Title: Simpson v. SISTERS OF CHARITY OF PROVIDENCE, ETC.
Citation: 284 Or. 547, 588 P.2d 4
Docket Number: N/A
State: Oregon
Issuer: Oregon Supreme Court
Date: December 19, 1978

588 P.2d 4 (1978)
284 Or. 547
Carl E. SIMPSON, Respondent,
v.
SISTERS OF CHARITY OF PROVIDENCE IN OREGON, d/b/a St. Vincent Hospital, Appellant.
No. 410-399; SC 25128.

Supreme Court of Oregon.
Decided December 19, 1978.
Argued and Submitted July 12, 1978.
*6 Edwin J. Peterson, Portland, argued the cause for appellant. With him on the briefs were Charles R. Holloway, III, and Tooze, Kerr, Peterson, Marshall &amp; Shenker, Portland.
Richard P. Noble and R. Ladd Lonnquist, Portland, argued the cause and filed a brief, for respondent.
*7 Before HOLMAN, P.J., and TONGUE, HOWELL, BRYSON, LENT and LINDE, JJ.
BRYSON, Justice.
Plaintiff brought this action against defendant hospital to recover for personal injuries suffered, alleging the hospital staff negligently failed to take adequate x-rays of plaintiff's cervical and thoracic spine. The jury returned a verdict in favor of plaintiff. Defendant appeals from the judgment entered on the verdict.
Defendant's first two assignments of error are the trial court's denial of its motions for a nonsuit and a directed verdict. When determining the propriety of such motions we view the evidence in a light most favorable to the plaintiff, and plaintiff is entitled to the benefit of all reasonable inferences that may be drawn from the evidence. Hendrix v. McKee, 281 Or. 123, 126, 575 P.2d 134 (1978).
We examine the evidence to determine if there is competent evidence, both as to causation and negligence, from which the jury could reach a verdict in favor of plaintiff.
Plaintiff built custom homes and was 60 years old on July 5, 1973, the time of his injury and the beginning of treatment. While working on a job he fell six feet off a scaffold, landing on his neck and shoulders. He was taken by ambulance to defendant hospital's emergency room. The physician on duty at the emergency room ordered x-rays of "[b]oth wrists, both forearms, AP chest, thoracic spine, cervical spine and skull." Several technicians began taking x-rays of plaintiff at 12:30 p.m. The technicians tried to obtain a picture of plaintiff's cervicothoracic junction, the point at which the cervical and thoracic portions of the spine join, by a cervical lateral film and six or seven "swimmer's views." The technicians changed their technique on approach from film to film in order to get a clear picture. The plaintiff's position on a stretcher and his pre-existing condition of rheumatoid spondilitis, which caused his head to tilt down and to the left side, made it difficult to obtain clear pictures. As a result, no clear x-rays of the junction were obtained. Nevertheless, there was evidence that without moving plaintiff and by making minor adjustments to the x-ray equipment, the technicians could have obtained a clear view of the junction. In fact, x-rays taken at a later date showed the cervical thoracic junction adequately for diagnostic purposes.
There is evidence that the plaintiff's physicians, after numerous x-rays, believed that the x-rays taken were the best that could be obtained under the circumstances and so the taking of x-rays was discontinued at 2:20 p.m. on December 5. One of plaintiff's physicians decided to order another x-ray of the cervical thoracic junction the next day, July 6, but this order was countermanded by another of plaintiff's physicians, Dr. Watson, a neurologist. Dr. Watson gave no reason for his action; however, there is evidence from which the jury could reasonably have inferred that Dr. Watson felt that the best possible x-rays had been taken and there was no point in moving plaintiff in an attempt to take further x-rays.
Plaintiff was immobilized from the time he arrived at the hospital. There is evidence that this strict immobilization could impair plaintiff's pulmonary function. In fact, plaintiff later suffered from lung congestion. For this reason, on July 8 Dr. Watson ordered plaintiff "dangled," meaning plaintiff sat on the bed with his legs dangled over the side. Dr. Watson was not concerned about a possible fracture in plaintiff's spine at the cervical thoracic junction. He testified:
Nevertheless, plaintiff had a fracture at the cervical thoracic junction resulting from the fall and when he was dangled the fracture compressed the spinal cord, paralyzing plaintiff from the shoulders down.
Plaintiff brought this action against his physicians and defendant hospital. He settled his action against the physicians for $150,000, leaving only the hospital as defendant.
Under defendant's first two assignments of error, the trial court's failure to allow defendant's motions for nonsuit and a directed verdict, defendant makes three separate arguments: (a) the defendant's x-ray technicians were not negligent because they were following doctors' orders; (b) the x-ray technicians were under the supervision and control of the treating physicians; and (c) "there is no causation in fact between the failure to take films showing the fracture on the 5th, and the ambulation on the 8th."
(a) The evidence shows that following plaintiff's admittance at the emergency room, plaintiff was taken to the x-ray department with orders to take x-rays of the thoracic and cervical spine. A chief x-ray technician and an assistant technician are in charge of the x-ray technicians in that department. All such technicians are defendant's employees. In taking x-rays, the technicians follow instructions from the hospital's booklet,[1] which was received in evidence, showing the procedure to be followed for taking x-rays ordered, including "cervical spine  trauma acute" and "thoracic spine." This is undoubtedly a text familiar to x-ray technicians and radiologists on the procedure for taking x-ray films. This was the procedure followed by the hospital in this case. The x-ray technicians are certified by a National Board after training and study in anatomy and physiology, radiographic positioning, x-ray physics, darkroom chemistry, nursing procedures, and terminology. A certain grade point must be achieved on examination "to be certified technicians or registered technicians."
The hospital administrator, Dr. Lee, testified that the technicians take the x-ray films per prescription or order. He testified:
There is no radiologist in the x-ray room while the x-ray technicians are performing their duties and normally the radiologist does not see or consult with the patient.
Dr. Watson testified:
There is, of course, some evidence to the contrary but the preponderance of evidence is to the effect that the hospital's employees, the technicians, were not under doctors' orders as to technique in taking and developing x-ray films. The jury could believe the evidence that showed the x-ray technicians to be negligent in failing to obtain a clear film of the cervical thoracic junction and that the technicians were not following the physicians' orders as to technique.
(b) Much of the above testimony, together with other evidence in the record, was sufficient to allow the jury to find that the x-ray technicians were not under the supervision and control of the treating physicians when performing their duty of taking and developing x-ray films of plaintiff's cervical thoracic junction of the C7/T-1 area.
Intertwined with this argument and that made in argument (a), the defendant asserts the so-called "Captain of the Ship" rule to the effect that "hospitals' support personnel are obligated to carry out the orders of the doctors, and so long as the order is carried out in a competent manner, hospital personnel are not negligent." (Citing Dumer v. St. Michael's Hospital, 69 Wis.2d 766, 233 N.W.2d 372 (1975); Stogsdill v. Manor Convalescent Home, Inc., 35 Ill. App.3d 634, 343 N.E.2d 589, 612 (1976); Mesedahl v. St. Luke's Hospital Ass'n of Duluth, 194 Minn. 198, 259 N.W. 819, 822 (1935), and cases from other jurisdictions.)
Oregon has not expressly adopted such a rule and the facts of this case do not require that we do so because said rule only excuses hospital personnel who carry out physicians' orders in a competent manner. The jury in this case could have found from the evidence that the orders were not carried out in a competent manner. The jury could have found that the technicians took the requested x-rays in a negligent manner, leading to the physicians' eventual decision to stop taking x-rays. We do not understand the "Captain of the Ship" rule to insulate hospitals or their employees from liability for following orders in a negligent manner.
In Piehl v. The Dalles General Hospital, 280 Or. 613, 571 P.2d 149 (1977), a case in which a piece of material known as a laparotomy sponge was left in plaintiff's abdomen, we stated, at 619-20, 571 P.2d at 152:
In the case at bar the evidence shows that the hospital and the radiologist each billed the patient separately for their services.
In May v. Broun, 261 Or. 28, 36-37, 492 P.2d 776, 780 (1972), we stated:
See also Penrose v. Mitchell Bros., 246 Or. 507, 512, 426 P.2d 861 (1967). Thus, under both the facts of this case and the law of Oregon, we conclude that the defendant was not entitled to a directed verdict pursuant to its argument (b).
(c) Defendant argues there is no causation in fact between the failure to take films showing the fracture on the 5th and the ambulation on the 8th because there is no evidence that had films been taken on July 5th showing a fracture of the C7/T-1, the ambulation and resultant injury would not have occurred on July 8. The issue raised is really whether the negligent conduct of the defendant, as alleged by the plaintiff, was a substantial factor in producing plaintiff's injury.[2] The causation question in a negligence action such as this is usually one of fact. The terms "proximate cause" and "legal cause," as used in defendant's brief, are usually misleading and should be avoided. See Stewart v. Jefferson Plywood Co., 255 Or. 603, 606, 469 P.2d 783 (1970); Babler Bros. v. Pac. Intermountain, 244 Or. 459, 463, 415 P.2d 735 (1966). The terms "proximate cause" and "legal cause" suggest that policy decisions have something to do with actual cause, which is not the case. Therefore, we conclude it is time to abandon those terms. In McEwen v. Ortho Pharmaceutical, 270 Or. 375, 385 note 7, 528 P.2d 522, 528 note 7 (1974), we stated:
In the case at bar we conclude there is competent evidence from which the jury could have found that the x-ray technicians', defendant's employees, failure to take x-rays showing the cervical thoracic junction was an actual cause of plaintiff's injury. The jury could have found that the x-ray technicians could have taken a picture of the crack in the junction in their original series of x-rays. Indeed, subsequent x-rays taken showed the crack in that junction. The jury could further have found from the evidence that if the doctors had received a proper x-ray of the critical junction they would not have ambulated plaintiff but, instead, would have rigidly immobilized him. There is testimony from Dr. Watson, Dr. Smith, and Dr. Leland Cross on this point. Dr. Cross testified:
The jury could have found from the testimony as a whole, including the above testimony, that the x-ray technicians' failure to take an adequate x-ray of the fractured area was an actual cause of plaintiff's injury.
Defendant argues that plaintiff failed to establish either lack of due care or foreseeability and there was no evidence of negligence on the part of the technicians. Our review is limited to the question of whether the jury could have reasonably found from the evidence that the technicians were negligent. The jury, in assessing negligence, must decide "whether the conduct in question falls above or below the standard of reasonable conduct deemed to have been set by the community." Stewart v. Jefferson Plywood, 255 Or. 603, 607, 469 P.2d 783, 785 (1970). The trial court should direct a verdict in favor of defendant in this case only if it can be said "that the actor's conduct clearly meets the standard * *." Stewart v. Jefferson Plywood, supra.
Defendant concedes that the technicians could have taken x-rays showing the fracture at the time they took the original series of x-rays but it argues that mere failure to take an x-ray that could have been taken does not necessarily show lack of due care.
There is evidence in this case that the registered and licensed technicians, defendant's employees, did possess the knowledge and skill necessary to detect whether they had produced x-rays of the cervical thoracic junction pursuant to the physicians' orders. Further, not every case of malpractice requires direct medical testimony on the issue of the applicable standard of care and whether that standard was met. "[I]f the jury is capable of deciding what is reasonable conduct without assistance from an expert medical witness no expert testimony is necessary to establish the standard of care." Getchell v. Mansfield, 260 Or. 174, 179-80, 489 P.2d 953, 955 (1971); cf. Lynd v. Rockwell Manufacturing, 276 Or. 341, 349, 554 P.2d 1000 (1976) (stating the general rule for when testimony of experts on technical matters is not essential). In this case, there was evidence that the x-ray technicians could have taken the necessary photograph had they made certain minor adjustments in the position of the film and the intensity of the x-ray beam and that they could have taken the picture without moving the plaintiff. There was evidence that after plaintiff had been paralyzed, the technicians were able to obtain clear views of his cervicothoracic junction without any difficulty.
The physicians ordered the x-rays stopped after two hours. The defendant apparently argues from this that the physicians should have allowed the technicians to continue taking pictures until they managed to produce a clear one. This argument ignores the probability that at some point the physicians could conclude, as the evidence shows they did, that the best possible pictures had been taken. The jury could have found from the evidence that for x-ray technicians to meet the standard of care expected of them, it is not enough for them to take a series of bad pictures hoping to obtain a good one.[3] From the evidence, it is quite *12 foreseeable that after the x-ray technicians failed to get a clear x-ray in a reasonable time, the physicians would not and did not order more x-rays on July 5 and that they would ambulate plaintiff to avoid plaintiff's pulmonary problems they were concerned with. The trial court concluded from all of the evidence that it was a jury question as to whether the x-ray technicians were or were not negligent in producing the faulty x-rays and that such was one of the causes of plaintiff's injuries. In James v. Carnation Co., 278 Or. 65, 69, 562 P.2d 1192, 1197 (1977), we stated:
We conclude that the trial court did not err in denying defendant's motions for a nonsuit and a directed verdict.
Defendant's third assignment of error is the court's instructing the jury as follows:
Defendant excepted as follows:
Defendant's brief admits "[w]e have found no Oregon cases questioning the instruction given by the trial judge" and then relies upon McDowell v. Davis, 104 Ariz. 69, 448 P.2d 869 (1969).
First, we have examined the trial court's instructions in regard to causation and no mention was made of "proximate cause." Defendant objected to the substantial factor language in the given instruction, arguing "that language is entirely meaningless to the jury." We disagree. We have approved the use of the substantial factor formula in numerous cases.[4] We see no reason to abandon our prior ruling and we are not aware of a better formula. Thus, we agree with Prosser that "[a]s applied to the fact of causation alone, no better test has been devised." W. Prosser, Law of Torts 240, § 41 (4th ed. 1971). We find no error in this assignment.
The fourth assignment of error is the court's refusal to give defendant's requested instruction No. 21A:
*13 The requested instruction uses the term "proximate cause," which we have found misleading and have abandoned. Further, the trial court did give instructions which, on the whole, covered the issue which allowed the jury to properly consider the matter. The term "proximate cause" is not the same as actual cause. Because the requested instruction contained objectionable language, it was properly rejected by the court. Owings v. Rose, 262 Or. 247, 258, 497 P.2d 1183, 57 A.L.R.3d 821 (1972).
Defendant's fifth assignment of error, the court's refusal to give defendant's requested instruction No. 21B, argues that the "but for" test of causation incorporated in the instruction would have been more appropriate in this case than was the substantial factor test because the allegation of negligence in this case was the negligent failure to do something rather than the negligent doing of something. In making this argument, defendant assumes that the substantial factor formula would allow the jury to find that a defendant's conduct was a substantial factor in producing injury, even though the jury felt that the injury would have occurred anyway. We do not agree with this assumption; instead, we agree with Prosser's comment on the relationship between the substantial factor test and the "but for" test:
Although the term "substantial factor" is concededly not perfect, it and the instructions as a whole were sufficient to alert the jury that to find actual cause in this case they must find that the injury would not have occurred had the technicians taken proper x-rays. The instructions as given adequately presented the issue to the jury, and the trial court did not err in refusing to give the requested instruction No. 21B. Barrell v. Brown, 261 Or. 463, 472, 495 P.2d 733 (1972).
Defendant next argues that the trial court erred in refusing to give the following requested instruction:
*14 Parties are entitled to instructions on the existence and effect of presumptions. Wiebe v. Seely, Administrator, 215 Or. 331, 359, 335 P.2d 379 (1959); Wyckoff v. Mutual Life Ins. Co., 173 Or. 592, 603, 147 P.2d 227 (1944). However, in the context of this case it appears parts "1" and "2" of the requested instruction simply amount to the presumption that a party is presumed to be free of negligence. The trial court did instruct:
The court also instructed on another issue that a disputable presumption "may be overcome. Whether it is overcome is a matter for your determination." The "ordinary course of business" presumption, which is really intended to apply to business activities, would apply to this case, if at all, only to refute negligence.
Frankly, we doubt if the entire instruction would or could be understood by the jury and, although jurors are to follow the court's instructions, the instruction as a whole would be confusing.
The court's instructions were sufficient to communicate the substance of the requested instruction to the jury and we conclude the trial court did not err in refusing to give the requested instruction.
Defendant's seventh assignment of error contends the court erred in failing to give the following requested instruction:
Part three of the requested instruction not given raises the point argued by defendant; that is, "[i]mpeachment by deposition is not substantive evidence."
The problem arose during trial in the following manner. Mr. Massey, one of defendant's witnesses and one of the technologists that took x-rays of plaintiff on July 5, testified extensively on the procedure followed in the taking of x-rays of plaintiff on July 5. He also testified that Doctors Jang and Watson reviewed the x-rays after they were taken. Defendant's brief argues that
The cross-examination by plaintiff's attorney based on Massey's deposition occurred as follows:
The first question we have to consider is whether or not the above testimony by deposition was impeachment or substantive evidence. To "impeach" a witness is "to attack or discredit the witness and to attack the jury's belief in his or her testimony." *15 State v. Gilbert, 282 Or. 309, 311, 577 P.2d 939 (1978). See also McCormick, Evidence § 33 (2d ed. 1972). Dr. Jang was a radiologist (physician) on duty at the hospital from time to time and examined or read the x-rays taken by defendant's x-ray department. Dr. Watson was a neurologist present at the hospital when plaintiff was brought there and became plaintiff's physician.
It appears from the record that the questioning via Mr. Massey's deposition on cross-examination was impeachment of witness Massey's testimony and that it was not offered as substantive evidence.
We further point out that both defendant's counsel and plaintiff's counsel used the deposition of Mr. Massey while he was testifying and both counsel read from the deposition. When the testimony complained of was elicited by plaintiff's counsel from Mr. Massey's deposition, no objection was made and no request was made that the jury be instructed to consider the testimony only as impeachment and not as substantive evidence.
Part 3 of the requested instruction not given should either have specified the testimony to which it applied or, preferably, the point should have been raised at the time the deposition testimony was read.
For all of the above reasons, we conclude that the court did not err in refusing to give defendant's requested instruction No. 24.
Defendant's assignments of error eight, nine and ten (which are related to defendant's assignments of error 11, 12, and 13) concern the testimony of plaintiff's witness, Charles Jerabek, an employee of defendant. Plaintiff was offering evidence to establish the cost of nursing care of plaintiff in the future as an element of damages.
Jerabek testified:
Defendant's objection was "on the grounds of relevancy, competency [sic] and materiality." A general objection on the basis of relevancy, competency, and materiality, "if overruled, cannot avail the objector on appeal." (Citations omitted.) Smith v. Oregon Agricultural Truck., 272 Or. 156, 160, 535 P.2d 1371, 1373 (1975). Of course there are exceptions to this rule but they are not applicable from the record in this case. McCormick, Evidence (2d ed.) 115-16, § 52.
However, when plaintiff rested defendant made the following motion:
We conclude from this motion and the entire record that the issues raised by these assignments are properly before the court.
It is true that Jerabek was testifying as to what it would cost a hospital in the community to provide plaintiff, paralyzed from the shoulders down, with nursing aide services in the future; however, plaintiff's next witness, called as an expert, was Dr. Russell Dawson, an economist. His qualifications are discussed in defendant's next assignment of error. Dr. Dawson testified that the sum of $3.91 per hour on an 8-hour day basis was a reasonable rate of pay for nurses' aides for in-home care. Dr. Dawson testified he made a study to arrive at the $3.91 per hour basis, which included inquires from Homemakers-Upjohn, Pathmakers, an employment service, and Medical Personnel Pool of Portland. He testified:
He testified that such services for in-home care were $5 to $4.25 per hour, "it [$3.91 per hour] is reasonable and I think probably conservative."
Although witness Jerabek's testimony had less specific probative value on the question of future costs than evidence of the salary rate of a nurse whose task was to care for a person in plaintiff's position, nevertheless, it was relevant and had some probative value and was merely cumulative to the evidence of Dr. Dawson. McCormick, Evidence §§ 183, 184 (2d ed. 1972). If there was error, as contended by defendant, it certainly was not reversible error for the court to allow the testimony.
Defendant's assignments of error 11, 12, 13 concern the testimony of plaintiff's witness, Dr. Dawson, an economist. The homogenized gist of defendant's numerous objections to portions of Dr. Dawson's testimony is that the economist testified regarding matters that did not require an expert's opinion or testimony. The court had sustained defendant's objections to some of the questions put to Dr. Dawson and denied others. For instance, plaintiff had offered a series of charts, exhibits 89 through 94, prepared by Dr. Dawson, to show damages suffered by plaintiff as a result of his injuries. The trial court returned to the courtroom from arguments in chambers and stated:
During colloquy between court and counsel the following occurred:
The following also occurred:
*17 There is no question about Dr. Dawson's qualifications. He received a degree of Doctor of Philosophy and Economics from the University of California at Berkeley. He was a professor of economics at the University of Maryland and at Portland State University. In addition, he worked as a research economist and consultant for other companies. The defendant argues that he should not have been allowed to testify as he did on the amount of plaintiff's damages in that an expert's opinion and testimony was not required.
In Yundt v. D &amp; D Bowl, Inc., 259 Or. 247, 486 P.2d 553 (1971), we reviewed the earlier opinions of this court regarding the use of an expert's testimony and in both the majority opinion, at page 258, and the dissenting opinion, at page 263, we stated the following rule from 7 Wigmore, Evidence 21, § 1923 (3d ed. 1940) with approval:
See also McCormick, Opinion Evidence in Iowa, 19 Drake L.Rev. 245, 257 (1970).
We conclude, as did the trial court, that Dr. Dawson's testimony on this subject was of appreciable help to the jury and therefore the trial court did not err.
Defendant's fourteenth and last assignment of error is that the trial court erred in giving the following instruction:
The defendant excepted as follows:
Defendant argues that the word "should" in the instruction was misleading and that the court should have used the word "may." We agree with defendant that the use of the word "may" would have been preferable. Where there is substantial evidence of permanent injury, the standard mortality tables may become admissible, at least if earning power is permanently impaired. Zimmerman v. Ausland, 266 Or. 427, 431 n. 3, 513 P.2d 1167 (1973). In the case at bar, defendant did not object to the giving of the instruction as a whole, but only to the use of the word "should." We take the instruction as a whole and the court told the jury such tables were only an estimate of the probable average length of life of people at a given age in our country. He also stated, "it may be longer; it may be shorter," and they should consider that evidence along with other evidence bearing on the subject. We conclude that the instruction as given under the circumstances of this case was not reversible error.
Affirmed.
[1]  Booklet published for the hospital's x-ray department has reference to "Merrill, Volume I, pp. 218-237" and "Merrill, Volume 1, pp. 238-245."
[2]  The substantial factor formula is discussed in McEwen v. Ortho Pharmaceutical, 270 Or. 375, 385, 528 P.2d 522 (1974); Stewart v. Jefferson Plywood Co., 255 Or. 603, 606, 469 P.2d 783 (1970); Babler Bros. v. Pac. Intermountain, 244 Or. 459, 463, 415 P.2d 735 (1966); and Dewey v. A.F. Klaveness &amp; Co., 233 Or. 515, 541, 379 P.2d 560 (1963).
[3]  This is not to say that anytime an x-ray technician upon a physician's request takes films of a portion of a person's body that the technician guarantees, upon the pain of being held to be negligent, that the resultant film will show all defects necessary to a proper diagnosis. It is the radiologist who reads the film and who decides whether it is sufficient to enable a diagnosis of the area about which there is concern. While a technician is supposed to be skilled in the taking of x-rays, he is not an expert in deciding whether they are sufficient for the purpose of a specific diagnosis. Therefore, had there been only one set of x-rays taken of the plaintiff when he was admitted and had those x-rays been satisfactory to and accepted by the radiologist and the treating physicians, who were not employees of the hospital, we would hold there was no basis for a jury to find that the technicians were negligent.
[4]  See cases cited in note 2, supra.