Opinion ID: 1583193
Heading Depth: 1
Heading Rank: 6

Heading: admission of medical testimony

Text: Kuehn objects to the admission of certain evidence, including testimony of the physicians who treated Cameron. The standard for reviewing the admissibility of expert testimony is abuse of discretion. State v. King, 269 Neb. 326, 693 N.W.2d 250 (2005). Four factors govern the admissibility of expert testimony: (1) whether the witness is qualified as an expert, (2) whether the testimony is relevant, (3) whether the testimony will assist the trier of fact, and (4) whether the probative value of the testimony, even if relevant, is outweighed by the danger of unfair prejudice or other considerations. Nebraska Nutrients v. Shepherd, 261 Neb. 723, 626 N.W.2d 472 (2001). See, also, State v. Reynolds, 235 Neb. 662, 457 N.W.2d 405 (1990), disapproved on other grounds, State v. Messersmith, 238 Neb. 924, 473 N.W.2d 83 (1991). We therefore consider whether the district court abused its discretion in admitting the medical testimony. Dr. Ivan Pavkovic, a pediatric neurologist who treated Cameron after his injury, testified that Cameron was developmentally delayed and blind, displayed spasticity, and had epilepsy as the result of a brain injury. Pavkovic stated that Cameron's injury was caused by rotational force, which occurs when the brain is rotated inside the skull. CT scans of Cameron's brain showed atrophy, which indicated a brain injury. Cameron's brain was shrunken, and corresponding fluid-filled spaces outside the brain were larger than normal because his brain was smaller than normal. His brain damage was diffuse. Pavkovic stated that a subdural hematoma which pressed on the surface of the brain caused dysfunction and problems such as motor function, paralysis, or seizures. Pavkovic testified that blunt trauma to an infant rarely results in subdural hemorrhage and even more rarely results in retinal hemorrhage, both of which were evident in Cameron. Pavkovic stated that Cameron's condition was due to inflicted or nonaccidental traumatic injury to the brain. CT scans and MRI results indicated that Cameron had also sustained subdural hematomas in the weeks or months prior to August 2004. In response to Kuehn's objection of no proper and sufficient foundation, speculation, and conjecture, Pavkovic stated: [Cameron's] initial presentation to the hospital . . . involved the presence of subdural hematomas . . . one of which was chronic. [O]ne was new. He had bleeding into both his retinal, what we call retinal hemorrhages and he had mental status changes and initially seizure activity too. And when you take all of those positive findings in combination with the fact that there was no history to support any kind of major trauma to his head, the only conclusion that can be reached is that this was some type of inflicted traumatic injury to his brain. Additional medical testimony was provided by DeMare, who stated that Cameron's physical findings were consistent with an inflicted traumatic brain injury. He explained that any time a child has a brain injury as significant as Cameron's, it is the result of a significant amount of force. DeMare stated: This is the kind of injury we'd expect from a fall from a couple stories high, from a high speed car accident, that's the kind of force we're talking about. In the absence of any explanation that would mirror that, we have to assume that inflicted injury is the only other reasonable explanation. . . . . [This is] a child who's got a brain injury that would require enough force that there's no way that it could happen without somebody knowing what happened. We're talking about a lot of force here. This isn't just a[n], oops, someone  the kid fell over and hit his head and this injury happened. There's a lot of force that's involved and someone must know what happened to the child. In addition to Pavkovic and DeMare, testimony was received from several other medical experts. Dr. Phillip Eckstrom, a radiologist who performed a CT scan on Cameron on August 4, 2004, stated that Cameron had subdural hematomas on both sides of the brain which were of different ages. This indicated that Cameron had experienced trauma at more than one time prior to August 4. Eckstrom was asked if he had an opinion as to the force normally associated with the injury Cameron had suffered, and over Kuehn's objection, Eckstrom said the injury was caused by rotational force. Dr. Robert Troia, an ophthalmologist, stated that Cameron's blindness was due to retinal hemorrhages Cameron had suffered. Dr. Daniel Davis, a forensic pathologist, stated that on August 4, Cameron suffered a primary sublethal brain injury that involved deep structures of his brain and possibly his upper cervical spinal cord. Throughout the medical testimony, Kuehn interposed objections based on lack of foundation, speculation, conjecture, and a violation of Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993). These objections were overruled. On appeal, Kuehn claims the district court improperly overruled her objections based on speculation and conjecture. We interpret her argument as a complaint that the medical testimony should not have been admitted because the physicians did not couch their opinions in terms of reasonable medical certainty. The preferred form of establishing the certainty of a medical expert's opinion is to ask for the opinion in terms of a reasonable degree of certainty or probability. In Paulsen v. State, 249 Neb. 112, 121, 541 N.W.2d 636, 643 (1996), we stated: Our well-known preference for the use of the phrases reasonable degree of medical certainty or reasonable degree of probability is an indication to courts and parties of the necessity that the medical expert opinion must be stated in terms that the trier of fact is not required to guess at the cause of the injury. Where the medical expert's testimony gives rise to conflicting inferences of equal degree of probability such that the choice between them is a matter of conjecture, the testimony should be excluded. See id. An opinion which is equivocal and is based upon such words as could, may, or possibly lacks the certainty required to sustain the burden of proof of causation for which the opinion has been offered. We have stated that [a]lthough expert medical testimony need not be couched in the magic words `reasonable medical certainty' or `reasonable probability,' it must be sufficient as examined in its entirety to establish a crucial causal link between a victim's injuries and a defendant's actions. See Fackler v. Genetzky, 263 Neb. 68, 74, 638 N.W.2d 521, 527-28 (2002) (referring to link between plaintiff's injuries and defendant's negligence). An expert's opinion is to be judged in view of the entirety of the opinion and is not validated or invalidated solely on the presence or lack of the words reasonable degree of medical certainty or probability. See Paulsen v. State, 249 Neb. at 121, 541 N.W.2d at 643. Such words are not necessary. See, Edmonds v. IBP, Inc., 239 Neb. 899, 479 N.W.2d 754 (1992); Hohnstein v. W.C. Frank, 237 Neb. 974, 468 N.W.2d 597 (1991). The expert's opinion must be sufficiently definite and relevant to provide a basis for the fact finder's determination of an issue or question. See Hohnstein v. W.C. Frank, supra . Whether an expert's opinion is too speculative to be admitted is a question for the trial court's discretion. Gourley v. Nebraska Methodist Health Sys., 265 Neb. 918, 663 N.W.2d 43 (2003). In the case at bar, the principal witnesses on the issue of causation were Pavkovic and DeMare. Both stated that Cameron's injuries were caused by inflicted or nonaccidental trauma to the brain. The physicians did not speculate as to the cause of Cameron's injury. They testified that (1) the injury was caused by rotational force when the brain was rotated inside the skull; (2) blunt trauma in an infant rarely results in a subdural hemorrhage such as that suffered by Cameron; (3) blunt trauma even more rarely causes retinal hemorrhages such as those seen in Cameron; (4) Cameron's injury was due to inflicted or nonaccidental traumatic injury to the brain; (5) a brain injury as significant as Cameron's is the result of a significant amount of force, such as a fall from a height of several stories or a high-speed car accident; and (6) Cameron's injury was entirely consistent with a child's being violently shaken. Pavkovic testified that inflicted traumatic brain injury was the only conclusion that [could] be reached on the basis of the history and objective findings. DeMare testified that in the absence of a history of significant accidental trauma, an inflicted injury [was] the only other reasonable explanation. As noted above, four factors govern the admissibility of expert testimony. Nebraska Nutrients v. Shepherd, 261 Neb. 723, 626 N.W.2d 472 (2001). Kuehn does not question the first factor: whether any of the witnesses were qualified to present expert testimony. The second factor concerns whether their testimony was relevant. The medical expert testimony was relevant to the question of whether Cameron's injury was sustained by accident or through an intentional action. The third factor is whether the experts' testimony will assist the trier of fact. In this case, it assisted the jury in understanding the extent of Cameron's injury and the manner in which it occurred, which was a controverted factual issue. We also find that the fourth factor was present: The probative value of the evidence was not outweighed by the danger of unfair prejudice. Therefore, we conclude that the district court did not abuse its discretion in admitting the State's testimony elicited from the medical experts. The evidence was sufficient to sustain the jury's verdict finding Kuehn guilty of negligent child abuse. Kuehn also interposed objections throughout the testimony of Pavkovic and DeMare as being in violation of Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993). Because these objections were overruled, we will address whether admission of the testimony violated the requirements of Daubert. During a pretrial hearing referred to as a  Daubert hearing by the district court, Dr. Robert Prokop, a forensic pathologist who had reviewed Cameron's records, opined that an injury could not be defined as intentional or accidental without knowledge of the entire facts of the incident. Prokop's testimony was the only evidence offered by Kuehn at the hearing. In a Daubert challenge, the initial task falls on the party opposing expert testimony to sufficiently call into question the reliability of some aspect of the anticipated testimony, and then the proponent of the expert testimony has the burden of showing that the testimony is reliable. See State v. Mason, 271 Neb. 16, 709 N.W.2d 638 (2006). Prokop suggested that Cameron's injury could not be defined as intentionally inflicted when all of the facts related to the incident were not known. We do not consider Prokop's testimony to be Daubert evidence, but, rather, an attempt to impeach the medical evidence presented by the State. The district court did not abuse its discretion in overruling Kuehn's objections made on the basis of Daubert. Kuehn also complains that the district court erred in failing to sustain her hearsay objection to a statement made by Dr. Joe Metcalf II, an emergency room physician, to Joe O'Brien, a police investigator. On redirect examination by the State, O'Brien stated that he had asked Metcalf whether Cameron's injuries could have been caused by dropping the child. Kuehn objected on the bases of hearsay and improper redirect because O'Brien was being asked about statements in his deposition. The court sustained this objection. O'Brien was then asked what he wrote in a report about Metcalf's telling you about the likelihood of this being caused by dropping. Kuehn objected on the basis of hearsay, and the court overruled the objection. O'Brien testified, I asked Doctor Metcalf if  I asked if it could have been caused by dropping Cameron. Doctor Metcalf told me that it didn't appear likely that that was the case. Prior to the exchange that led to Kuehn's objections, O'Brien had been cross-examined by Kuehn's attorney, who read portions of O'Brien's deposition into the record. During that cross-examination, counsel elicited the fact that Metcalf had stated that Cameron had a subdural hematoma and that it was probably caused by Cameron's having been dropped. After defense counsel repeated information in O'Brien's deposition concerning Metcalf's opinion as to the cause of Cameron's injuries, the State sought on redirect to clarify the information, leading to the questions which Kuehn objected to as hearsay. Kuehn initiated the line of questioning concerning statements made by Metcalf to O'Brien. The testimony was initially elicited by Kuehn's counsel, and the district court did not abuse its discretion in allowing the testimony on redirect.