Opinion ID: 195070
Heading Depth: 2
Heading Rank: 2

Heading: Testimony of Plaintiff's Expert Witness

Text: 14 Appellants' attack on the sufficiency of the evidence focuses on the testimony of plaintiff's expert witness, Dr. James Kahn. Their claim is that no expert witness identified any act of negligence that more probably than not caused the infection. Appellants' Brief at 9. Both sides agree that New Hampshire law controls this issue. We will therefore examine New Hampshire law and rule accordingly. 15 In Thorpe v. New Hampshire Department of Corrections, 575 A.2d 351, 353 (N.H. 1990), the court stated: The general rule in medical malpractice cases is that the proximate cause between the negligence and the injury must be established through expert testimony. In Martin v. Wentworth-Douglass Hospital, 536 A.2d 174, 176 (N.H. 1987), the court held that expert testimony was necessary to establish the causal link between the injury complained of and the health care provider sought to be held accountable, and [t]he quantum of such evidence necessary to survive a motion for nonsuit had to be enough to warrant the conclusion of a reasonable juror that the causal link probably existed. See also Wilder v. Eberhart, 977 F.2d 673, 676 (1st Cir. 1992). In Pillsbury-Flood v. Portsmouth Hospital, 512 A.2d 1126 (N.H. 1986), the court held: 16 In New Hampshire, the plaintiff in a medical malpractice action must prove that the defendant's negligence caused the patient's injury or loss. See Carrigan v. Sacred Heart Hospital, 104 N.H. 73, 80, 178 A.2d 502, 506-07 (1962). [N]egligent conduct is a proximate or legal cause of harm, if the actor's conduct is a 'substantial factor in bringing about the harm.'  Maxfield v. Maxfield, 102 N.H. 101, 105, 151 A.2d 226, 230 (1959) (quoting Restatement of Torts § 431(a) (1934)). This issue is normally one for the trier of fact once a prima facie case is established. See id.; W. Keeton, D. Dobbs, R. Keeton & D. Owen, Prosser and Keeton on the Law of Torts § 41, at 269 (5th ed. 1984) (hereinafter cited as Prosser & Keeton). 17 Id. at 1129. 18 We now turn to Dr. Kahn's testimony. There was no objection to Dr. Kahn's expert qualifications in the field of infectious diseases. The crux of his testimony came in the answers to a series of questions. Dr. Kahn was asked: Based on your review of all the information, do you have an opinion, based on reasonable medical probabilities, as to whether or not Mrs. F.'s infection, outbreak of herpes in August of 1986 was a primary infection? He answered: Yes, I continue to feel very emphatically that it was a primary infection. In prior testimony Dr. Kahn had explained that the term primary infection meant a first-ever herpes infection. Dr. Kahn had explained the nature of herpes infections and how outbreaks of the disease are manifested. 19 The next question bearing on the issue was: Do you have an opinion, based on reasonable medical probabilities, as to whether or not the hospital was the probable source of-general source of Kimberly F.'s infection in August of 1986? Dr. Kahn answered that the infection was clearly associated with the plaintiff's hospitalization. The following question was then asked: What were the possible means of transmission within the hospital that could have resulted in her infection? There was an objection based on the use of the word possible; that the plaintiffs' burden of proof is probabilities. The court denied the objection, pointing out that the main question was premised on reasonable medical probabilities, and these were the factors the expert considered in arriving at his opinion. Dr. Kahn was asked again to state the possible sources of plaintiff's infection. He answered: The likeliest, I think, is another patient who at the time of your client's hospitalization had what to all intents and purposes sounded like a recurrent genital herpes outbreak and in at least one instance shared a care giver over a short period of time. This answer was followed by a series of questions and answers: 20 What is your understanding as to whether or not there was any potential patient source at the hospital? 21 A. My understanding from reading the record is that there were two patients that I'm aware of who had what was either diagnosed by somebody else as an active herpes infection or to my reading certainly compatible with an active herpes infection. 22 Q. Were both those patients possible sources? 23 A. Yes, I think they're both possible sources. 24 Q. Would you consider health care workers as possible sources? 25 A. Yes, they're possible sources too, yes. 26 In his prior testimony Dr. Kahn had discussed inanimate objects-called fomites-such as toilet seats, flat surfaces and ice packs, as potential transmission sources of herpes. He was asked if he considered fomites as a possible infection source. 27 I did. I considered them, but my own judgment is that that's considerably less likely. I know there was one instance in particular-I don't know if it's been raised before so I don't know if I should mention it-well, I read it so I guess I can mention there was some talk about an ice pack applied to the perineum. 28 My sense of that was that even though the ice pack could have been wrapped in gauze and therefore, could have held the virus in it, it was more consistent with what we know about herpes transmission, that it was the hand of the nurse applying the ice pack rather than the ice pack that would have been the likelier source of transmission. Dr. Kahn was then asked: 29 Having considered all of the potential sources of infection, did you arrive at one that was most likely in your mind? His answer was: 30 I think the likeliest explanation is the patient who had vaginal lesions with a second crop on the left labia, I believe, and was taken care of at one point by a health care giver who very shortly thereafter took care of Kim [plaintiff]. 31 Dr. Kahn identified the patient as J.D. He then testified that, in light of the fact that the hospital records showed that J.D. had left labial lesions that had not been cultured it was imprudent to take her off herpes infection precautions. He testified: 32 The probability or the possibility of her having transmission-transmissible viruses was very high based on her history and her presentation. 33 On cross-examination Dr. Kahn was asked, Is the best you can say is that J.D. is a possible source of the herpes infection in this case? Then came the following exchange: 34 A. Comparing her to the other patient, I'd say very possible. But again, I can't say probable or with definite certainty. But a very credible likelihood. 35 Q. So the best you can say is possible, but you cannot say probable, correct? 36 A. Slightly high on the possible but not probable. Probable meaning certainty, high possible meaning that's my choice. 37 To our knowledge, no New Hampshire case requires the incantation of the word probable to establish probable causation. In a case involving expert testimony the New Hampshire Supreme Court held: 38 The possibility that the blasting caused the damage could reasonably be found the most probable possibility disclosed by the evidence, and blasting the most probable cause. Emery v. Tilo Roofing Company, 89 N.H. 165, 167, 195 A. 409, and cases cited. 39 Crocker v. W.W. Wyman, Inc., 110 A.2d 271, 274 (N.H. 1954). In Emery v. Tilo Roofing Company, 89 N.H. 165, 195 A. 409 (N.H. 1937), the issue was the cause of a fire to the roof of a building. Defendant was hired to re-roof the building. There was evidence that defendant's employees were seen smoking cigarettes on the roof before the fire started. There was no direct evidence that the fire had been caused by a cigarette stub. In upholding a verdict for plaintiff the court stated: 40 That the fire was caused by a cigarette stub was the most probable possibility disclosed by the evidence and we think that the jury were justified in finding it to be more probable than otherwise that the fire resulted from this cause. Staples v. Railroad, 74 N.H. 499. It is not a case of conjecture between equal possibilities, but the ordinary determination of a conclusion from inferences supported by a balance of probabilities. Saad v. Papageorge, 82 N.H. 294. Not only was the conclusion of the jury as to the cause of the fire proper as a direct inference from the testimony but the improbability of any other explanation as an exclusionary premise may serve to strengthen the force of the deduction. 41 Id. at 167. 42 In the case before us the main defense was that plaintiff was infected with herpes before she was admitted to the hospital. There was no direct evidence of such an infection. As with the plaintiff's evidence, it depended on expert testimony. 43 We read Dr. Kahn's testimony to say that the probable cause of the infection was one or more acts of negligence by the hospital, and find that this conclusion, which was rationally supported and explained, is sufficient to establish causation even though the doctor could not identify a single cause as the more-likely-than-not cause of this infection. It follows, therefore, that the jury verdict that the plaintiff was infected with herpes while a patient at the Mary Hitchcock Memorial Hospital is unassailable on causation grounds.