo Clinic in Rochester, Minnesota, replied to the question,
"A. Yes, there certainly are other risks."
Frank M. Tilton, M.D., a physician and specialist in the field of neurology practice in Wichita, Kansas, testified that in his best medical judgment the conus medullaris would not ever go down to the second and third lumbar interspace and that he would not agree with Dr. Faulconer that in about two percent of the people the spinal cord ends below the L-2 interspace. However, after being cross-examined from the anatomical record, Dr. Tilton changed his testimony and agreed that in the big majority of people the end of the spinal cord would be at the L-1 or L-2 level of the spine.
The record establishes that Dr. Fieldman either knew or should have known that spinal anesthesia carried with it more risks than mere headaches for the patient, and that such other risks were greater in severity. When Dr. Fieldman then undertook to tell *535 Mrs. Funke that a headache was the only possible danger he misinformed and misled Mrs. Funke. In other words, her consent to the administration of a spinal anesthesia by Dr. Fieldman was not an informed consent. As such, it was a nullity.
In Collins v. Meeker, supra, the court said:
But we are not here faced with total silence on the part of a physician, or a failure to make a disclosure that would deviate from acceptable medical practice. Here we are confronted with a misleading statement by Dr. Fieldman upon which Dr. Fieldman knew Mrs. Funke was relying when she gave her consent for the spinal anesthetic. As such, the misleading statement was equivalent to a false statement by Dr. Fieldman and vitiated Mrs. Funke's consent.
While there does not necessarily have to be negligence in the administration of the spinal anesthetic for the resultant damage which Mrs. Funke experienced, the risk was still present.
On the record here presented we find Dr. Fieldman failed to obtain the informed consent of Mrs. Funke to the spinal anesthetic prior to its administration.
No more than breach of any other legal duty does nonfulfillment of the physician's obligation to disclose alone establish liability to the patient. An unrevealed risk that should have been made known must materialize, otherwise the omission, however unpardonable, is legally without consequence. Occurrence of the risk must be harmful to the patient, for negligence unrelated to injury is non-actionable. And, as in malpractice actions generally, there must be a causal relationship between the physician's failure to adequately divulge the risks and damage to the patient. (Canterbury v. Spence, 464 F.2d 772 [1972].)
A causal connection exists when, but only when, disclosure of significant risks incidental to treatment would have resulted in a *536 decision against it. The patient obviously has no complaint if she would have submitted to the spinal anesthetic notwithstanding awareness that the risk of permanent nerve damage was one of its perils. On the other hand, the very purpose of the disclosure rule is to protect the patient against the consequences which, if known, she would have avoided by foregoing the spinal anesthetic. (Canterbury v. Spence, supra, and Natanson v. Kline, 186 Kan. 393, 350 P.2d 1093.)
This court said in Natanson v. Kline, supra:
The factual issue on causal connection has not heretofore been determined by this court, except to say the burden of proof rests on the patient throughout the trial of a malpractice action. Should the issue be determined on an objective or a subjective basis? The point was fully discussed in Canterbury v. Spence, supra, where the United States Court of Appeals, District of Columbia Circuit, concluded the objective basis was the better. There the court said:
We think the foregoing reasoning is persuasive. Whether a patient would have refused treatment or a medical procedure had the physician made adequate disclosure is to be determined objectively. If adequate disclosure could reasonably be expected to have caused the patient to decline the treatment or procedure because of revelation of the kind of risk or danger which resulted in her harm, causation is shown but otherwise not, and the patient's testimony is relevant on such issue, but should not be controlling.
The appellant's third point is that the trial court erred in finding the doctrine or res ipsa loquitur was not applicable to this case.
The doctrine of res ipsa loquitur and the elements thereof were examined as applied to malpractice cases in Voss v. Bridwell, 188 Kan. 643, 364 P.2d 955, and reviewed in Tatro v. Lueken, 212 Kan. 606, 512 P.2d 529, together with our prior decisions on the subject.
In Tatro the court held, consistent with our prior decisions, that the doctrine of res ipsa loquitur applies in a medical malpractice action only where a layman is able to say as a matter of common knowledge and observation, or from the evidence can draw an inference, that the consequences of professional treatment were not such as ordinarily would have followed if due care had been exercised.
In Tatro, which was a malpractice action based upon the occurrence of a vesicovaginal fistula following an abdominal hysterectomy, *538 it was held that such operation is so complicated as to lie beyond the realm of common knowledge and experience of laymen as to whether such result would not ordinarily occur in the absence of negligence.
The law on the doctrine of res ipsa loquitur need not be further reviewed in connection with malpractice actions in this opinion. The reader is referred to Tatro v. Lueken, supra.
In our opinion the administration of spinal anesthesia which results in permanent nerve damage to the patient is a procedure so complicated, considering the delicate anatomy of the human spine and the various possibilities of injury from the needle or anesthetic solution, as to lie beyond the realm of common knowledge and experience of laymen as to whether such result would not ordinarily occur in the absence of negligence.
The judgment of the lower court is reversed with directions to grant a new trial in accordance with the views expressed in this opinion.