C r ai g K endal l , Sher r i D y er K endal l ’ s hu s band, was i ni t i al l y a n amed pl ai nt i f f i n t hi s s ui t , howev er , an O r der 1

o f V o lun ta ry D ism issa l wa s e n te re d p rio r to trial d ism issin g C ra ig K e n d a ll’ s c la im s a g a ins t D e fen d a n t.

S h e rr i D ye r K e n d a ll a n d C ra ig K e n d a ll a lso su e d J o h n so n & J o h n so n , In c
. a n d O rth o -M c N e il P h a rm a c e u tica l, 2 In c ., b u t an A g re e d O rd e r o f D ism issa l wa s e n te re d a s to the se d e fen d a n ts p rio r to trial.



### IN THE COURT OF APP EALS OF TENNESS EE

AT KNOXVI LLE Ma y 12, 200 4 S es sio n

SHE RRI DYER KENDALL v. LANE CO OK, M.D.

Appeal f romthe Circ uit Court for Knox County No. 2-750-01 Har old Wimber ly, Jud ge

No. E2003-02227-COA- R3-CV F iled Jul y 21, 2004

Sh e rr i D y e r

K e n d a ll ( “ Pl a in ti f

f ” ) s o u g h t t

r e a tm e n t f

o r b ip o la r d is o r d e r f r o m a p s y c h iatris t, L ane Cook, M.D. (“De fenda nt”). De fenda nt prescribed Topama x for Plaintiff. L ess than one w eek later, Pla i n t i ff beg an to experienc e loss of vision, severe heada che, and sever e vomiting. Plaintiff wa s diag nosed with a cute ang le closure g laucoma and under went seve ral surg ical proc edure s to control or cor re ct t h e p roblem. When Def endant pr escribed Topama x to Plainti ff, it was unknow n in the medical c ommunitythat a potential side e ffe ct of Topa max was acute ang le closure g laucoma. That acute ang le closure g laucoma w as a pote ntial si d e effect wa s discovere d later by the medica l community , and Plaintiff sued De fenda nt for medical malprac tice. At the close of Plaintiff’s proof 1 2
a t tria l, D e fe nd a nt m ov e d f or a dir e c ted ver dic t, w hic h th e Tria l Co urt g rante d. Pla int if f a pp e a ls. We affirm. Te nn. R . A pp. P . 3 App e al a s o f Rig ht ; J udgm e nt of t he Ci r c uit

Co ur t A ffirm e d; Case Re m anded
D. M I CH A EL S WI NEY , J ., delivere d the opinion of the court, in which H ER SCH EL P. F RAN KS , P.J ., E. S. and H O WE LL N. P EOPL ES , S P
. J ., joined.
Samuel W. Brown a nd Arthur F . Knig ht, I I I , Knoxvi lle, Tenne ssee, f or the Appe llant, Sherri Dy er Ke nd a ll.
F. L aure ns Br ock, Anthony A. J ackson, a nd J u s t i n M. Sveadas, Chattanoog a, Te nnessee , for the Appellee , L ane Cook, M.D.-2- OP IN ION
Bac kgr ound

The Trial Court directe d a ver dict for De fenda nt at the clos e o f P l ai ntiff’s proof

. Th e re fo re , th e e vid e nc e we dis c us s in thi s O pin ion is the e vid e nc e pr e se nte d b y Pla int if f at tria l. Plaintiff beg an see ing D efe ndant in 1993, for treatment of her previously diag nosed bip ola r d iso rd e r. Pla int if

f s a w D e fe nd a nt o n a n ir re g ula r b a sis fo r a

pp ro xim ate ly

e ig ht y e ars
. Def endant pr escribed seve ral diff ere nt medications for Plaintiff during that period.
I n 2 00 1, De fe nd a nt c ha ng ed Plaint if f’ s me dic a tio n a ndpr e sc ri be d T op a ma x. L e ss than one w ee k l at er, Plaintiff be g an to experienc e loss of vision, severe heada che, and sever e vomiting. P laintiff’s husband took her to the emerg ency room. After

extensive testing, Plaintiff was se nt b y a mbu la nc e to s e e a n oph tha lmo log ist . T hat day , a ndov e r the c ou rs e of the ne xt fe w d a y s, Plaintiff saw seve ral doctors including an ophthalmolog ist, a g laucoma spe cialist, a re tinologist, a neurolog ist, and a rhe umatologist. Plaintiff al s o u n d erwent some surg ical proc edure s and wa s hospitaliz ed as a

result. During this ti me, Plaintiff was in what she described as “ excruciating pain” and her ey es we re swollen shut. She wa s diag nosed with ac ute ang le closure g laucoma.
P l aint iff’s vision slowly

beg an to re turn afte r five day s. Howeve r, Plaintiff was leg ally blind during those f

ive day s. Although Plaintiff wa s told when she first went to the hospital to stop taking Topa max, i t w asn’t until seve ral months later that Plaintiff’s problems def initely wer e lin ke d to the To pa ma x. I n t ot al, P lai nt if f h a d f ive su rg e ri e s o n h e r rig ht e y e a ndtw o o n h e r l e ft

. Currently , Plaintiff’s vision is 20/ 20 with g lasses corr ection, and she has a slight catara ct in one ey e. Plaintiff sued Def

endant f or medica l malprac tice for his having presc ribed the Topamax for her. At trial, Plaintiff prese nted the expert witness testimony of S u s an A. Van Me ter, M. D. , a ps y c hiatr ist

wh o s peci ali z e s in moo d d iso rd e rs c ha ra c te ri zed by de pr e ssi on a ndma nic depre ssion or bipolar disorder

. Dr. Van Me ter stated she is employ ed cur rently by GlaxoS mithKline Pharmac eutical Company working in drug development.
Dr. Va n Meter te stified she uses The Ex pert Co n s e n s u s G u id e li n e s Serie s , M e d ic ation Tr e a tme nt o f B ipo lar D iso rd e r for th e y e ar 2 00 0 ( “ Gu ide lin e s” ), wh ic h a re pu bli sh e d to he lp phy sicians “e valuate w hat ar e op t i o n s t h at have be en known to wor k, what ar e options that are potentially

eff ective, and what ar e options that we don’t really have enoug h information about.” The Guidelines list Topamax as a treatment of last resort to add to e x isting medication. However , Dr. Van Me ter a dmitted the Guidelines are “not something that phy sicians s hould follow exactly . I t’s a re commendation. . . .” D r. Van Meter testified “[t] he standard of car e would be to try a first-line agent [as listed in the Guidelines, such a s], l ithium, Depakote, Te g retol; a trial of an aty pical antipsy chotic, Risperda l, Z yprexa. And fa iling that, lo o kin g at o th e r o p ti o n s , lamotrigine , Cloz apine,-3-

the addition of Topama x , Neuontin.” Dr. Van Meter would consider Topamax to be a treatment of last resort a fter try ing e ven ele ctric shoc k thera py first.
Dr. Va n Meter te stified that at the time D efe ndant presc ribed Topamax f or Plaintiff, neither w ere there any studies show ing Topamax w as ef fec tive for tre ating bipolar disorder , nor had the drug passed a ny

clinical trials or doub l e b l i n d place bo controlled studies. Howe ver, D r. Va n Meter admitted that at the time D efe ndant presc ribed Topamax, the re w ere case reports and article s in medical publications docume nting c ases whe re patients were trea ted with Topamax by itself for bipolar disorder

with good r esults.
Dr. Va n Meter testified “medications do have side ef fec ts.” Howe ver, D r. Va n Meter admitted it was unknown in the me dical community at the time Def

endant pr escribed Topama x that a potential side e ffe ct of this drug was a cute a ng le closure g laucoma. D r. Va n Meter a dmitted Def endant c ould not have warne d Plaintiff about a possible side eff ect that was unknown. D r. Va n Me ter didno t te sti fy

abo ut any

sp e c if ic sid e e ff

e c ts o f T op a ma x tha t w e re kn ow n at th e tim e Def endant pr escribed Topama x for Plaintiff.

Dr. Va n Meter a dmitte d there are nationally rec og nized ex perts in the tre atment of bipolar disorder who sug g est try ing Topamax a s a second or third-line c hoice on its own. Dr. V an Me ter a lso a dmi tte d th e re are do c tor s w ho are a s skill e d, or mor e sk ill e d th a n s he , w ho wo uld presc ribe Topa max as a first-line drug by itself. Ba si ca l l y , s h e d i sag ree s with these other doc tors wi t h s i m i l aro r m o re ex p er i en ce ab o u t t h e o rd er i n wh i ch t h e m ed i ci n e s h o u l d b e gi v en
. Al t h o u gh Dr. Va n Meter testified she believes Topamax is a last resort for the treatment of bipolar disorder , sh e te sti fi e d th a t sh e ha s pre sc ri be d Top a ma x fo r som e of he r psy c hiatr ic patie nts fo r w e ig ht l os s.

At the close of

P l aint iff’s pr oof at trial, De fenda nt moved for a direc ted ver dict arg uing that Plainti ff f

ailed to prove Def

endant breac hed the standard of ca re, a nd that Plaintiff failed to p ro ve De fe nd a nt c ou ld ha ve fo re se e n Pla int if f’ s inj urie s, wh ic h de mon str a te d th a t D e fe nd a nt d id not prox imately

cause Plaintiff’s injuries. I n an Or der of J u d gm en t enter ed Aug ust 25, 2003, the Tria l Co urt g rante d D e fe nd a nt’ s mo tio n. Pla int if f a pp e a ls t o th is C ou rt

. Discussion Although not state d exactly as such, Plaintiff r aises one issue on a ppeal: whe ther the Trial Court er

red in g ranting Def

endant’ s motion for directe d verdic t. As our Supreme Court has instructed:
I n r uli ng on a mot ion fo r dir e c te d ve rd ic t, t ri a l c ou rt s mu st t ake the str on g e st le g iti m a t e v i e w o f t h e e v i d e n c e i n f a v o r o f t h e n o n
- m o v i n g p ar t y , c o n s tru i ng a ll evidenc e in that party ’s fa vor and disre g ar ding a ll counterva iling evide nce. Eaton v . M c Lai n , 8 91 S.W. 2d 58 7, 59 0 (T e nn . 199 4)

. A co urt may g rant the mot ion on ly-4-

if rea sonable minds could re ach only one conc lusion from the evidenc e. Id

. Appellate c ourts apply

the same standa

rd in revie wing t he trial c ourt’s dec ision on a dire cted ve rdict. Sauls v. Evans , 635 S.W .2d 377, 379 (Tenn. 1982)

. Gaston v. Tennesse e Farme rs Mut. Ins. Co. , 120 S.W .3d 815, 819 (Tenn. 2003)

.

I n a medica l malprac tice ac tion, such as this case, a plain t i ff has the burde n of p ro v i n g: (1) The rec og nized standard of a cce ptable prof essional pra ctice in the pr ofession and the spec iality

there of, if any , that the defe ndant prac tices in the community in which the def endant pr actice s or in a similar community at the time the alleged i njury or wrong ful ac tion occurr ed; (2) That the defe ndant ac ted with less than or failed to act w i t h o rd i n ar y and rea sonable c are in acc ordanc e with such standa rd; and (3) As a proxi mate re sult of the defe ndant’s neg lige nt a ct or omission, t he plaintiff suffe red injuries w hich would not otherwise ha ve occ urre d. Tenn. Code Ann. § 29- 26-115 (a ) (2003)

.

I n th is c a se , th e Trial Cou rt he ld that Pla int if

f’ s e xpe rt wi tne ss f a ile d to e sta

bli sh either the standard of

car e or pr ox imate cause. We first will addre ss the standard of car e. Th e Tria l Co urt st a te d th a t Pla int if f’ s e xpe rt wi tne ss: described and de fined the standa rd of c are as being t he basic ally acc epted medic al app ro a c h to tr e a tme nt of a patie nt. She sa id that th e sta nd ardof c are in Kno xvill e in 2001 , w h e n th e s e e v e n ts w h ic h ar e th e s u b je c t o f th is c a s e o c c u rr e d , in v o lv ed the cou rs e o f treating a

patient as set out in one of the exhibit s, exhi bit entitled Ex pert Consensus Guideline Series, Me dical Tre atment of B ipolar Disorde r, Ye ar 2000. She say s that the defe ndant in this case violated the standard of car e in that he d idn o t p r o c e e d in a c c o r d a n c e w ith th a t g u id e li n e a n d d idn o t g o th r o u g h the a c c e pte d fir st line tr e a tme nts a nd pr oc e e d on dow n the lis t of tre a tme nts a s sh ow n in that g uideline.
I n relation to the standard of c are , while s he agr eed that this guideline, or any g uid e lin e , d id n ot, in i tse lf, e sta bli sh a ri g id f ormul a , sh e didsa y

that th is d e fe nd a nt, in her opinion, violated t he st andar d of care by moving to the bottom of the list and presc ribing this medication, Topamax, with out first try ing or at least off

ering the oth e r t re a tme nts on the lis t.-5- She ag ree d that other phy sicians, some of which wer e rec og nized a s - - by her as experts, national experts with national reputation, may well have other ideas a

bout the cour se of treatment, t he ti ming of trea tment, whether medications such as the one in q ue sti on he re , T op a ma x, sh ou ld b e us e d o r c ou ld b e us e d b y the mse lve s o r s ho uld be us e d o nly

in c on ne c tio n w ith oth e r m e dic a tio ns
. She ag ree d that she had a disagre em en t with other doctors of similar experience or g reater e x perie nce a bout the order

in which medicine should be g iven, but that in her opinion, she would pr escribe to this consensus g uideline, and a ny thing else would be a violation of the then e x isting standar d of ca re. * * *
Now it’s inter esting to note that the use of Topamax, itself, would not be an improper thing to do, even under this witness’ testimony and opinions. I t could be used, as she expressed many times, as a last re s o rt , o r in combination with other medications. It c ould a lso be used, as she uses it sometimes, in the situations where a patient wa s interested in losing weig ht, and that was a n appropriate conside ration for a medical doc tor.
As t h i s C ourt stated in Roddy v . Volunteer Me d. Clini c, Inc

. , “[t] he testimony of a phy sician as to what he would do or his opinion of what should have bee n done does not prove the statutory standard of

medical pr actice .” Roddy v . Volunteer Me d. Clini c, Inc

. , 926 S.W .2d 572, 578 (T e nn . Ct . A pp . 1 99 6)

. “ I t is no t a dep artur e fr om the app lic able sta nd ard of c are fo r a phy sic ia n to use a pr ocedur e that is but one of se vera l proce dures recog nized in the profe ssion as adequate in the treatment of the plaintiff’s c ondition.” Harris v. Buck span , 984 S.W .2d 944, 952-53 (Tenn. Ct. App. 1998).
I n this case , Dr. Van Meter did testify she believe d it fell below the standa rd of c are to prescribe Topama x befor e trying othe r options. Howeve r, Dr. V an Meter a dmitted that other rec og nized ex perts in the fie ld, so me with more e x perie nce tha n she has, would disag ree with her position t hat Topama x is a treatment of last resort. She a lso admitted that the Guidelines she follows ar e m e r e l y

a r e c o m m e n d a t i o n , “ n o ts o m e t h i n g t h a t p h ys i c i a n s s h o u l d f o l l o w e x a c t l y . . . . ” In addition, Dr. Va n Meter a dmitted she has presc ribed Topa max byitself to some of her patients for weig ht loss. Thus, Dr. Van Mete r testified merely about what she would have done , or what she believes Defe ndant s hould have done rathe r than what actually constitutes the sole treatment choice that is the rec og nized standard of a cce ptable prof essional pra ctice in this situation.
Dr . V a n Met er a dmi tte d th a t T op a ma x did a pp e ar o n th e Gu ide lin e s a s a po ssi ble tr e a tme nt fo r bip ola

r d iso rd e r andthat, at th e tim e De fe nd a nt p re sc ri be d T op a ma x, the re we re c a se re po rt s a ndart ic le s in me dic al pu bl icatio ns do c ume nti ng c a se s w he re patie nts we re tr e a te d w ith Topamax by

itself for bipolar

disorder w ith good r esults. Dr. Va n Meter a lso admitte d t h er e ar e oth e r phy sic ia ns , some wi th mor e e xpe ri e nc e than s he ha s, wh o w ou ld p re sc ri be To pa ma x by its e lf-6-

as a first or sec ond-line drug for the tr eatment of bipolar disorder . Dr. Va n Meter me rely disag ree s with other phy sicians about the or der in whic h T o p am ax s h o u ld be pre scribed. T hus, Dr. Va n Meter’ s testimonyestablishes that De fenda nt chose one of se vera l rec og nized options for the treatment of

Plaintiff’s bipolar disorder , an ac t which does not fa ll below the standar d of ca re e ven though it would not be the treatment option used by Dr. Va n Meter. A lthough Dr . Van Me ter stated she be l i ev ed De fe n d ant fe ll below the standar d of ca re, w e ag ree with the Trial Court that her te sti mon y , w he n ta

ke n a s a wh ole , do e s no t e sta bli sh a ny sta nd ardof

c are br e a c he d b y

the De fe nd a nt.
Re g ard ing pr oximate c a us e , t he Tri a l Co urt he ld that Pla int if f’ s e xpe rt wi tne ss te sti mon y : fail[s] to establish a leg al causal conne ction or a pr ox imate cau s al connec tion betwee n t h e violation of the standa rd of c are described by

this witness and the unfortunate result which wa s suffer ed by this particular pla intiff.
* * * These pa rticular injurie s, the ey e injury and the se vere distress and discomfort su ff e re d b y the plaint if

f at th a t ti me we re un kn ow n s ide e ff e c ts o f th e us e of th is medication. . . .
I n Bara v. C larksville Mem’l Health Sys., I nc. , th is C ou rt

dis c us se d th e fo re se e abil ity re q u i re m en tfo r f

i n d i n g p ro x i m at e c as e, s t at i n g: Take n as a w hole, our c ases sug g est a three -prong ed test for proximate causation: (1) the tortfea sor’s conduc t must have bee n a “substantial f actor ” in bringing about the harm be ing c omplained of; and ( 2) there is no rule or policy that should relieve the wrong doer f

rom liabilitybeca

use of the manner in w hich the neg lige nce ha s resulted in the harm; and ( 3) the ha rm g iving rise to the ac tion could h av e reasonably been fore seen or

anticipated by

a per son of ordinary

intelligenc e and pr

udence

. The for esee ability require ment is not so strict as to r equire the tortfea sor to forese e the exact manner

in which the injury

takes plac e, provided it is determined tha t the tortfea sor could for esee , or throug h the exercise of rea sonable dil ige nce should have fore seen, the g ener al manner in which the injury or l oss occur red. ‘The fa ct that an a c c ide nt m a y

be fr e akis h d oe s n ot p e r s e make it un pr e dic ta ble or un fo re se e n. ’ It is sufficie nt that harm in the abstra ct could re asonably be for esee n. Bara v. Clarksville Me m’l He alth Sys., Inc. , 104 S.W .3d 1, 11-12 (Te nn. Ct. App. 2002) (quoting McClenahan v. Cooley , 8 06 S.W. 2d76 7, 77 5 ( Te nn . 1 99 1) ) ( c itatio ns omi tte d) . A s o ur Sup re me Court noted in M

o o n v . S t. Th omas Hosp. , “the p art ic ula r h arm ne e d n ot h a ve be e n f

or e se e able if another ‘harm of a like g ener al cha rac ter wa s rea sonably

fore seea ble.’” Moon v. St. Thomas Hosp. ,-7-

9 8 3 S

. W

. 2 d 2 2 5 , 2 2 9 (T en n
. 1 9 9 8 ) ( q u o t i n g Spivey v. S t

. T homas Hosp. , 211 S.W .2d 450, 457 (Tenn. Ct. App. 1947))

.

Plaintiff’s appellate brief argue s that “the lac k of knowledg e on the pa rt of the medical c ommunityof the c onnection between Topa max and acute a ng le closure g laucoma is not rele vant to the issue of leg al causation, or any other issue to be tried in this case.” Ba sically , Plaintiff arg ue s tha t eve n thou g h the pa rt ic ula r inj ury su ff

e re d b y Pla int if f w a s n ot f

or e se e able , it

wa s w ith in a ra ng e of risk created by the alleg ed neg lige nce and s o m e harm could have rea sonably been fore seen. Plaintiff states “ [i ]t is undisputed that Topamax caused the re action.” Plaintiff c ites Pitman v. Upjohn Co. for the pr oposition “that drug s are co n s i d er ed to be unavoidably unsafe products” and arg ues that since a ll drug s have side e ffe cts, whethe r known or unknown, t he injury to Plainti ff wa s a harm that could rea sonably be for esee n. See P ittman v. Upjohn Co. , 890 S.W .2d 425, 428 (Tenn. 1994)

.

We have ne ither t he authority nor t he inclination to rew rite Tenn. Code Ann. § 29-26- 115(a) so as to delete the proxi mate ca use re quirement by

holding that since all drug s have pote ntial side eff ects of some type, whe ther known or unknown and whe ther mild or dea dly , any injury can re a so na bly be fo re se e n. Ad op tio n o f the ru le pr op os e d b y P l ai n t if f w ou ld e lim inate the fo re se e abil ity require ment as an element of proxi mate causation, contrary to both Tenn. Code Ann. § 29-26- 115(a) an d l o n g es t ab l i s h ed ca s e l aw i n cl u d i n g Mo on v . S t. T ho ma s H os p . and Bara v. Clarksville Me m’l Health Sys., Inc

.

I n this case, the potential side eff ect of acute ang le closure g laucoma was a n unknown sid e e ff e c t of To pa ma x whe n D e fe nd a nt p re sc ri be d T op a ma x for Pla int if f. Pla int if f’ s e xpe rt wi tne ss a d m i t t e d D e f

e n d a n t c o u l d n o th a v e w ar n e d P l a i n t i f f o f a p o s s i b l e s i d e e f

f e c tt h a tw a s u n k n o w n
. In addition, other t han P laintiff’s ex pert’s assertion t hat all drug s have side eff ects, P laintiff produc ed no e vid e nc e sh ow ing a ny po te nti a l side e ff e c t of taking To pa ma x. Th e rang e of po ssi ble sid e e ff

e c ts from ing estion of drug s can r ang e fr om mild ones, such as dry mouth, to severe one s, such as sudden death. Neither the jury nor the Trial Court or this Court i s fre e to spec ulate about what the potential side eff ects, if a ny , of Topama x might be.
P l ai n t i ff p ro d u ce d n o ev i d en ce s h o wi n g t h at De fe n d an t “c o u l d fo re s ee , o r t h ro u gh the exercise of

rea sonable dilig ence should ha v e foresee n, the g ener al manner in which the injury or loss [to Pl aintiff] occurr ed.” Ba ra , 1 0 4 S

. W

. 3 d at 1 1 -1 2 (q u o t i n g McClenahan , 806 S.W .2d at 775). Plaintiff produce d no evidenc e of any potential side eff ect or any specific possible harm, eve n a “ha rm in the abstra ct”, that De fenda nt could have f orese en fr om Plainti ff’ s taking Topamax. Id

. Plaintiff presente d no proof whatsoever that any harm, e ven a “harm of a like g ener al char acte r wa s rea sonably

fore seea ble” f rom Plaintiff’s taking Topamax. Spivey , 211 S.W .2d at 457. As there was no showing that Def

endant c ould have r easona bly fore seen a ny

harm , P l ai n t i ff failed to prove a proxi mate ca

usal conne ction betwee n the all eged violation of the standard of car e and the unfortunate and serious result suffer ed by Plaintiff.-8- Taking the strong est leg itimate vie w o f the e vidence in favor ofPlaintiff, the nonmov i n g party , construing all evidenc e in Plaintiff’s fa vor and disre g arding all counter vailing evidenc e, as w e must, we hold that re asonable minds could r each only one conc lusion from the evidenc e, i.e., that Plaintiff fai l ed to prove all of the e lements of her claim. We aff

irm the Trial C o u rt ’s Orde r of Judgment e ntere d Aug ust 25, 2003, gr anting Def endant’ s motion for a direc ted verdic t. Conclusion

The judg ment of the Trial Court is aff irmed, and this cause is rema nded to the Tria l Cou rt fo r c oll e c tio n o f the c os ts b e low . T he c os ts on app eal are a sse sse d a g a ins t th e Ap pe lla nt, Sherri Dy er K endall, and he r sure ty

.

___________________________________ D. MI CHAEL

SW I NEY, JUDGE