Title: Hackman v. Christiana Care Health
Citation: N/A
Docket Number: 514, 2003
State: Delaware
Issuer: Delaware Supreme Court
Date: November 15, 2004

IN THE SUPREME COURT OF THE STATE OF DELAWARE
CAROL G. HACKMAN, Individually
§
and in her Capacities as Surviving Spouse
§
No. 514, 2003
of Charles H. Hackman, and as
§
Administratrix of the Estate of
§
Charles H. Hackman, Deceased, and
§
CHARLES H. HACKMAN, JR.,
§
§
Plaintiffs Below,
§
Appellants,
§
§
v.
§
Court Below: 
§
Superior Court of the
CHRISTIANA CARE HEALTH
§
State of Delaware in and
SERVICES, INC., a/k/a CHRISTIANA
§
for New Castle County
CARE HEALTH SYSTEM, a corporation
§
C.A. No. 00C-05-184
of the State of Delaware, WILLIAM J.
§
C.A. No. 00C-11-207
SCHICKLER, M.D., P.A., WILLIAM J.
§
(Consolidated Cases)
SCHICKLER, M.D., VASCULAR
§
CONSULTANTS, P.A., a corporation of
§
the State of Delaware, BRUCE A. 
§
FELLOWS, M.D., and VASCULAR §
SURGERY ASSOCIATES, P.A., a 
§
corporation of the State of Delaware, §
§
Defendants Below,
§
Appellees.
§
Submitted: September 8, 2004
Decided: November 15, 2004
Before STEELE, Chief Justice, BERGER and JACOBS, Justices.
Upon appeal from the Superior Court.  AFFIRMED.
2
Ben T. Castle, Esquire (argued), and Neilli Mullen Walsh, Esquire, of Young,
Conaway, Stargatt & Taylor, LLP, Wilmington, Delaware, for Appellants.
Dennis D. Ferri, Esquire (argued), of Morris, James, Hitchens & Williams,
LLP, Wilmington, Delaware, for Appellee Christiana Care Health Services,
Inc., a/k/a Christiana Care Health System, and Danielle K. Yearick, Esquire
(argued), of Tybout, Redfearn & Pell, Wilmington, Delaware, for Appellee
William Schickler, M.D., P.A. and William J. Schickler, M.D. and Vascular
Consultants, P.A., and John A. Elzufon, Esquire (argued), and Colleen D.
Shields, Esquire, of Elzufon, Austin, Reardon, Tarlov & Mondell, P.A.,
Wilmington, Delaware, for Appellees Bruce A. Fellows, M.D., and Vascular
Surgery Associates, P.A.
BERGER, Justice:
In this appeal, we consider whether the Superior Court erred in excluding
expert testimony in a medical malpractice case.  Appellant’s expert was
prepared to testify that it would have been a breach of the applicable standard
3
of care if the appellee surgeon had punctured the patient’s duodenum during
surgery.  But there was no evidence that the surgeon did puncture the
duodenum, and even appellant’s expert did not believe that the perforation that
later proved fatal to the patient occurred during the surgery.  Given these facts,
we conclude that the trial court acted within its discretion in excluding the
disputed expert testimony.  Since appellant had no other medical expert to
opine that there was a breach of the standard of care, the trial court properly
granted the surgeon’s motion for judgment as a matter of law.
Factual and Procedural Background
On November 24, 1998, William J. Schickler, M.D., a board certified
vascular surgeon, operated on Charles Hackman to repair an abdominal aortic
aneurysm.  Due to the size and location of the aneurysm, the surgery took
almost ten hours, twice as long as expected.  Schickler had to use surgical
scissors to separate the duodenum, which is part of the bowel,  from the aorta.
There were no reported complications immediately following the surgery.
The next day, Schickler examined Hackman, and saw no evidence of
bleeding.  Hackman’s vital signs were stable and his femoral pulses indicated
that the aortic repair was functioning properly.  That evening, Schickler went
4
off-call for Thanksgiving. For the next five days,  Hackman was transferred to
the care of surgical residents at Christiana Care Health Services, Inc. and Bruce
A. Fellows, M.D., also a board certified vascular surgeon.  By Saturday,
November 28 , Hackman was suffering increased pain, labored breathing,
th
difficulty speaking, and abdominal swelling and tenderness.  The attending
physician believed that Hackman had developed pneumonia, which is not an
unusual complication.  On the evening of November 29 ,  Fellows telephoned
th
Schickler and reported that Hackman had been placed back on a ventilator
because he had developed pneumonia. Fellows reported no evidence of a
breakdown of the bowels or any other abdominal problem.  
When Schickler returned on November 30 , he immediately recognized
th
serious deterioration in Hackman’s condition.  Hackman had no bowel sounds,
his abdomen was distended, and he was complaining of significant abdominal
pain.  Schickler called Dr. Zern, a general surgeon, to perform emergency
surgery.  During that surgery, Zern and Schickler found bile-stained fluid in the
abdomen and a hole in the duodenum.  Zern attempted to repair the perforation,
but due primarily to the level of infection and leakage that had already
occurred, the repair failed.
5
On December 3 ,  Zern attempted a second repair of the duodenum, but
rd
Hackman’s condition continued to deteriorate.  He remained in the Christiana
Care hospital, undergoing multiple procedures, until February 10, 1999, when
he was transferred to the University of Pennsylvania hospital for further
abdominal surgery. Dr. Jeffrey Carpenter performed emergency surgery that
day, but Hackman died on the operating table.
Hackman’s wife and son filed suit against Schickler, his professional
corporation, Vascular Consultants, Christiana Care Health Services Inc.,
Fellows, and his professional corporation, Vascular Surgery Associates.
Appellants alleged that Schickler negligently: (1) perforated Hackman’s
duodenum during the November 24  surgery; and (2) failed to leave adequate
th
instructions for the other attending physicians during the period that Schickler
was on vacation.  They also alleged that the hospital and its attending
physicians should have detected the duodenal perforation before the November
30   emergency surgery, in light of symptoms that were apparent no later than
th
November 29 .  
th
On the first day of the trial, Schickler moved to exclude certain testimony
of Dr. Novin, appellants’ only medical expert.  Novin was prepared to testify
that, although he did not believe that Schickler had done so, if Schickler had
6
perforated the bowel during the November 24   surgery, then that would have
th
been a breach of the standard of care.  The trial court granted Schickler’s
motion, reasoning that Novin’s testimony was merely hypothetical, since there
was no evidence that the perforation occurred during that surgery.  The court
concluded that the testimony would be unduly prejudicial and confusing. 
The trial court also excluded Carpenter’s Report of Operation.  The
Report, which had been admitted into evidence without objection, included a
statement that,“[t]here was a duodenal injury at the time of the aneurysm repair,
which went unrecognized; and [the] patient developed abdominal sepsis…”  As
appellants’ counsel was asking Schickler to read that sentence, appellees
objected on hearsay grounds and the objection was sustained.  
At the close of all the evidence, the trial court granted Schickler’s motion
for judgment as a matter of law.  The court found that there was no evidence
from which a jury could find that Schickler’s alleged lack of instructions to the
other attending physicians caused any harm.  The jury returned verdicts in favor
of the remaining appellees.  This appeal followed.   
DISCUSSION
In order to survive a motion for judgment as a matter of law, appellants
must produce medical expert testimony that specifies (1) the applicable
   
1
Green v. Weiner, 766 A.2d 492, 494-495 (Del. 2001); 18 Del. C. §6853.
7
standard of care, (2) the alleged deviation from that standard, and (3) the causal
link between the deviation and the alleged injury.   Appellants attempted to
1
meet this burden by having Novin testify that, if Schickler had perforated the
duodenum during the November 24   surgery, Schickler would have breached
th
the applicable standard of care.   Appellants then intended to rely on other
evidence, including Schickler’s admissions, to establish that he did, in fact,
puncture the duodenum.  There was no dispute about the fact that the perforated
duodenum caused the serious injuries that culminated in Hackman’s death. 
Having excluded Novin’s surgery standard of care testimony, the trial
court did not even consider the negligent surgery claim when ruling on
Schickler’s motion for judgment as a matter of law.  The trial court found that
the remaining claim –  that Schickler negligently failed to provide Fellows with
enough information about Hackman’s condition after the surgery – was
unsupported in the record.  Accordingly, the trial court granted Schickler’s
motion for judgment as a matter of law.
Appellants did not appeal the decision on the “lack of information”
claim, and they only suggest in passing that the surgery claim remained viable
We are not considering appellants’ one paragraph argument on this point because, among other
2
things, it does not appear that it was presented to the trial court.  See: Supr. Ct. R. 8.
8
despite the exclusion of Novin’s testimony.   The crux of their appeal is that
2
Novin’s testimony should have been allowed.  They argue that Novin’s
testimony, combined with  the note in Carpenter’s report and Schickler’s trial
testimony, provided enough evidence to defeat a motion for judgment as a
matter of law.  We disagree.
Viewing the evidence in the light most favorable to appellants, one could
conclude that Schickler “nicked” or “bruised” the duodenum during the first
surgery.  There is no evidence, however, that Schickler punctured it.  This
distinction is critical because no medical expert, including Novin, was prepared
to testify that it would be a breach of the standard of care for a surgeon to nick
or bruise the duodenum during a complicated surgery such as this one.  Thus,
without evidence that Schickler actually punctured the bowel, there was nothing
to support a finding of negligence. 
Novin and Schickler basically agreed on what happened during the
aneurysm surgery and on the conclusion that the perforation occurred several
days later.  Novin also opined unequivocally that Schickler did not breach the
applicable standard of care during the course of the surgery:
9
  Q: And here’s a sentence in the report which says,
“in his opinion,” meaning yours, “a breach in the
standard of care occurred with an instrumentation
perforation injury to the duodenum.”
Am I correct that you do not agree with that statement?
  A: I modified it, that the procedure of dissecting the
duodenum off the aorta and the aorta off the
duodenum using clamps, scissors, fingers, knives,
retractors, resulted in damage to the fourth portion of
the duodenum that caused the perforation that was
manifest 24 to 48 or even 72 hours after the
operative procedure was completed. 
       
    Q: You do not believe that there was an
instrumentation perforation during the surgery,
correct?
   A: That is correct.
*          *          *
    Q: Other than failing to, in your opinion,
communicate to Dr. Fellows the length and difficulty
of this aneurysm repair, do you have any other
opinions that Dr. Schickler breached the standard of
care in the treatment he rendered to Mr. Hackman?
    A:  No.
Schickler’s testimony provided no evidence to the contrary.  After the
November 30  surgery, during which he and Zern discovered the hole in
th
Hackman’s duodenum, Schickler thought about how the perforation occurred.
He told the Hackman family and, later, the attorneys, the same thing:
10
     Q: And I would expect the next natural question
[from the family] would be; how did that happen?
Do you remember any discussion about that?
     A: I stated to the family that this may very well
have been following the manipulation of the
duodenum.
*          *          *
     Q:...I asked you when you saw the perforation
with Dr. Zern, this would have been on November
30, did you make a judgement at that time about
what had caused it?  Could you tell us what your
answer was?
      A: My concern was that it was possibly related to
the mobilization of the duodenum to get to his aorta.
Later in his testimony, Schickler agreed that, if he had punctured the
duodenum, and he failed to notice that it was leaking for three to four hours,
that he would have breached the standard of care.  But he did not believe that
he punctured the duodenum, and he explained why:
     Q:  Did you make a hole in the duodenum?
     A:  No, ma’am.
     Q:  How do you know?
     A:  Because the duodenum is sitting right
there....At the end of the procedure you close that big
aneurysm sack over the graft, you then close the
retro peritoneal because you want to keep your
aneurysm repair separate from the intestines.  That
Carpenter’s report, which was excluded from evidence, is not necessarily inconsistent with that
3
conclusion.  The report stated that there was a “duodenal injury at the time of the aneurysm
repair, which went unrecognized....”  Whether labeled a “nick,” “bruise,” or “injury,” the fact
remains that it was something other than a puncture.
11
process, the duodenum is sitting right there in middle
of your operative field.  The hole, if it were to be
made, would have been made early in the operation.
This would have been leaking for at least three, four,
five hours before we closed.
*           *           *
     Q: Describe for the jury, if you could, we heard
leakage and fluid; what would the leakage look like?
       A: We would expect it to be greenish color
because it is right after the bile duct enters the
duodenum.
      Q: Would that be noticeable and how would that
appear?
       A: Extremely easy to notice. 
In sum, the evidence relating to the initial surgery, and the manner in
which Schickler performed that surgery, was consistent.  The aneurysm repair
was a very difficult procedure that required manipulation of the duodenum.
During that surgery, Schickler may have nicked or bruised the duodenum.   At
3
some point during the five days following the surgery, the duodenum
perforated.  Although it would have been a breach of the applicable standard
12
of care if Schickler had punctured the duodenum during the surgery, there are
no facts suggesting that the perforation occurred at that time.
Based on our review of the record, we are satisfied that the Superior
Court acted within its discretion in excluding Novin’s standard of care opinion
relating to the surgery.  Since there was no factual support for the predicate
assumption – that Schickler punctured the duodenum during the surgery –
Novin’s opinion lacked probative value and, if admitted, could have confused
the jury.  The same lack of evidence required the entry of judgment in
Schickler’s favor, as there was no medical expert testimony from which a jury
could find that he breached the applicable standard of care.
Conclusion
Based on the foregoing, the judgment of the Superior Court is affirmed.