C O U R T O F A P P E A LS EI GHTH D I STRI CT OF TEXAS ELPASO, TEXAS

DORI S PENROD, Ap pe lla nt,
v. DAVI D R. SCHECTER , M.D., I ND I VI DU AL L Y A

ND D/ B /A SCHECTER AND BLUMENF EL D, P.A., Appellee s. § § § § § § No . 0 8- 07 -0 01 21 -C V

Appea l from County Court at L aw No. 5 of El Paso County , Texas (TC # 2005-206)

O P I N I O N I s it rever sible err or to permit a jury to decide a

case based on a

n instruction that is neither supported by

the evidenc e, intended by the trial court, nor proper ly define d? Be cause we c onclude that it is, we reve rse a

nd rema nd. F ACTUAL SUMMA RY Doris Penrod a

ppeals from a take nothing judgment entered in fa vor of Da vid R. S chec ter, M.D., I ndividually , and d/b/a Schec ter a nd Blumenf

eld, P.A., f

ollowing a jury trial on her me dical malprac tice cla im. The Events at Dr. Schec ter ’s Off ice On Aug ust 6, 2003, J essica Penr od took her g randmother , Doris Penrod, to a sur g ical ce nter fo r c a tara c t surg e ry . Pe nr od wa s sc he du le d to un de rg o cat aract s ur g e ry on he r l e ft e y e wi th Dr. Sche cter
. At approximately 11:30 a .m., Ce sar Be rdeja , M.D., an ane sthesiologist, administered

a re trobulbar injec tion of anesthesia

. The injection cause d a small retrobulbar hemorrha g e (RB H) about the siz e of a dime in the superior portion of Penrod’s ey e. RBH is a r ar e c o m plication,A t t he t i m e o f tr i al , D r. Sche ct er had seen ab o ut t wenty
- f i ve cases o f

R B H duri ng hi s t wenty
- f i ve y ear career. 1 A bru i s e o r cont us i on i s s om et i mes r ef er r ed t o by do ct ors as ec chy mo s i s . I t i nv ol ves i nj ur y t o t i s s ues i n w hi ch 2 t he capi l l ar i es ar e damaged, al l owi ng bl oo d t o s eep i nt o t he s ur r oundi ng t i s s ue.

P ro p to sis is a b u lgin g o f t h e e ye a n te rio rly o u t o f t h e o rb it. 3 oc c ur ri ngin l e ss t

ha n 2 pe rc e nt o f p a tie nts wh o r e c e ive a re tr ob ulb ar i nje c tio n, and of thi s su bs e t, about .025 perc ent suffe rs damag e to the optic nerve

. RBH c an ca use pre ssure to build up behind 1 the e y e wh ic h the bo dy re lie ve s by a llo wi ngthe e y e to m ov e fo rw ard a g a ins t th e e y e lid . T he op tic

nerve has some ela sticity

which enable s the ey e to push out to relieve pr essure . I n that instance, a rise in the intraoc ular pre ssure will not occur . The bleeding often stops due to clotting or fr om the incre asing pressure which tamponade s the bleeding

. I f t he R BH continues t o bleed, the pressure can incre ase to the point that the patient is at risk for injury to the optic nerve

. Dr
. Be rd ej a o b s er v edt h e R BH fo r fi ft ee n t o t we n t y m i n u t es . T h e s i z e o f i td i d n o tch an ge during this period of observation. Dr. Ber deja took Penrod i nto the operating room and Dr . Schecte r examined the RBH unde r a micr oscope f or three to five minutes. The RB H did not chang e and ha d tamponaded. D r. Schec ter did not observe any swelling o f t h e ey elids, redne ss in the ey e,
e c c hy mos is , disc olo ratio n of the e y e , o r p ro pto sis

. He sp e c if ic a lly e xami ne d Pe nr od ’s e y e lid s to 2 3 deter mine if there was room for the ey e to push out and re lieve the pr essure . Dr. Sche cter observe d that the ey elids were not taut. Ba sed on his clinical eva luation, he did not believe the re w as a ne ed to use the tonometer to a ssess intraocula r pressure . Neve rtheless, Dr. Schecte r canc eled the catara ct surg ery due to the risk of c omplications. A shield and ey epatc h wer e plac ed over the ey e and Penr od

wa s d isc ha

rg e d at a pp ro xima te ly

2 p .m. wi th ins tr

uc tio ns to ap ply an ice pa c k to the e y e fo r t wo to thr e e ho ur s and

to c a ll D r. Sc he c te r i f s he ha d a ny pr ob le ms. S he was als o instru c te d to re tur n to Dr. Sche cter ’s offic e the f ollowing morning

. P enrod Leaves Dr . Schecte r’s Off iceJ essica dr ove Penrod to a podiatris t’s office wher e Jessica’s mother, L ily Penrod, worke d. Th e tr ip fr om the surg ic a l c e nte r to L ily ’s pla c e of e mpl oy me nt t oo k tw e nty

to t we nty -f ive min ute s. When they

arr ived, J essica c ould see re dness ar ound the ey epatc h which had not be en ther e whe n t h ey we re at Dr
. S ch ec t er ’s o ff i ce . L i l y re m o v ed t h e ey ep at ch an d s h i el d an d s aw a l ar ge h em o rrh age around the ey e. L ily ’s employ er l o o k ed at the ey e and r ecommende d that she take Penrod to a hospi t al

. L i l y i nstead de cided that Jessica should drive Penrod home . After war d, Penrod beg an complaining of seve re pa in. J essica c laimed that she called Dr. Schecte r that afte rnoon to repor t that Pe nr od wa s e xpe ri e nc inge xtre me pai n and a sk e d w he the r s he sh ou ld t a ke Pe nr od to t he ho sp ita l. Dr . Sc he c te r p ur

po rt e dly tol d Jess ic a no t to g o to the ho sp ita l and ins tr uc te d h e r t o r e tur

n Pe nr od to his office the following morning . He a lso told J essica to g ive P enrod some Ty lenol 3. Dr. Sche cter denied speaking with J essica that afte rnoon and denied prescr ibing Ty lenol 3. He would not have advised Jessica ag ainst taking her g randmother to the hospital. The Second Visi t and the Afterm ath P en ro d , ac co mp an i edb y

J es s i ca , re tu rn ed

t o Dr
. S ch e c t e r ’ s o ff

i ce t h e f o l l o wi n g m o rn i n g. There was substantial bruising around the ey e and Penrod had no vision--only light per ception. She could n o t id e n ti f

y tw o f in g e r s h e ld u

p in f r o n t o f h e r . D r . Sc h e c te r c o n c lu d e d th a t Penr od had suffe red a reble ed af

ter she le ft hi s o ff

i ce the pre vious day . He pr escr ibed L umiga n drops and Ne p ta zi n e , w h ic h ar e u s e d to lo w e r in tr a o c u la r p r e s s u r e . Je s s ic a to o k Pe n r o d h o me b u t she

con ti n u e d to s u f f e r f r o m s ig n if

ic an t e y e p a in

. Je s s ic a

c a ll e d D r . Sc h e c te r

ar o u n d 1 p . m. that

a ft e rn oo n and he a dv ise d he r to take Pe nr od to the ho sp ita l and to te ll the e me rg e nc y ro om sta ff to
c a ll h im. Pe nr od

did no t pr e se nt at th e ER u

nti l 6 p .m. that e ve nin g and th e ER st aff d id n ot c a ll Dr. Sche cter

until approx imately

2:30 a .m. He went direc tly to the ER and examined the ey e. The proptosis appea

red the same a

nd Dr. Sche cter conclude d that Penrod’s ey e pain was due to swellingA l at er al c an t h ot omy i s a s u r g i ca l di v i s i on of t h e ou t er c an t h u s t o r el ea s e t h e ac cu mu l at ed bl ood. 4 of the c on jun c tiv a and str e tc hin g of ne rv e e nd ing s. He dis c us se d p e rf or min g a la te ra l c anth oto my 4 but did not believe it was nec essar y . Penrod re turned to Dr. Sche cter ’s offic e a w eek later. Th e v i s ion in the left ey e had not improved. Dr. Schecte r measure d the intraocula r pressure using the tonometer a nd deter mined that it was normal. When Penrod’s vision di d not improve afte r three wee ks, Dr. Schec ter sent he r to a sp e c ia lis t, D r. Roy

L e vit , to de te rm ine wh e the r s he had op tic ne rv e or

re tin a l da

ma g e . D r. L e vit f o u n d t h a tP e n r o d

d i d n o th a v e m a c u l ar o r r e t i n a l c h an g e s b u ts h e h a d s e v e r e i s c h e m i c o p t i c a t r o p h y. RBH is one possible c ause of ischemic opti c atr ophy , but Dr. L evit opined it could also be c aused by tox icity resulting from the injec tion, or blockag e in a blood vesse l from the injection. The Exp ert s At t ri al , P en ro d

o ff er edt h e t es t i m o n y

o f O l i v er S ch ei n , M
. D. , a p ro fe s s o r o f o p h t h al m o l o gy
a t th e Wilme r Ey e I ns tit

ute a t J oh ns Ho pk ins Un ive rs ity

. Dr . Sch e in spe nd s a bo ut o ne -h a lf

of his tim e in d ir e c t patie nt c are wi th mos t of the re ma ind e r of his tim e de vo te d to c lin ic a l re se arc h. Hi s expertise is in the anterior se g ment of the e y e and h e primarily specia liz es in catara ct, catara ct surg ery , and complications of catar act surg ery . Dr. Schein explained to the jury the structure s of the ey e and the function of those structure s, including the optic nerve . The optic ne rve r equire s ox y g en to survive. Consequently , if the blood supply to the optic nerve and its c oating is dimi nished from

c omp re ssi on

fo r a lon g e no ug h pe ri od of tim e , th e n th e ne rv e wi ll c e a se to f un c tio n a nd wi ll r e su lt in loss of vision. When a retrobulbar injection is made, the needle is inserted between the bone and the ey e into the space behind the ey e. I t is possi ble that the nee dle could enc ounter a nd lace rate a blood vessel. Beca

use the spac e behind the e y e is enc losed, it fills up wit h blood within seconds and there is no pla ce for the blood to esca pe. As a re sult, it seeps f

orwa rd and c an be se en in the upperand lower

ey elids and i n t h e wh i t e p art of the ey e. The bleedingoften stops bec ause the pressure tamponades the lace rate d vessel, but pre ssure is also plac ed on the e y e itself. Dr. Sche in viewed a

photogr aph of Penr od taken by her gr andmother on Aug ust 6, 2003, the day of surg ery . The uppe r and lowe r lids a re dark with blood and the ey e is swollen and pr otruding from pre ssure. In Dr. Sche in’s expert opinion, the standard of c are require d Dr. S chec ter to mea sure intraocula r ey e pre ssure through the use of a tonom eter
. I f the pre ssure is substantially elevated, the appropr iate interve ntion would be to perform a proc edure known as a latera l canthotomy

which involves cutting a

tendon in the ey elid to cre ate a n opening for the blood to move forwar d and re duce p r e s s u r e o nt h e e ye . If t h a t f a i l e d t o r e d

u c e t h e p r e s s u r e , a

s m a l l o p e n i n g c o u l d

b e m a d e i nt h e e ye to remove some of the aqueous. Dr. S chein acknowledg ed that there ar e medicine s which ca n bring the pre ssure down but they take thirty

to six ty minutes t o wo rk . Dr. Sche in believed that Dr. S chec ter’s method of detec ting e levated e y e pre ssure-- moving the e y elid to determine mobility

-- was not an a ssessment at all bec ause the pressure could be elevated even wher e the e y elid is mobil e. On cr oss-examination, he admitted that clinical obser vation of ey elid elasticity is part of a

n assessment, but he maintaine d that mere observation is i nadequate and Dr . Schecte r shoul d have used a tonomete r. In his opinion, Dr
. S ch ecte r did not do enoug h to determine w hether a later al canthotomy

should have be en per formed. Dr. Sche in also testified t h at t here could be c ompression of the optic ne rve e ven in the pr e se nc e of a no rm a l e y e pr e ssu re re a din g . Thus , the sta

nd ard of c are a lso re qu ir e d Dr
. Sc he c te r t o evaluate Penrod’s vision a nd the response of her pupils to light four to six hours af ter surg ery . Due to the anesthe sia injection, i t i s i m p o s s ible to measure vision unti l the anesthe sia wea rs off. Acc ording to Dr. Schein, damag e to the optic ner ve fr om compression could occur in an hour or two,
or occ ur over

a long er pe riod of t ime. He c ould not state whether the damag e to Penrod’s optic ne rveoccur

red two hour s after

the RBH or

twenty -four

hours later . Dr. Sche cter d i d not examine her vision until the foll owing day approximately

twenty -four

hours af ter the r etrobulbar

injection. I f her vision was poor at this time, a phy sician should be conc erne d about compre ssion of the optic nerve

. I n such a case , a CAT scan of the ey e would be the next s tep. Fina lly , a phy sician should perf orm surg ery to evac uate the blood acc umulated behind the ey e. All of t hese procedur es shoul d be done within twenty -four

hours of the r etrobulbar

injecti o n. I n Dr. Sche in’s opinion, Penrod’s loss of vision could have oc curr ed through two mecha nisms: incre ased intraocular pressure or compre ssion of the optic ne rve f

rom blood acc umul at ed i n t h e b ac k of the e y e. F urther, he opined that it was

re a so na bly fo re se e a ble that Dr
. Sc he c te r’ s fa ilure to me a sure the int ra oc ula r pr e ssu re and e va luate h er v i s i o n l ed t o d am age o f t h e o p t i c n er v e an d l o s s o f v i s i o n . Dr
. S ch ei n ac kn o wl ed gedt h at d am age to the optic nerve following RBH c ould occur without neg lige nce. Dr. Sche cter

offe red the ex p ert testimony of B erna

rd A. Milstein, M.D., the Clinical Pr of e sso r o f O ph tha lmo log y

a t th e Un ive rs ity

of Te xas M e dic a l B ra

nc h in G a lve sto n. Dr . M ils te in de vo te s a pp ro xima te ly

95 pe rc e nt o f h is t ime to p a tie nt c are , a nd in the la st fi ft e e n to tw e nty y e ars , his pr a c tic e ha s c e nte re d a ro un d c a tara c t surg e ry

and int ra oc ula r l e ns imp lantatio n u sin g Ve ri sy se Phakic and L asik surg ery . Dr. Milstein aver ag es 400 to 500 case s of catara ct surg ery per y ear and he has extensive e x perie nce with r etrobulbar injections. Dr. Milstein explained for the jury how a retrobulba

r injection is perf

ormed and he descr ibed the potential complications which could occ ur. I n addition to an RBH, the optic nerve can be damage d by the i njection i tself or the ane sthetic ca n
cause a toxi c injury . He c ould not determine whic h of these e vents ca used Penro d ’s o p t i c ner

ve
a tr op hy . In h is o pin ion , if Dr . B e rd e

ja inj e c te d th e op tic ne rv e or if the ane sth e tic c a

us e d a toxic injury , Dr. Sche cter co u l d not have take n any action which w ould have pr evente d damag e to the optic nerve . I t ha s been postulated that if there is pressure behind the ey e fr om the blood pushingI n hi s b ri ef on ap p eal , D r. Sche ct er maint ai ns t hat he did no t request an i nst ruct i o n on new and i nd ep end ent 5 cau s e but i ns t ead r eques t ed an un avoi dabl e a cci dent i ns t r uct i on. In his fi r s t amended an s wer , D r . Sche ct er r ai s ed num erous de f

en s i v e mat t er s , i n cl u di n g bot h u n av oi dabl e ac ci den t an d n ew an d i n depe n den t ca u s e. Pri or t o t r i al , D r. Schec t er f

i l ed hi s r eques t ed def

i ni t i ons an d i ns t r uct i ons wh i ch i ncl uded an i ns t r uct i on o n new and i ndependen t ca us e. T he reco rd b ef

o re us ref

l ect s t hat D r. Sche ct er i nd eed t end ered a wri t t en i nst ruct i o n o n unavo i d ab l e accident whi ch t he t r i al c ou r t de n i ed du r i n g t r i al

. Coun s el ’ s obje ct i on t o t h e a bs en ce of a “ n ew a n d u n ex pec t ed ca u s e” i n s t r u ct i on s ou n ds m o re li ke “new an d i nd ep en d en t ca use ” t ha n “ un av o i d ab l e ac cid en t ,” b ut t he rec o rd d o es no t i nc l ud e a writ t en req ue st f o r a “ new and i nd ep end ent cause” i nst ruct i o n. the g lobe forw ard, the pressure of the e y e ag ainst the lids can ca use pre ssure insi d e t h e ey e . Dr. Milstein agr eed w ith Dr. Sc h ec ter that a n ophthalmologist ca

n assess whe ther ther e is too much pressure behind the ey e by fee ling the te nsile pres s u re o n t h e lids. I f the lids are taut, a later al

c anth oto my

c an b e pe rf

or me d to re du c e or

re lie ve the pr e ssu

re on the lid s and

a llo w the g lob e to move forw ar d

. I f there is no pressure on the lids from the ey e, then ther e is no rea son to use a tonometer or to pe rfor

m the latera l canthotomy . Ba sed on his r eview of the rec ords and the evidenc e prese nted to him, Dr. Milstein conclude d that a re asonably prudent ophthalmic surg eon would not have use d a tonometer

on the day o f s u rge ry

g iven the abse nce of

tautness in the ey elids. Dr. Mil ste in a lso fo un d that a reas on a bly pr ud e nt o ph tha lmo log ist

wo uld have re le a se d Pe nr od

wi th instructions to call if a proble m arose a nd to return to the of

fice the following day

. The Charge Conference During the cha rg e conf er en ce , Dr
. S ch ec t er ’s co u n s el o b j ec t edt o t h e c o u rt ’s fa i l u re t o i n clude an instruction on “new and unexpected c ause.” The c ourt denied that reque st. I mmediately afte r 5 t h at ru l i n g, P en ro d ’s co u n s el p o i n t edo u tt h at t h e p ro x i m at e cau s e de fi n i t i o n i n cl u d ed i n t h e c h ar ge had the “ unbroken by

any new a nd independe nt c ause” lang uag e in it. The cour t cut counsel off

, stating that Dr. Schec ter’s c ounsel had re quested a n instruction on una

voidable acc ident and said, “L et’s just not waste time.” The court’s c harg e included the following definition: ‘P RO XI MA TE CA USE ’, wh e n u se d w ithre sp e c t to the c on du c t of DA VI D R
. SCHECTER, M .D., means that cause which, in a natura l and continuous sequenc e, un br ok e n by an y ne w an d ind

e pe nd e nt c au se , produce s an event, and without whichcause such eve nt would not have occur red. I n order to be a pr ox imate ca use, the a ct or omission complained of must be such tha t an o phthalmic surg eon exerc ising ordinary car e would have fore seen that t h e ev ent, or some sim ilar eve nt, might rea sonab ly

r e s u lt th e r e f r o m. T h e r e ma

y b e mo r e th ano n e p r o xim a te c a u s e o f an e v e n t. [E mp h a s is a d d e d ]. The jury found that the neg lige nce, if any , of Dr. Schecte r did not proxi mately cause the occ urre nce in question. Penrod filed a mot i o n fo r n ew trial complaining that the inclusion of the “ne w and independe nt cause ” languag e in the proximate cause instruction was errone ous. At the hea ring on t h e m o t i o nfo r n ew t ri al , t h e t ri al j u d ge a d m i t t edt h at i twa s n o th i s i n t en t i o nt o l ea v e t h at l an gu age in the definition since he ha d denie d Dr. Sche cter ’s re quest for a n instruction on “new a nd independe nt cause .” He had noticed the err or whe n he wa s rea ding the char g e to the jury . The c ourt also observe d that Penrod’s c ounsel had attempted to bring t h e er ro r t o his attention but he was focuse d on something e lse at the time. Trial court: An d f

or the re c or d, it wa s the Court ’s mis take to le a ve that w or din g in under p ro x i m ate c ause be cause Ihad found not to instruct them on new and independe nt cause . You did point it out to me; however , Ithink I was looking at something e lse at the time and, f rankly , as I wa s re ad ing the char g e, I rea liz ed that that shouldn’t have be en i n t h ere in proxi mate ca use. And then I

know Mr. Hicks argue d th a t. So, for the re cord, the Court did make a mistake in le aving that in the definition of proxi mate ca

use. Whether that’ s harmful e rror or no er ror at all, we’ll see

. * * * * * Trial court: And fra

nkly , my mind was some place else, but he’ s telling me, “I f y ou leave it in there,” quote , “unbroke n by any new and independe nt cause ,” bec ause you a ssume d th a t y ou

we re g oin g to g e t th e inf e re nti a l r e bu tta l. S o , I ’ v e g o t m y m i s t a k e an d t h e n r i g h t f u l l y s o , r i g h t f

u l l y s o , I d o n ’ tthi nk

y ou did any thi ngwr on g in ar g uin g it be c a us e it’ s th e re . I

g a ve it t o y ou . So Ido n’ t kn owif that compounds or mag nifies my err or. * * * * * Trial court: And, for the rec ord, whoe ver r eads this record upstairs, I never intendedfor that to g o in. Imade a mistake. Now, whether that’s harmful or harmless is for somebody

else to dec ide. Ultimately , the trial cour

t denied the motion for ne w trial and this appe al follows. P RO XI M AT E C AU SE IN STR UC TIO N I n two related i ssues for review, Penrod contends that the take nothing judgme nt should be

reve rsed be cause of the e rrone ous inclusion of t he “ne w and indepe ndence cause ” languag e in the definition of proxi m at e cause. Dr. Sche cter responds that the de finition did not misstate the law. Al te rn a tiv e ly , h e argue s th a t th e e rr or is h arm le ss. P rese rvation of E rror Dr. Sche cter

did not raise prese rvation of err or in his brief, but he asser ted at ora l argument that Penrod has waived her complaint about the proxi mate ca use instruction. Rule 274 of the Te x as Rul e s o f C ivi l Pr oc e dure pr ov ide s: A par ty objecting to a char g e must point out di stinctly the objectionable matter a nd the g rounds of the o b

j ec t i on. Any

complaint as to a que stion, definition, or ins tr uc tio n, on a c c ount of any de fe c t, omi ssi on , or f a ult in p le a din g , is wa ive d unle ss specific ally

in cl u d ed in the objec tions. W hen the c omplaining pa rty ' s objection, or re qu e ste d q

ue sti on , d e fi nit ion , o r i ns tr uc tio n is, in the op ini on

of the a pp e llate c ourt , obscure d or concea led by

voluminous unfounded objections, minute differ entiations or numerous unnece ssary reque sts, suc h objection or reque st sha ll be untenable. N o objection to one part of the char g e may be adopted and applied to a ny other pa

rt of the cha rg e by ref ere nce only

. T EX .R.C IV .P. 2 7 4
. Un d er R u l e 2 7 2 , t h e t ri al co u rt i s re qu i re d t o ru l e o no b

j ec t i o n s t o t h e c h a r ge befor e reading the cha

rg e to the jury

. See T EX .R.C IV .P. 272. This rule also imposes a pre sumption that “the pa

rty making such objec t i o n s p rese nted the same at the prope r time and e x cepte d to the ruling there on.” Id. The Te x as Suprem e C o urt has held that Rule 272’s pr esumptive provision means that if a

n objection is articulate d and the tria l court make s no chang e in the c h ar ge, the objection i s, of nec essity , overr uled. Acord v. Gene ral Motors Corp. , 6 6 9 S. W. 2 d 1 1 1 , 1 1 4 ( T e x.1984). Rule 33.1(a )(2) (A) of the Texas Rules of Appe llate Proce dure is consistent with the Ac or d decision bec au s e it permits error to be pre serve d by

either a n express or implicit ruling on an objection. See T EX .R.A PP .P. 33.1(a)( 2)(A)

. I t is undisputed that Penrod’s attorney specific ally

objected to the inc lusion of the “unbroke n by any new and independe nt cause ” langua g e in the prox imate cause i nstruction. The trial court cut counsel off

stating, “ She reque sted one on unavoidable ac cident. L et’s just not waste time.” The court then instruc ted def

ense c ounsel to proce ed. B eca use the de finition of prox imate c a use included the lang uag e objec ted to by Penrod, we conclude that the cour t impli edly

overr uled the objec tion. There fore , Penrod pre serve d err or under Ac or d and Rule 33.1(a )(2) (A).Stand ard of Review

Rule 278 require s the trial court to “submit the questions, instructions and definitions in the form provide d by

Rule 277, which ar e ra ised by the written plea dings a nd the evidenc e.” T EX .R.C IV .P. 278. We revie w an alleg ation of j ury char g e error for an abuse of discretion. Texas Departme nt of Human Servic es. v. E.B

. , 802 S.W .2d 647, 649 (Tex. 1990); Alfiji , S.A. de C.V. v. W o o d al , 2 8 0 S
. W
. 3 d 8 9 7 , 8 9 9

- 9 0 0 ( T e x. A p p . - - E l P a s o 2 0 0 9 , n o p e t
. )

. A t r i a l c o u rt a bu se s it s discretion by

actingarbitra

rily , u nr e a s o nably , or without consideration of g uiding pr inciples. W alker v. Gutierrez , 111 S.W .3d 56, 62 (Tex. 2003). Ne w and In de pe nde nt Ca use New a nd independe nt cause is a component of the proxi mate cau s e i ssue. Col um bia Ri o Grande He althca r e, L.P. v. Hawley , 284 S.W .3d 851, 856 (Tex. 2009), citing Dallas Railw ay & Terminal Co. v. Bailey , 151 Tex. 359, 250 S .W.2d 379, 383-84 (Tex. 1952)(“The theory of newand ind e pe nd e nt c a

us e is n ot a

n a ff ir ma tiv e de fe ns e ; it is bu t an e le me nt t o b e c on sid e re d b y the jur y in deter mining the e x istence or

non-existence of pr ox imate ca use.”)

. A new and independe nt c ause of

an occ urre nce is the act or omission of a separate and indepe ndent ag ent, not rea sonably fore seea ble, that d e s tr o y s th e c a

u s a l c o n n e c ti o n , if an y , b e tw e e n th e a c t o r o mi s s io n in qu ir e d a b out and the

occur renc e in question. Columbia Rio Grande Healthcare, L.P. , 284 S.W .3d at 856. I f t he a c t or omi ssi on a lle g e d to have been a new and ind e pe nd e nt c a

us e is r e a so na

bly fore seea ble at the time of the defe ndant’s alleg ed neg lige nce, the new a ct or omission is a concur ring

cause as opposed to a supe rsedingor newand indepe ndent ca use. Id. at 857; Dew v. Crown Derrick Erectors, Inc

. , 208 S.W .3d 448, 451 (Tex. 2006). A new and indepe ndent ca

use alter s the natura l sequenc e of e vents, produce s results that would not otherwise have occurr ed, is an a ct or omission

no t br ou g ht i nto op e ratio n b y the or ig ina l w ro ng fu l a c t of the de fe nd ant, and

op e ra te s e nti re lyindepende ntly of the de fenda

nt’s all ege d ly

neg lige nt act or omission. Columbia Rio Grande Healthcare

, L.P. , 284 S.W .3d at 857.

Is t he De finit ion Er r one ous ? An instruction is proper only if it (1) assists the jury , (2) a ccur ately s t at es t h e l aw, a nd (3) f inds support in the pleading s and evide nce. Columbia Rio Grande Healthcare, L

. P. , 284 S.W .3d

a t 85 5; El Paso Refining, Inc. v . Scurlock Permian Corporation , 77 S.W .3d 374, 388 (Tex.App.-- El Pa so 20 02 , pe t. de nie d)

. Th e de fi nit ion of pr oximate c a us e su bmi tte d to the jur

y fa ils on a ll

acc ounts. I t does not assist the j u ry b ecause it includes the phr ase “ unbroken by any new a nd ind e pe nd e nt c a

us e ” wi tho ut any e xplanator y pr ov isi on s. F ur

the r, the de fi nit ion do e s no t a c c ur a te ly state the definition of prox imate cause applicable i n this case . Finally , Dr. S chec ter’s a nswer r aised t h e i s s u e o f

n e w an d i n d e p e n d e n tc a

u s e , b u tt h e e v i d e n c e d i d

n o t s u p p o rt i t s s u

b m i s s i o n t o t h e j u r

y. We understand Dr . Schecte r to posit that the new and inde pendent c ause i s the re bleed whic h

occur red a fter Penr od left t h e surg ical ce nter. While there is some e vidence in the rec ord that the RBH ha d tamponaded be fore Penrod left the sur g ical ce nter a nd beg an to reble ed sometime af ter she left, there is no evidence of what act or omission cause d the re bleed. Thus, ther e is no evidenc e that the ac t or omission which cause d the reble ed wa s not broug ht into operation by the orig inal wrong ful

a c t of the de fe nd ant. Th e re is n o e vid e nc e that th e re ble e d a lte re d the nat ur a l se qu e nc e of

e ve nts , pr od uc e d r e su lts tha

t wo uld no t oth e rw ise have oc c ur re d, or that it op e ra te d e nti re ly

ind e pe nd e ntl y of the de fenda

nt’s alleg edly

neg lige nt act or omission. We the ref ore conclude that the def

inition of proxi mate ca

use is err oneous bec ause it included the “unbroke n by new a nd i n d ep endent c ause” lang uag e. Is t he Er r one ous De finit ion Har m ful? We turn now t o a harm analy sis. A judgment will not be re verse d for c harg e er ror unless thee rr or

wa s h arm fu l be c a

us e it p ro ba

bly c a us e d th e re nd iti on

of an im pr op e r v e rd ic t or

pr ob a bly preve nted the petitioner f rom proper ly

prese nting the c ase to t h e ap p ell ate c ourts. T EX .R.A PP . P. 44.1; W al-Mart Stores, Inc. v . Johnson , 1 06 S.W. 3d 71 8, 72 3 ( Te x. 20 03 ); Alfiji , S.A. de C.V. , 280 S.W .3d at 900. Charg e er

ror is g ener ally

considere d harmful if it re lates to a contested, c ritical issue. Columbia Rio Grande Healthcare, L.P. , 284 S.W .3d at 856. Th e re c or d r e fl e c ts that c a us a ti on was a conte ste d, c ri tic a l is su e a t tr ia l. P e nr od ’s e xpe rt , Dr. Sche in, testified that the s tandar d of care require d an ophthalmolog ist to evaluate the patient’s

e y e pr e ssu

re and vis ion fo llo wi ngthe RB H a

nd fo r s e ve ra l ho ur s a ft e rw ard to e ns ur e that th e op tic

nerve had not been da

mag ed. In Dr. Sche in’s expert opinion, it was likely that Penrod’s e y e pre ssure was hig h as a r esult of t h e R BH , such that Dr. Sche cter ’s fa ilure to measur e intraoc ular pre ssure
re su lte d in

a fa ilure to t

re a t e le vate d p re ssu

re wh ic h in

tur n r e su lte d in

op tic ne rv e dama g e and

los s of vis ion

. Dr . Sch e c te r, on the oth e r hand , tes tif ie d tha t the sta

nd ard of c are did

no t r e qu ir e him

to
c o n t i n u e t o e v a l u a t e P e n r o d o n t h e d ay o f t h e s c h e d u l e d s u r g e r

y . D r . M i l s t e i na g re e d th a t a
rea sonably

prudent ophthalmolog ist woul d h ave relea sed Penrod with instructions to call if a pr ob le m aro se and

to r e tur n to the of

fi c e th e fol lo wi ng da

y . B oth Dr s. Sc he c te r a

nd Mil ste in believed that Penrod experience d a re bleed a fter she left the surg ical ce nter. Penrod maintains that the er roneous de finition of prox im ate c ause pr obably cause d the rendition of an improper judgme nt be cause it pe rmitted Dr. Schecte r to a dvocate a def ensive theor

y otherwise una

vailable to him

. I n support of her contention, Penrod points to the following portion of de fe ns e c ouns e l’ s f

ina l argume nt: Prox imate ca

use say s, ‘That c ause w hich in a continuous seque nce unbr oken by any new or independe nt cause produce s an event.’ Unbroke n by any new or independe nt cause . There was a new independent cause. A new independe nt cause is whateve r cause d it to rebleed. That is w hat broke. Even if you think Dr. Schec ter should have used th e to n o me te r , a f

te r s h e le f t h is c ar e , a f

te r th e n u r s e s f

r o m th e s u r g ic a l centerW e agree wi t h the t ri al c o urt ’ s ass ess m ent that c o unsel d i d no t hi ng w rong i n a rgui ng the i ss ue b ecause t he 6 l ang uag e wa s i ndeed i ncl uded i n t he cha r ge. saw he r, af

ter he saw her, s omething happene d that she had a reble ed. That’s a new and ind e pe ndent c a

us e that oc c ur

re d. I f you

g e t to Qu e sti on

Numbe r O ne , it

say s: Di d th e ne g lig e nc e of

Da vid R. Sc he c te r, M. D. pr oximate ly c a us e the oc c ur

re nc e in question? My

sug g estion is that the answer to that is no. I f y o u an s we r no, then y ou’re done. Def ense c ounsel seized upon the inadver tent but errone ous lang uag e in the jury char g e to ar g ue that “whatever ” ca

used the re -blee d afte r Penrod lef t the surg ical ce nter wa s a new an d independe nt
c a us e , a nd the re fo re , th e jur

y sh ou ld f ind that D r. Sc he c te r’ s n e g lig e nc e , if an y , did not pr oximate ly

cause the occ urre nce in que stion. This argument co u l d not have be en made absent the de fec tive 6 proxi mate ca

use instruction. The a

rg ument is significa

nt beca use it provided a de fense to Penrod’s claim that Dr. Sche cter

failed to monitor the RBH complication. While defense cou n s el ar g ued, based on the evidenc e, that the standard of car e did not require Dr. Sche cter to continue to monitor Penrod’s c ondition on the day of surg ery , the defe ctive proxi mate cause definition permitted counse l to sidestep Dr. Sche in’s expert opini o n t hat Dr. Sche cter should have c ontinued to monitor the complication. I nstead, he was a ble to argue t h at t h er e was a newand indepe ndent ca use for the reble ed, albe it that the “whate ver c aused it to reble ed” w as neve r identified. Dr. Sche cter

contends that the e rror

is harmless bec ause the jury could have reje cted Dr

. Schein’s testi mony g iven t he testi mony about alternative causes for Appellant’s loss of vision that

we re un re la te d to Dr . Sc he c te r’ s c on du c t. H e c ite s Jame s v. Kloos , 75 S.W .3d 153 (Tex.App.--F ort Worth 2002, no pet.) in sup p ort of his argument. There , the trial cour t gr anted the de fenda

nt’s reque st for an instruc tion on new and independe nt cause . The c ourt of appe als deter mined that the instruction should not have been give n beca use t he defenda

nt failed to prese nt any evidenc e of a n act or omission of a separ ate and independe nt ag ency that destroy ed the c ausal c onnection betwe enthe def

endant’ s alleg edly neg lige nt a ct and the pla intiff’s injury

. Id. a t 16 3. Thus , th e de fe nd ant d id not offer evidenc e that the plaintiff’ s injury was not a r easona

bly fore seea ble re sult or natural conseque nce of

the in ci d en t i n q uestion. Id. at 162-63. The court de termined, howe ver, that the ins tr uc tio n w a s n ot h arm fu l be c a us e de fe ns e me nti on ed new and ind e pe nd e nt c a

us e on ly tw ic e in sixte e n p a g e s o f a

rgume nt an d it c ou ld n ot b e de te rm ine d th a t th e imp ro pe r i ns tr uc tio n r e su lte d in an improper

judgme nt. Id. at 163-64. J am es is f a c tua lly dis tin g uis ha

ble . T he tr ia l c ourt

the re int e nti on a lly su

bmi tte d a pr op e rl y worde d instruction on new and inde pendent cause . As it turne d out, the char g e should not have bee n g ive n. He re , the tr ia l c ourt did no t in str uc t th e jur y on ne w a nd ind e pe nd e nt c a

us e bu t in a dv e rt e ntl y left the new and independe nt c ause lang uag e in the definition of proxi mate cause . I n the abse nce of

an in str uc tio n to g uid e the jur

y ’s c on sid e ra

tio n of ne w a nd ind e pe nd e nt c a

us e , th e jur

y wa s a ble to disreg ard w hether

Penrod’s injury

was a natura l conseque nce of Dr. S chec ter’s failure to moni tor the

c omp lic a tio n if

it f ound , at de fe ns e c ouns e l’ s urg ing , th a t something cause d it to rebleed a fter she left the surg ical ce nter. CO NC LU SION Under the unique fa cts prese nted, we c onclude that t h e ch arge err or proba bly cause d the

re nd iti on of an im pr op e r v e rd ic t. A c c or din g ly , w e su sta in I ssu e s O ne and Tw o an d re mand the c a us e fo r a ne w tri a l.
November

12, 2009 ANN CRAWFORD McCLURE, J ustice B e f o r e C h e w , C
. J. , M c C l u r e , a n d R i v e r a , JJ.