Opinion ID: 746887
Heading Depth: 1
Heading Rank: 4

Heading: Moore's Proffers of Expert Clinical Medical Testimony

Text: 75 The plaintiffs set out to prove that Moore's personal injury, viz., his reactive airways disease, was proximately caused by his exposure to the mixture of chemicals he encountered at Ashland's premises. Moore's case depended on expert testimony that his disease was reactive airways disease and that it had been caused by his exposure to the chemicals at Ashland. The plaintiffs proffered the opinions and inferences of Dr. Daniel E. Jenkins and Dr. B. Antonio Alvarez based on their clinical medical knowledge and facts and data in this particular case for these purposes.
76 Dr. Jenkins received his medical degree from the University of Texas in 1940. He received medical training at the University of Michigan Hospital as an intern, resident in medicine, resident in Tuberculosis and Chest Disease, and resident in Allergy in 1940-1945. The American Board of Internal Medicine certified him in 1947. Between 1943 and 1947 he served as Instructor and Chief Resident in Medicine and as Assistant Professor of Medicine and Physician in charge of the Tuberculosis and Chest Unit, University of Michigan Medical School. From 1947 to 1991 he served as Assistant Professor, Associate Professor, and Professor of Medicine at Baylor College of Medicine, Houston, Texas. From 1947 to 1974 he was Chief, Pulmonary Disease Section, Baylor College of Medicine. From 1975 to 1991 he was Chief, Environmental Medicine, Baylor College of Medicine. In 1991, he went into practice with The Respiratory Consultants of Houston, consisting mostly of a group of physicians that he had trained. He is either Attending Physician or Consultant in Medicine or Pulmonary Medicine at eight Hospitals in Houston, Texas. Additionally, Dr. Jenkins is a member of sixteen national, state and local medical organizations and has served as president or chairman of a section for three of them. 77 In formulating his opinion, Dr. Jenkins personally took a detailed medical history from Moore, performed a thorough physical examination, personally observed him three times, performed or supervised a series of tests on Moore including pulmonary function tests, a bronchial challenge test, a bronchodilator test, a spirometry test, a plethysmographic test, a lung volume determination, an intrapul gas distribution test, a diffusion test, an arterial bloods test, a mechanics test, X-rays, and laboratory tests, reviewed the medical records and reports of Dr. Alvarez and Dr. Simi, including a report of the bronchial dilator test by Dr. Simi two or three weeks after the accident that showed severe airways obstruction and a report of an allergy test performed by Dr. Alvarez--among some fifteen reports of examinations and tests by him--that ruled out allergic or immunologic disease and confirmed reactive airways disease as the proper diagnosis of Moore's illness, reviewed the material safety data sheet MSDS prepared by Dow Corning, and consulted a medical treatise, Carl Zenz, OCCUPATIONAL MEDICINE: PRINCIPLES AND PRACTICAL APPLICATION (2d ed.1988) and other medical literature. 78 In his proffered testimony, Dr. Jenkins explained that reactive airways disease, also known as reactive airways dysfunction syndrome (RADS), is recognized in the field of clinical medical knowledge as a disorder consisting of a reactive obstruction of air passageways in the bronchial trees and the lower respiratory tract, producing labored breathing, wheezing, shortness of breath, coughing and the raising of phlegm. Dr. Jenkins' testimony as to the nature and symptoms of reactive airways disease was accepted as accurate by the parties and other experts on both sides. In the history taken by Dr. Jenkins, Moore reported that he had been in comparatively good health until about one hour after his exposure to the chemical gases at Ashland when he began to experience these types of symptoms. In his physical examinations and tests of Moore, Dr. Jenkins observed symptoms and signs of reactive airways disease. Dr. Jenkins stated that the objective medical tests performed by him and the several doctors who had seen Moore after his exposure indicated conclusively that Moore was not malingering. 79 Dr. Jenkins offered his opinion that Moore suffered from reactive airways disease that had been caused by Moore's exposure to gases emanating from a spill of blended chemicals which Moore had cleaned up without a respirator. He testified that the manufacturer's material safety data sheet stated that the principal substances contained in the mixture of chemicals that Moore breathed were toluene, naphtha, and propylene glycol methyl ether, and that all of these have irritating properties. He further stated that any chemical with irritating properties can cause reactive airways disease in a person who is capable of responding in that way. Dr. Jenkins also stated that toluene, one of the chemicals to which Moore was exposed, is similar to the chemical nature of other properties upon which there have been written articles on reactive airways disease. Dr. Jenkins testified that, based on the history given by Moore that a substantial amount of the mixed chemical solvent had leaked onto the truck-trailer floor from two 55 gallon drums while the cargo was enclosed and en route, he roughly estimated that Moore had been exposed to 200 parts per million or higher of the chemical vapors. Dr. Jenkins also testified that Moore informed him that neither Ashland nor anyone else had taken air samples with mechanical devices at the time of Moore's exposure. 80 Although Dr. Jenkins acknowledged that he could not recall having seen a patient who had been exposed to the same chemicals under the same circumstances, he testified that he had examined and evaluated over one hundred other patients who had been exposed to chemicals under various circumstances. During Dr. Jenkins' deposition, the interrogating lawyers and the doctor sometimes referred to the mixed chemical spillage as toluene, which was in fact just one of its many ingredients. But a fair reading of the deposition as a whole clearly indicates that when the lawyers and Dr. Jenkins used the word toluene they intended to refer to the chemical mixture containing toluene and simply called the solvent mixture toluene for the sake of convenience. Dr. Jenkins' proffered testimony was that, based on his education, knowledge, training, and experience, personal examination of Moore, personal taking of Moore's history, supervision and study of his own tests on Moore, review and study of other doctors' reports, tests and opinions, study of a medical treatise and numerous medical literature articles, he concluded that Moore's exposure to the mixture of chemical gases contained in the solvent to which he was exposed caused his disease, because any chemical with irritating properties can cause reactive airways disease, and each of the chemicals in the solvent mixture had irritating properties.
81 Dr. Alvarez testified that he was born in Mexico and came to the United States in 1964 for internship and residency in internal medicine, followed by two years of fellowship in pulmonary at the Baylor College of Medicine in Houston. Dr. Daniel E. Jenkins was one of Dr. Alvarez's professors at the Baylor College of Medicine. Dr. Alvarez had practiced in Houston since 1973 and was on the active staff of three, and courtesy staff of one, Houston area hospitals. 82 At the proffer stage, Dr. Alvarez, offered his opinion based on clinical medical knowledge as an internist and pulmonary specialist, enhanced by his experience in having seen fifty to sixty patients injured from exposure to chemicals, and on the facts and data contained in the medical history taken by Dr. Jenkins, the X-rays and numerous medical tests performed by Dr. Jenkins, a sinus X-ray, an allergy or RAST test performed by Dr. Alvarez tending to rule out allergies as the cause of the illness, numerous physical examinations and observations of Moore, and the manufacturer's material data sheet pertaining to the chemicals to which Moore was exposed. Applying his knowledge, education, training and experience to these facts and data, but admittedly relying heavily on Dr. Jenkins' work and opinion, Dr. Alvarez expressed his opinion that Moore suffered from reactive airways disease that had been caused by his inhalation of chemical gases while he was cleaning up the chemical spillage at Ashland. When asked whether he relied heavily on the evaluation and documentation provided from Dr. Jenkins, Dr. Alvarez replied very much. In addition, he testified that he had not seen the history and evaluations of Dr. Warren Simi first hand. Dr. Alvarez was asked how important it was to know the duration of an exposure, the amount of chemical present, the dimensions of the area or enclosure, the ventilation, and the temperature. In response, Dr. Alvarez indicated that if such data were available it would be very important, but, he explained, it is always very difficult for a medical doctor, who must make decisions as to causation and diagnosis in treating patients accidentally exposed to chemicals or other toxic substances, to obtain exact or mechanically measured data on these issues because of the very fact that the injury always results from an accident and not a controlled experiment. 83 C. Dr. Jenkins' opinion as to causation was soundly grounded in traditional clinical medical knowledge, principles and methodology. 84 Dr. Jenkins, a specialist in pulmonary and environmental disease, based his opinion on principles, theories, methodology and techniques, which are well accepted within his discipline. In summary, the proffered testimony of Dr. Jenkins reflects that he: 1) Examined Moore personally: Dr. Jenkins saw Moore on three occasions, between June 26, and August 1, 1990. On each occasion the doctor personally observed the patient. The doctor performed a thorough physical examination of Moore. (Personal observation has always been an adequate basis for an expert's opinion, and indeed has been called  'the most desirable of all bases.'  3 WEINSTEIN p 703, 703-7; Rheingold, The Basis of Medical Testimony, 15 VAND.L.REV. 473, 489 (1962)). 2) Personally took a detailed medical history from Moore: Dr. Jenkins personally took Moore's history involving his health and the accident in an interview of approximately one and one-half hours. (Reliance on patient statements to render a medical opinion is usually justified as trustworthy because patients have a strong incentive to tell their treating physician the truth--the desire to recover. In re Agent Orange Product Liability Litigation, 611 F.Supp. 1223, 1246 (E.D.N.Y.1985); Rheingold, supra at 495; Ferebee v. Chevron Chemical Co., 736 F.2d 1529, 1535 (D.C.Cir.1984)(especially when corroborated by medical records, physical examination, and medical tests); See O'Gee v. Dobbs Houses, Inc., 570 F.2d 1084 (2d Cir.1978); Birdsell v. United States, 346 F.2d 775, 780 (5th Cir.1965); Rheingold, supra at 488.) 3) Used Differential Diagnosis and Etiology: In his determination of the cause and nature of the disease, Dr. Jenkins performed or supervised a series of tests on Moore. He studied, compared and synthesized the results so as to eliminate all possibilities but the most likely diagnosis and cause of the disorder. The gamut of tests performed on Moore included pulmonary function tests, a bronchial challenge test, a bronchodilator test, an allergy test, X-rays, and laboratory tests. Dr. Jenkins and Dr. Alvarez testified that it would have been impossible for Moore to fake RAD signs on the objective tests. See Birdsell v. United States, 346 F.2d 775, 779-780 (5th Cir.1965) ([T]he physician making a diagnosis must necessarily rely on many observations and tests performed by others and recorded by them; records sufficient for diagnosis in the hospital ought to be enough for opinion testimony in the courtroom.; McCullock v. H.B. Fuller Co., 61 F.3d 1038, 1043-1044 (2nd Cir.1995); Benedi v. McNeil-P.P.C., Inc., 66 F.3d 1378, 1384 (4th Cir.1995)). 4) Reviewed tests, reports and opinions of other doctors: Dr. Jenkins reviewed the records and reports of Dr. Simi, who had seen Moore shortly after the accident. Dr. Jenkins testified that Dr. Simi's records showed even more severe airways obstruction in response to bronchial dilators which indicated there was not any question that Moore had acquired reactive airways disease. Dr. Jenkins also stated that he had reviewed the allergy studies performed by Dr. Alvarez that confirmed the reactive airways disease diagnosis and ruled out an allergic or immunologic disease as the cause. (Reliance on reports and observations of other physicians and medical technicians is accepted practice in medical field and may be relied on by expert witnesses. Jenkins v. United States, 307 F.2d 637 (D.C.Cir.1962)). 5) Reviewed the MSDS: The Occupational Safety and Health Act authorizes the Secretary to promulgate safety and health standards and requires employers to comply with them. 29 U.S.C. §§ 654(a)(2), 655. Pursuant thereto, the Hazard Communication Standard, 29 C.F.R. § 1910.1200, requires that a manufacturer of hazardous chemicals inform its own employees and downstream employers and employees of the dangers posed by the chemicals. The manufacturer is required to prepare a material safety data sheet (MSDS) for each hazardous chemical, including the identity of the chemical; health hazards posed; and handling precautions. See Martin v. American Cyanamid Co., 5 F.3d 140 (6th Cir.1993) Dr. Jenkins and Dr. Alvarez reviewed the MSDS that Dow Corning provided with the chemicals to which Moore was exposed. The MSDS is a type of fact or data reasonably relied upon by medical experts in forming opinions or inferences as to medical causation. See McCullock v. H.B. Fuller Company, 61 F.3d 1038, 1044 (2d Cir.1995). Because federal regulations require manufacturers to truthfully disclose in the MSDS the identity and health hazards of materials, it is reasonable for medical experts to rely at least in part on the MSDS in forming diagnostic and causal opinions. See also Peteet v. Dow Chemical Co., 868 F.2d 1428, 1432 (5th Cir.1989)(In making this determination, the trial court should defer to the expert's opinion of what data they find reasonably reliable.) 6) Referred to medical literature on the properties of irritant chemicals that cause RAD: Dr. Jenkins relied on a medical treatise, Carl Zenz, OCCUPATIONAL MEDICINE: PRINCIPLES AND PRACTICAL APPLICATION (2d Ed.1988), and a number of published articles in medical literature in forming his opinion or inference that the chemicals to which Moore was exposed were irritants that caused Moore's RAD. (Facts or data found in the literature of the profession, even though not themselves admissible in evidence, properly form a part of the basis for an expert's opinion. Bauman v. Centex Corporation, 611 F.2d 1115, 1120, n. 6 (5th Cir.1980) (quoting Nanda v. Ford Motor Co. 509 F.2d 213, 222 (7th Cir.1974))). 7) Utilized his training and experience: During his 53 years of medical practice, Dr. Jenkins had a considerable amount of experience with injuries caused by occupational inhalants. Due to the chemical industries along the Gulf Coast, inhalant disease victims were a large part of the patients seen by the Pulmonary and Environmental Medicine sections that Dr. Jenkins headed at Baylor College of Medicine at Houston, Texas for a combined period of 43 years. Dr. Jenkins had been called upon to make a determination whether a particular condition was caused by a particular chemical on more than one hundred occasions. (A witness's training and long experience may qualify him as an expert and enable him to assist the jury regarding subjects within his training and experience. United States v. Chappell, 6 3d. 1095, 1100 (5th Cir.1993); United States v. Hernandez-Palacios, 838 F.2d 1346, 1350 (5th Cir.1988); West Wind Africa Line, Ltd. v. Corpus Christi Marine Services Co., 834 F.2d 1232, 1236 (5th Cir.1988)).