Title: Poliquin v. Daniels
Citation: N/A
Docket Number: 961719
State: Virginia
Issuer: Virginia Supreme Court
Date: June 6, 1997

Present:  All the Justices 
 
JAMES R. POLIQUIN, M.D., ET AL. 
 
v.  Record No. 961719 
 
FELICIA DANIELS, ADMINISTRATRIX 
  OF THE ESTATE OF SAMUEL DANIELS, DECEASED 
 
 
OPINION BY JUSTICE ROSCOE B. STEPHENSON, JR. 
 
June 6, 1997 
 
M. ABEY ALBERT, M.D., ET AL. 
 
v.  Record No. 961761 
 
FELICIA DANIELS, ADMINISTRATRIX 
OF THE ESTATE OF SAMUEL DANIELS, DECEASED 
 
 
FROM THE CIRCUIT COURT OF THE CITY OF RICHMOND 
 
Melvin R. Hughes, Jr., Judge 
 
 
These two related medical malpractice cases present issues 
regarding (1) the testimony of expert witnesses, (2) the 
sufficiency of the evidence to support the trial court's 
judgment, and (3) the refusal of certain jury instructions. 
 
I 
 
Samuel Daniels (Daniels) died following surgery on June 13, 
1993.  His widow, Felicia Daniels (the Plaintiff), qualified as 
administratrix of the estate and, thereafter, filed a motion for 
judgment against James R. Poliquin, M.D., a general surgeon, 
along with his professional corporation, Commonwealth General and 
Vascular Surgery, P.C. (collectively, Poliquin), and against M. 
Abey Albert, M.D., an anesthesiologist, along with his 
professional group, Midlothian Anesthesia Associates, Inc. 
(collectively, Albert).  The Plaintiff alleged that Drs. Poliquin 
and Albert negligently breached the applicable standards of care 
and that their negligence proximately caused Daniels' death. 
 
 
 
 
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The case was tried by a jury which returned a verdict in 
favor of the Plaintiff against Poliquin and Albert in the amount 
of $1,004,929.14.  After considering the defendants' motions to 
set aside the verdict, the trial court overruled the motions, 
except to reduce the amount of the verdict to $1,000,000 in 
accordance with the statutory limitation on recovery.  Code 
§ 8.01-581.15.  On May 29, 1996, the trial court entered final 
judgment on the verdict as amended.  Poliquin and Albert 
(collectively, the Defendants) appeal. 
 
II 
 
According to established law, we must view the evidence in 
the light most favorable to the Plaintiff, the prevailing party 
at trial.  On June 12, 1993, Daniels went to a medical clinic for 
treatment of a perirectal abscess and associated pain and fever. 
 The clinic referred Daniels to the emergency room of Johnston-
Willis Hospital for further evaluation.  At the hospital, Daniels 
was examined by Dr. Poliquin who determined that the abscess 
required surgery.  Dr. Poliquin admitted Daniels to the hospital 
and scheduled him for surgery the next morning. 
 
Daniels was hypertensive, diabetic, and obese, and, because 
of the surgical risks associated with these conditions, Dr. 
Poliquin ordered, among other tests, an electrocardiogram (EKG) 
to detect whether Daniels had any pulmonary or cardiac diseases. 
 The EKG was performed on June 12, 1993, about 10:30 p.m., and 
Dr.  Poliquin referred the EKG tracing to a cardiologist for 
 
 
 
 
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interpretation.   
 
On the morning of June 13, Dr. Albert arrived at the 
hospital to administer the anesthesia for Daniels' surgery.  Dr. 
Albert noted that Daniels was obese and had a history of 
hypertension and diabetes and that Daniels suffered from 
shortness of breath.  Dr. Albert also noted that the EKG tracing, 
which had not yet been interpreted by a cardiologist, showed 
signs of abnormality, but he neither reported that fact to Dr. 
Poliquin nor sought an interpretation of the tracing by a 
cardiologist.    
 
The surgery, performed by Dr. Poliquin, proceeded as 
scheduled, and Daniels was placed under general anesthesia.  At 
the conclusion of the surgery, Dr. Albert noticed that Daniels 
was experiencing difficulty breathing, and he attempted to 
intubate Daniels again.  Daniels, however, became unresponsive, 
went into cardiac arrest, and, despite resuscitation efforts, 
died. 
 
Later on the morning of June 13, a cardiologist interpreted 
Daniels' EKG tracing and noted that it showed that Daniels 
possibly had previously suffered a myocardial infarction; i.e., 
heart attack.  According to an autopsy, Daniels had suffered a 
silent myocardial infarction at least one week prior to his 
death.
1
                     
     
1At trial, an expert witness explained that a silent 
myocardial infarction "refers to the fact that the patient does 
not feel pain . . . .  It is typically found . . . in patients 
who are diabetics . . . .  So it's not uncommon for a diabetic 
 
 
 
 
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(..continued) 
 
At trial, Dr. Stephen Carl Rerych, a general surgeon, Dr. 
Richard J. Hart, Jr., a cardiologist, and Dr. Brian Gerard 
McAlary, an anesthesiologist, were called by the Plaintiff as 
expert witnesses.  They explained that surgery under general 
anesthesia places stressful demands on the heart.  They further 
explained that a healthy heart tolerates these stresses, but a 
patient who has had a myocardial infarction is at risk during 
surgery.   
 
Dr. Rerych, over the Defendants' objection, testified 
regarding the standard of care required of a general surgeon.  He 
stated that the standard of care required a surgeon to know prior 
to surgery the results of tests ordered and that this was 
particularly important for a patient like Daniels, with a high 
risk for undiagnosed heart disease.  Therefore, before surgery on 
such patients, a surgeon must order an EKG and receive an 
interpretation of the results by a qualified physician.  Dr. 
Rerych opined that Dr. Poliquin's failure to ascertain the 
results of the EKG prior to performing the surgery was a 
violation of a surgeon's standard of care. 
 
Dr. Hart testified that diabetics are at risk for silent 
myocardial infarctions and, therefore, a proper interpretation of 
Daniels' EKG by a cardiologist was essential.  Such an 
interpretation would have led to a cardiac evaluation which would 
not to have chest pain, and, yet, they have a major heart problem 
going on." 
 
 
 
 
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have shown the extent of the damage to Daniels' heart from the 
silent myocardial infarction.  With this knowledge, Drs. Poliquin 
and Albert could have explored other treatment options that, in 
Dr. Hart's opinion, would have prevented Daniels' death. 
 
Dr. McAlary was the Plaintiff's expert witness on the 
standard of care for an anesthesiologist treating a patient like 
Daniels.  Dr. McAlary testified that an anesthesiologist must be 
sensitive to the possibility that a diabetic may have had a 
silent myocardial infarction and may have heart disease, 
particularly when the patient is also hypertensive and obese.  He 
also testified that there were a variety of available monitoring 
options that would have provided the surgical team with early 
indications of Daniels' heart failure and that such early 
indications would have led to immediate treatment.  Dr. McAlary 
opined that Daniels would have survived the surgery had 
appropriate actions been taken for his condition.  According to 
Dr. McAlary, Dr. Albert breached the standard of care required of 
an anesthesiologist by failing to know the interpretation of the 
EKG tracing, to consult with a cardiologist which consultation 
would have led to invasive monitoring, and to use invasive 
monitoring of Daniels during surgery. 
 
III 
 
Following a voir dire hearing, the trial court qualified Dr. 
Rerych as an expert witness on the standard of care for a general 
surgeon in Virginia.  Poliquin contends on appeal, as at trial, 
 
 
 
 
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that the trial court erred in qualifying Dr. Rerych. 
 
Code § 8.01-581.20 provides for a statewide standard of care 
in medical malpractice cases unless a health care provider proves 
that a local standard of care is more appropriate.  Neither the 
General Assembly nor this Court has ever recognized a nationwide 
standard of care.  Code § 8.01-581.20 provides, in pertinent 
part, as follows: 
 
[I]n any action against a physician . . . to recover 
damages alleged to have been caused by medical 
malpractice . . . in this Commonwealth, the standard of 
care by which [the alleged malpractice is] to be judged 
shall be that degree of skill and diligence practiced 
by a reasonably prudent practitioner in the field of 
practice or specialty in this Commonwealth and the 
testimony of an expert witness, otherwise qualified, as 
to such standard of care, shall be admitted . . . .  
Any physician who is licensed to practice in Virginia 
shall be presumed to know the statewide standard of 
care in the specialty or field of medicine in which he 
is qualified and certified.  This presumption shall 
also apply to any physician who is licensed in some 
other state of the United States and meets the 
educational and examination requirements for licensure 
in Virginia. 
 
(Emphasis added.) 
 
Dr. Rerych received a medical degree from Columbia 
University College of Physicians and Surgeons in New York.  
Thereafter, he attended a surgical residency program in North 
Carolina at Duke University Medical Center.  From 1985 to 1986, 
Dr. Rerych was Chief Resident in General and Thoracic Surgery at 
Duke University Medical Center, and, from 1986 to 1991, he served 
as Assistant Clinical Professor of General, Thoracic, and 
Vascular Surgery at the same facility.  Dr. Rerych is a board 
 
 
 
 
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certified general surgeon.  He is licensed to practice general 
surgery in North Carolina and has practiced his specialty in 
North Carolina since 1988. 
 
During voir dire, Dr. Rerych testified that he was "clearly 
eligible" for licensure in Virginia.  Additionally, the trial 
court received into evidence a letter to that effect from the 
Commonwealth's Department of Health Professionals.  Dr. Rerych 
also testified that he knew "the standard of care that would have 
prevailed in Virginia in June of 1993 with respect to the issues 
in this case."  However, the doctor, when asked if he was making 
an "assumption . . . with regard to the [standard of] care in 
Virginia," answered, "A strong assumption." 
 
Poliquin asserts that, even if Dr. Rerych met the 
requirements for licensure in Virginia, his testimony rebutted 
the statutory presumption and showed that he did not know the 
standard of care in Virginia.  We do not agree.  The voir dire 
hearing was extensive, and, at the conclusion thereof, the trial 
judge stated:  "I'm going to overrule the objection[;] the 
witness is qualified by the thinnest of reeds under the statute." 
 Thus, the trial court weighed all the evidence before it, 
applied the statutory presumption, and concluded that Dr. Rerych 
was qualified to testify as to the standard of care in this 
Commonwealth.   
 
The question whether a witness is qualified to express an 
expert opinion rests within the sound discretion of the trial 
 
 
 
 
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court.  King v. Sowers, 252 Va. 71, 78, 471 S.E.2d 481, 485 
(1996).  We cannot say, based upon the record before us, that the 
trial court abused its discretion in qualifying Dr. Rerych as an 
expert witness. 
 
IV 
 
A 
 
Both Albert and Poliquin contend that no evidence was 
presented to show that their alleged negligence proximately 
caused Daniels' death.  Thus, they assert, the trial court erred 
in overruling their motions to strike the evidence and to set 
aside the verdict. 
 
In medical malpractice cases, as with other tort litigation, 
issues of negligence and proximate cause are ordinarily questions 
of fact for a jury.  Brown v. Koulizakis, 229 Va. 524, 531, 331 
S.E.2d 440, 445 (1985).  Only when reasonable minds could not 
differ about such issues do they become questions to be decided 
by a court.  Hadeed v. Medic-24, Ltd., 237 Va. 277, 285, 377 
S.E.2d 589, 593 (1989).  In viewing the evidence, an appellate 
court must give the prevailing party at trial the benefit of all 
substantial conflict in the evidence and all inferences 
reasonably deducible therefrom.  Id. at 280-81, 377 S.E.2d at 
590.  Thus, a verdict should not be set aside unless it is 
contrary to the evidence or without evidence to support it.  Code 
§ 8.01-430; Brown, 229 Va. at 531, 331 S.E.2d at 445. 
 
In the present case, the Defendants contend that the 
 
 
 
 
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evidence, at most, showed only what might have occurred, rather 
than what necessarily would have occurred had the Plaintiff's 
experts' recommended standards of care been followed.  They 
assert that there was a complete lack of expert testimony that 
their alleged negligence caused Daniels' death.  We do not agree. 
 
In medical malpractice death cases, a plaintiff is not 
required to prove to a certainty that the patient would have 
survived had certain actions been taken.  Brown, 229 Va. at 532, 
331 S.E.2d at 446; Whitfield v. Whittaker Mem. Hospital, 210 Va. 
176, 184, 169 S.E.2d 563, 569 (1969).  A defendant physician's 
action or inaction which "has destroyed any substantial 
possibility of the patient's survival" is a proximate cause of 
the patient's death.  Brown, 229 Va. at 532, 331 S.E.2d at 446; 
accord Bryan v. Burt, 254 Va. ___, ___, ___ S.E.2d ___, ___ 
(1997) (this day decided); Whitfield, 210 Va. at 184, 169 S.E.2d 
at 568. 
 
In the present case, each of the Plaintiff's experts 
testified that it was his opinion to a reasonable degree of 
medical probability that, had the Defendants known what they 
should have known about Daniels' condition prior to surgery and, 
thereafter, employed the appropriate procedures during surgery, 
Daniels would have survived the surgery.  Therefore, we think the 
trial court properly submitted the issue of proximate cause to 
the jury.
2
                     
     
2On brief, Poliquin presents the question whether the 
Plaintiff showed a breach of the standard of care for general 
 
 
 
 
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B 
 
The Defendants further contend that the trial court erred in 
allowing the testimony of Norman Fayne Edwards, Plaintiff's 
economic damages expert.  The Defendants objected to Dr. Edwards' 
testimony because, in formulating the present value of Daniels' 
lifetime income, Dr. Edwards based his calculations on life 
expectancy tables contained in Code § 8.01-419 and on tables 
published by the United States Department of Labor (DOL).  They 
assert that the Plaintiff's own evidence contradicted the 
assumptions which served as the basis for Edwards' opinions. 
 
According to Dr. Edwards, Daniels, who was 38 years old when 
he died, had a life expectancy of 34.6 years pursuant to Code 
§ 8.01-419.  Under the DOL tables, Daniels had a work life 
expectancy of 24 years, or to age 63. 
 
Dr. Hart testified that, had Daniels survived the surgery, 
he would have lived no more than 10-15 years, unless he made 
significant lifestyle changes.  If he had made such changes, 
including losing 100 pounds within a year and exercising, his 
life expectancy would have been 20-25 years. 
 
Code § 8.01-419 provides that the table of life expectancy 
set forth therein shall be received "as evidence, with other 
evidence as to the health, constitution and habits of [the] 
person" in issue.  (Emphasis added.)  As we said in Edwards v. 
(..continued) 
surgeons in the Commonwealth.  Poliquin, however, did not file an 
assignment of error relating to this issue, and therefore, we 
will not consider it on appeal.  Rule 5:21(i). 
 
 
 
 
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Syrkes, 211 Va. 600, 602, 179 S.E.2d 902, 903 (1971), 
 
it is the duty of the court, when so requested in an 
action for wrongful death, to tell the jury that a 
mortality table introduced into evidence is to be 
considered . . . along with all the other evidence 
relating to the health, habits and other circumstances 
of the person which may tend to influence his life 
expectancy. 
 
 
In the present case, the trial court properly instructed the 
jury, in accordance with Edwards, that it "should consider 
[Daniels' life expectancy of 34.6 years] along with any other 
evidence relating to the health, constitution, and habits of 
. . . Daniels in determining his life expectancy."  Thus, based 
upon the evidence before it, the jury could determine Daniels' 
life expectancy in formulating the present value of his lifetime 
income.  We hold, therefore, that the trial court did not err in 
allowing Dr. Edwards' testimony. 
 
C 
 
Finally, the Defendants contend that the trial court erred 
in refusing their tendered instructions B, C, and D.  We think 
the legal principles set forth in those instructions were 
adequately and objectively covered in granted instructions 1, 13, 
and 17.  "When granted instructions fully and fairly cover a 
principle of law, a trial court does not abuse its discretion in 
refusing another instruction relating to the same legal 
principle."  Stockton v. Commonwealth, 227 Va. 124, 145, 314 
S.E.2d 371, 384, cert. denied, 469 U.S. 873 (1984); accord 
Hubbard v. Commonwealth, 243 Va. 1, 16, 413 S.E.2d 875, 883 
 
 
 
 
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(1992).  Therefore, we conclude that the jury was fully and 
fairly instructed and the trial court did not abuse its 
discretion in refusing instructions B, C, and D. 
 
V 
 
In sum, we hold that the trial court did not err in 
qualifying Dr. Rerych as an expert witness, submitting the 
proximate cause issue to the jury, allowing Dr. Edwards' 
testimony, and refusing certain jury instructions.  Accordingly, 
we will affirm the trial court's judgment. 
 
Affirmed.