Title: Wasem v. Laskowski
Citation: 274 N.W.2d 219
Docket Number: 9460
State: north-dakota
Issuer: north-dakota Supreme Court
Date: January 8, 1979

274 N.W.2d 219 (1979) Leslie R. WASEM and Lenora Wasem, Plaintiffs and Appellants, v. E. J. LASKOWSKI, K. G. Foster, and Quain and Ramstad Clinic, a partnership, Defendants and Appellees. Civ. No. 9460. Supreme Court of North Dakota. January 8, 1979. *221 Freed, Dynes, Malloy &amp; Reichert, Dickinson, and Mandel &amp; Stiegler, Minneapolis, Minn., for plaintiffs and appellants; argued by Alan Stiegler, Minneapolis, Minn. Fleck, Mather, Strutz &amp; Mayer, Bismarck, and Nilles, Hansen, Selbo, Magill &amp; Davies, Fargo, for defendants and appellees; argued by William A. Strutz, Bismarck. PEDERSON, Justice. This is an appeal by Mr. and Mrs. Wasem from a judgment dismissing a medical malpractice claim against Dr. Laskowski, Dr. Foster, and the Quain and Ramstad Clinic. The appeal is also from an order denying a motion for new trial. The trial record includes 16 volumes of transcript, plus numerous depositions and exhibits. Although a very complex medical question is involved, the only issues raised on this appeal relate to the failure to give requested jury instructions. Mr. and Mrs. Wasem claim that they were entitled to specific instructions that: (1) It is prima facie evidence of negligence when a doctor deviates from a drug manufacturer's instructions; (2) The jury may infer from an injury and the circumstances surrounding it that the doctor failed to exercise proper skill and care; and (3) The doctor had an obligation and duty to inform the patient when an abnormal condition developed. Wasem visited the Quain and Ramstad Clinic in Bismarck in April 1973. He was suffering from neck pains and recurring numbness of the right arm and hand. He had previously consulted doctors in Dickinson. Dr. Laskowski performed a myelogram by injecting Pantopaque dye into Wasem's spinal canal. This diagnostic test uses the dye as a contrast medium for observing the interior of the spinal canal on the fluoroscopy screen and on x rays. When the test was completed, the dye did not flow back out of the needle and no effort was made to remove the dye at that time. In the months that followed, severe paralysis of the lower extremeties occurred, allegedly caused by an inflammation and scarring of the arachnoid membrane in the spinal canal. Wasem contended that, when conducted properly, a Pantopaque myelogram is a harmless test and that removal of the dye is the only way to properly conduct the test. He further contended that adhesive arachnoiditis resulted from a toxic reaction to the dye and that the paralysis resulted therefrom. He further contended that, even though the results may have been extremely rare, the doctors failed to fulfill their obligation to inform him of the abnormal condition. Wasem requested, and the court refused to give, the following instruction: *222 "Plaintiff's Requested Instruction No. 8 The trial court was not asked to, and did not, define the words "prima facie evidence." The specific instruction given to the jury was: The manufacturer's statement of directions was introduced as an exhibit. It was a comprehensive statement containing a description and chemical-structured configuration, pharmocology, indications and contraindications, warnings, precautions, directions for dosage and administration (which include removal procedures), as well as a statement of "Adverse reactions," which provides: Wasem relies principally upon Mulder v. Parke Davis &amp; Company, 288 Minn. 332, 181 N.W.2d 882 (1970), a case in which the trial court directed a verdict for defendant. Mulder did not involve jury instructions. The only question in that case was whether there was sufficient evidence to make a prima facie case. Wasem says "the Mulder instruction has been approved in the case of Mueller v. Mueller, 221 N.W.2d 39 (S.D. 1974)." Although Mueller does involve jury instructions, the court in that case omitted the words "prima facie evidence" and substituted therefor the words "evidence of negligence." See also Lhotka v. Larson, 238 N.W.2d 870 (Minn.1976). The other cases cited by Wasem, Nolan v. Dillon, 261 Md. 516, 276 A.2d 36 (1971), and Southern Florida Sanitarium &amp; Hospital, Inc. v. Hodge, 215 So. 2d 753 (Fla.App.1968), do not support his position. In Nolan v. Dillon, supra, at 276 A.2d 48, the court specifically approved an instruction that manufacturer's labeling "is evidence to be considered with all other evidence." Southern Florida Sanitarium &amp; Hospital, Inc. v. Hodge, supra, did not involve instructions on manufacturer's recommendations. In North Dakota we have consistently said that "in passing on the correctness of jury instructions given by a trial court, we will consider the instructions which were given as a whole rather than consider individual instructions or portions *223 of such instructions." Belinskey v. Hansen, 261 N.W.2d 390, 396 (N.D.1977). Even when an instruction is insufficient or erroneous standing alone, we would consider the apparent error cured if the instructions as a whole fairly advise the jury as to the law which pertains to the essential issues. See Leake v. Hagert, 175 N.W.2d 675 (N.D. 1970); Thornburg v. Perleberg, 158 N.W.2d 188 (N.D.1968); Jasper v. Freitag, 145 N.W.2d 879 (N.D.1966); Stokes v. Dailey, 97 N.W.2d 676 (N.D.1959); Lund v. Knoff, 85 N.W.2d 676 (N.D.1957); Donahue v. Noltimier, 61 N.D. 735, 240 N.W.2d 862 (1932); and Axford v. Gaines, 50 N.D. 341, 195 N.W. 555 (1923). That is not to say that an erroneous instruction cannot be so prejudicial as to require a new trial even though it may be offset by a correct instruction. The case before us is not of that nature. Wasem wanted the jury to be instructed that the doctor's deviation from the manufacturer's recommendations constituted "prima facie" evidence of negligence. The trial court instructed that the deviation was evidence of negligence. We agree with a statement made by the Iowa Supreme Court that: We also approve, as a general statement: As the Supreme Court of Texas said in Coward v. Gateway Nat. Bank of Beaumont, 525 S.W.2d 857, 859 (Tex.1975): We defined "prima facie evidence" in Schnoor v. Meinecke, 77 N.D. 96, 40 N.W.2d 803, 808 (1950), and, in Kuntz v. McQuade, 95 N.W.2d 430 (N.D.1959), we discussed the distinction between permissible inferences and presumptions in applying the doctrine of res ipsa loquitur. See also Bergley v. Mann's, 99 N.W.2d 849 (N.D.1959). The Wasems do not argue that they were entitled to an instructed verdict. There was "evidence to the contrary" introduced in this case and, accordingly, the labeling of the evidence as "prima facie" would have been improper even if those words had been fully defined. It was not error to refuse to give requested instruction No. 8. The Wasems requested and the trial court refused to give the following instructions: The Wasems argue that the trial court erred in not giving one or the other of these requested instructions because, they have concluded, the doctrine of res ipsa loquitur applies to this action. Procedurally, the doctrine of res ipsa loquitur creates a permissible inference from harmful results that the defendant did not exercise the correct standard of care. In an appropriate case, the jury may accept or reject this inference regardless of any explanation offered to rebut it. Bergley v. Mann's, supra, 99 N.W.2d at 858. In Bismarck Baptist Church v. Wiedemann Indus., Inc., 201 N.W.2d 434, 440 (N.D.1972), this court said that negligence is never presumed and that res ipsa loquitur does not shift the burden of proof. See also Whitson v. Hillis, 55 N.D. 797, 215 N.W. 480 (1927). In Schoening v. Smith, 59 N.D. 592, 231 N.W. 278 (1930), we said that the doctrine of res ipsa loquitur does not apply to medical malpractice actions.[1] This holding appears to be grounded in the public policy of encouraging physicians to practice unfettered by financial liability for their services.[2] Although the public has an interest in promoting the practice of medicine, there may be circumstances in a medical malpractice case in which it may be appropriate to instruct the jury that negligence may be inferred from bad results. In Tvedt v. Haugen, 70 N.D. 338, 294 N.W. 183, 190 (1940), Justice Morris, in dissenting, said: The majority of the court in Sagmiller v. Carlsen, 219 N.W.2d 885 (N.D.1974), in setting aside a summary judgment which had dismissed a medical malpractice action because of the failure of the plaintiff to show that she had expert testimony to establish the standard of medical care in the area and the failure of the doctor to meet that standard, said at 893: See also Arneson v. Olson, 270 N.W.2d 125, 132 (N.D.1978), where this court said that expert testimony is not necessary "to establish a duty, the breach of which is a blunder so egregious that a layman is capable of comprehending its enormity." It is obvious that in neither Tvedt v. Haugen, supra, nor Sagmiller v. Carlson, supra, did this court say in what circumstance a jury should be instructed that it may infer negligence from the bad result. Federal District Judge Davies in Swanson v. Hill, 166 F. Supp. 296, 299 (D.C.N.D.1958), cited in Sagmiller v. Carlson, supra, said that "the North Dakota Supreme Court circumvented the rule of the Gallagher case [see footnote 1], and in so doing, impliedly rejected it." Judge Davies significantly added: Ordinarily, juries should not be instructed on rules of evidence, however it is necessary to instruct the jury as to distinctions between direct and circumstantial evidence. In this case, the jury was instructed that: It would have been preferable that the court give the pattern jury instruction on circumstantial evidence.[3] Wasem did not, however, object to that general instruction, and he has not convinced us that an instruction on a specific inference here would be proper. Applying the criteria of Tvedt v. Haugen, supra, Sagmiller v. Carlsen, supra, and Swanson v. Hill, supra, the circumstances of this case make the doctrine of res ipsa loquitur inapplicable. One issue here was whether or not Mr. Wasem's paralysis was the result of the failure to remove the Pantopaque dye from his spinal canal. The evidence on this issue presented a complex medical questionone which would not be within the common knowledge of laymen. Expert testimony was essential to support a factual determination by the jury that the doctor was negligent. Since 1928 this court has said that a bad result is not always evidence of negligence. See Dolan v. O'Rourke, 56 N.D. 416, 217 N.W. 666 (1928), footnote 1. Some of the evidence in this case would support a jury conclusion that Wasem's paralysis would have occurred absent any negligence in the administering of the Pantopaque myelogram. That issue is one of proximate cause. The jury was instructed on proximate cause and there was no objection thereto. It was not error for the trial court to refuse to give either requested instruction No. 10 or No. 11. Wasem requested, and the court refused to give, the following instruction: The trial court gave the following instructions: In addition, the trial court instructed extensively on malpractice and duty of physician.[4] We find nothing objectionable in Wasem's requested instruction No. 12; however, as we have previously stated herein, we do not evaluate instructions out of context. The instructions given, as a whole, fairly informed the jury of the law it must apply. The instruction might have been easier to understand if it had said that providing information to a patient is a continuing obligation. We agree with Wasem that he was entitled to have his theory presented to the jury. See Johanson v. Nash Finch Company, 216 N.W.2d 271, 274 (N.D.1974). However, a trial court need not give instructions in the specific language requested where the substance thereof is already fully and fairly covered by another charge. Haugen v. Mid-State Aviation, Inc., 144 N.W.2d 692 (N.D.1966). The instructions should fairly cover the claims made by both sides of the case. Rott v. Provident Life Ins. Co., 69 N.D. 335, 286 N.W. 393 (1939). The instruction given in this case was adequate. It is not the function of the court to explain the thought processes of a jury. Regan Farmers Union Co-op. v. Swenson, 253 N.W.2d 327 (N.D.1977). It was not error to refuse to give requested instruction No. 12. A motion for a new trial is directed largely to the sound judicial discretion of the trial court. Before this court will overturn a trial court denial of a motion for new trial, it must be clear that there was an abuse of discretion. Vasichek v. Thorsen, 271 N.W.2d 555 (N.D.1978); Demaray v. Ridl, 249 N.W.2d 219 (N.D.1976). Wasem's argument is based entirely upon his own conclusion that there was error in the instructions. Having found no error in the instructions given, we find no basis for a conclusion that there was an abuse of discretion in denying the motion for new trial. We are not convinced that justice requires a new trial. The judgment of dismissal and the order denying a new trial are affirmed. VANDE WALLE and SAND, JJ., and KIRK SMITH, District Judge, concur. KIRK SMITH, District Judge, and EUGENE A. BURDICK, Supreme Court Commissioner, sitting in place of ERICKSTAD, C. J., and PAULSON, J., disqualified. EUGENE A. BURDICK, Supreme Court Commissioner, concurring specially. In addition to the reasons assigned by Justice Pederson for holding that it was not error to refuse to give Plaintiff's Requested Instruction No. 10 concerning res ipsa loquitur, I shall add another. Strictly speaking, the doctrine of res ipsa loquitur is a "rule" of evidence the judge applies, where there is a motion for a directed verdict, in determining whether or not the claimant has proved a prima facie case against the defendant. In applying the rule as developed under the criteria of the cases, the judge merely determines whether or not the jury could draw the requisite inference of negligence in a case lacking direct evidence of negligence. This does not mean, however, that the jury should be instructed on the doctrine at all. In discussing the evolution of this rule, Professor William L. Prosser observed that: "A small minority of the courts, however, uniformly give res ipsa loquitur a greater effect than that of a mere permissible inference from the evidence. . . . Actually this enlarged procedural effect of res ipsa loquitur is fast disappearing from the courts, as recent decisions in many jurisdictions have swung over to the view that there is as a general rule no more than a permissible inference which merely gets the plaintiff to the jury. There was at one time considerable support for the position that where the action is by a passenger against his carrier, res ipsa loquitur is given increased procedural effect, in the form of a presumption, or even a shifted burden of proof; but except in Alabama and Oklahoma there appears to have been a retreat from this distinction. There may perhaps be other such relations, such as that of physician and patient, where special conclusions are called for. Apart from such instances, however, remarkably few jurisdictions now treat res ipsa loquitur as anything more than a simple matter of circumstantial evidence." Prosser, Torts, Sec. 40, p. 234 et seq. (3d ed. 1964). The Washington supreme court appears to be a forerunner among courts in putting res ipsa loquitur in proper perspective. In Chase v. Beard, 346 P.2d 315 (Wash. 1960) the court discusses the origin and purpose of the rule and concludes, as do I, that "its primary purpose is to withstand the challenge of the defendant's motion for a nonsuit." The Court concluded by saying "There was no necessity for any instruction." This view was followed by the Washington court in Ball v. Mudge, 391 P.2d 201 (Wash.1964) and in Zukowsky v. Brown, 488 P.2d 269 (Wash.1971). In the latter case, the Washington court, at page 279, refines the application of the rule as follows: Accordingly, I would limit the holding of Bergley v. Mann's, 99 N.W.2d 849 (N.D. 1959) to the facts of that casethat the instruction given by the trial court with respect to res ipsa loquitur was an erroneous and prejudicial statement of the law. An adequate instruction on circumstantial evidence is all that is needed or is proper. SAND, J., and SMITH, District Judge, concur. [1] See also Gallagher v. Kermott, 56 N.D. 176, 216 N.W. 569 (1927); Dolan v. O'Rourke, 56 N.D. 416, 217 N.W. 666 (1928); McDonnell v. Monteith, 59 N.D. 750, 231 N.W. 854 (1930); and Tvedt v. Haugen, 70 N.D. 338, 294 N.W. 183 (1940). For a discussion of holdings from other states see Fehrman v. Smirl, 20 Wis.2d 1, 121 N.W.2d 255 (1963). [2] Crabb, John H., and Johannson, Kenneth F., Res Ipsa Loquitur in North Dakota, 38 N.D.L. Rev. 390, 399 (1962). [3] See Pattern Instruction, NDJI 1009, which provides in part: "Circumstantial evidence consists of facts and circumstances in the case from which the jury may reasonably infer, from the common experience of mankind, the existence of a fact in dispute." [4] See NDJI 410, 411, 412 and 413 for pattern instructions on this subject.