Opinion ID: 163939
Heading Depth: 2
Heading Rank: 4

Heading: Did the Medical Literature Support the General Causation Opinion?

Text: 21 The Railroad first argues that the district court abused its discretion because Dr. Teitelbaum's general causation opinion was not supported by the medical literature he cited. The district court specifically found that Dr. Teitelbaum's methodology — i.e., surveying medical literature, drawing general propositions and then applying them to arrive at a conclusion of general causation — was reliable. III R. at 664. The Railroad does not contend that this methodology is per se unreliable, Aplt. Br. at 29, but instead argues that an otherwise reliable method was applied to the facts of this case in an unreliable manner. First, the Railroad suggests that Dr. Teitelbaum erroneously reached certain generally accepted propositions regarding the symptoms, causes and typical occurrences of HACE only by selecting and relying on portions of the literature that were favorable to his ultimate conclusion without explaining or even considering unfavorable portions. Second, it argues that Dr. Teitelbaum then unjustifiably extrapolated from these erroneously drawn general propositions to conclude that general causation existed here. Aplt. Br. at 21, 30-38.
22 After conducting a thorough review of the articles, the district court found that Dr. Teitelbaum's reliance on them for various general propositions was proper and that his conclusions were adequately supported by the scientific literature. III R. at 664. The court emphasized that [a]nalyzing each individual article and requiring that each article fully support Dr. Teitelbaum's theory, instead of focusing on the cumulative weight of the evidence, would be overemphasizing [his] conclusions, as opposed to his methodology. Id. at 665. The court found that this is not [a] case where too great an analytical gap existed between the data and the opinion. Id. After noting that the effects of each component of Mr. Goebel's injury — high altitude, oxygen deficiency and diesel fume exposure — had been individually studied and widely accepted in the medical community and that neither the court nor the Railroad had uncovered evidence suggesting an opposite conclusion, the court concluded that Dr. Teitelbaum's opinion was reliable: Dr. Teitelbaum's methodology is scientifically sound, and ... his opinion reasonably flows from the data upon which he purportedly relies. Id. at 667. 23
24 In arguing that the district court's review of the literature was insufficient, the Railroad directs us to specific passages in the articles that, in its view, undercut Dr. Teitelbaum's general propositions and his ultimate conclusions. Aplt. Br. at 30-38. As expected, Mr. Goebel reviews the same articles and, like the district court, reaches a conclusion in direct opposition to the Railroad. Aplee. Br. at 38-52. Notable, however, is that the Railroad apparently agrees with the district court that there is no requirement that each individual article must fully support Dr. Teitelbaum's precise theory. Aplt. Br. at 29; see also Joiner, 522 U.S. at 146-47, 118 S.Ct. 512 (noting that studies may support a conclusion either individually or in combination ) (emphasis added); III R. at 665-66 (collecting cases). 25 The Railroad's core argument is that the district court incorrectly concluded that this is not [a] case where too great an analytical gap existed between the data and the opinion. III R. at 665. When faced with such a claim, we must, as did the Supreme Court in Joiner, review the literature to determine whether the district court was within its discretion in finding an adequate link between the existing data and the conclusions. 522 U.S. at 145-46, 118 S.Ct. 512. Given the lack of scientific literature directly addressing the confluence of all of the factors at issue in the tunnel, such a review is all the more important here. 26 As we stated above, our review is deferential — only if we are convinced that the district court made a clear error of judgment or exceeded the bounds of permissible choice in the circumstances will we disturb its ruling. Dodge, 328 F.3d at 1223 (quoting Atlantic Richfield Co. v. Farm Credit Bank of Wichita, 226 F.3d 1138, 1163-64 (10th Cir.2000)). Despite our expertise on the law, our role as judges is not to second-guess well qualified and highly trained medical experts on difficult judgment calls within their field of expertise; our role is merely to ensure that the district court did not abuse its discretion by concluding that the expert testimony in this case was admissible under the standards outlined above. Neither the district court nor this court is in a position to declare or even to know with any degree of certainty whether otherwise admissible expert testimony is, in fact, correct. See, e.g., Daubert, 509 U.S. at 596, 113 S.Ct. 2786 (Vigorous cross-examination, presentation of contrary evidence, and careful instruction on the burden of proof are the traditional and appropriate means of attacking shaky but admissible evidence.). We also approach our review mindful that the district court here had the added benefit of the Railroad's voir dire of Dr. Teitelbaum and its cross examination of him at trial. 27 After a careful review of the Railroad's arguments, Dr. Teitelbaum's affidavits, the underlying medical literature and the record as a whole, we perceive no basis to conclude that the district court abused its discretion by ruling that Dr. Teitelbaum's opinion was adequately supported by the scientific literature. Given the record before us, we too are unpersuaded that this is a case where too great a gap exists between the proffered expert opinion and the underlying data. 28
29 The Railroad first argues that Dr. Teitelbaum's basic contention — that Mr. Goebel exhibited symptoms classically associated with HACE — is not supported by the cited literature. Aplt. Br. at 30. Among the many symptoms exhibited by Mr. Goebel were a severe headache, tightness in his chest, significant aches and soreness, shortness of breath, nausea and disorientation that rendered him unable to read. In the Railroad's view, the studies cited by Dr. Teitelbaum do not support a diagnosis of HACE based on these symptoms. After reviewing the Railroad's citations to various studies and uncovering no significant support for its position, we conclude that the district court did not abuse its discretion. 30 Dr. Teitelbaum's opinion — that Mr. Goebel suffered from acute mountain sickness (AMS) which developed into non-acute HACE, see II R. at 356, ¶ 8 — was supported by The Lake Louise Consensus on the Definition of Altitude Illness, available in Thomas E. Dietz, High Altitude Medicine Guide (2000), II R. at 398. That study indicates that in the setting of a recent altitude gain, a headache plus nausea is alone sufficient to support a diagnosis of AMS. Id. Mr. Goebel clearly satisfied this criteria. The study also states that in such a setting, the presence of a change in mental status in a person with AMS is sufficient to support a diagnosis of HACE. Id. The included Lake Louise Consensus worksheet makes it clear that Mr. Goebel's disorientation is also sufficient to constitute a change in mental status. Id. at 400. Thus, contrary to the Railroad's suggestion, the Lake Louise Consensus supports Dr. Teitelbaum's conclusions. 31 In support of its argument, the Railroad also directs us to an isolated statement in Thomas E. Dietz, Altitude Illness Clinical Guide for Physicians, High Altitude Medicine Guide (2000), II R. at 403-12, where the author notes that I have not yet seen a case of HACE in which the patient didn't ascend with AMS symptoms. Id. at 408. The Clinical Guide admittedly relies on the Lake Louise Consensus guidelines relating to symptoms and diagnosis of altitude illnesses. Id. at 403, 407. Because under those guidelines Mr. Goebel exhibited symptoms of AMS and HACE, the quoted statement relied upon by the Railroad is utterly irrelevant. When read as a whole, the portions of the High Altitude Medicine Guide contained in the record support Dr. Teitelbaum's opinion. See id. at 416-18 (discussing the symptoms associated with AMS and HACE and essentially echoing the conclusions of the Lake Louise Consensus ). 32 Another of the Railroad's contentions is that the chapter in Michael P. Ward et al., High Altitude Medicine and Physiology 412-18 (2d ed.1995), entitled High Altitude Cerebral Edema and Retinal Haemorrhage, II R. at 333, contradicts Dr. Teitelbaum's opinion. In fact, in discussing the typical symptoms associated with AMS and HACE, this chapter once again echoes the conclusions of the Lake Louise Consensus. Id. (symptoms of AMS include headache and nausea; clouding of consciousness indicates HACE). Contrary to the Railroad's suggestion, Aplt. Br. at 31, this chapter at no point states that loss of consciousness is among the  classic symptoms of HACE. Id. (emphasis in original). Although the chapter states that [o]ften there is also an element of pulmonary edema exhibited in HACE sufferers, II R. at 334, it is undisputed that Mr. Goebel did not exhibit signs of that condition. Nonetheless, this quite general and self-limited statement is insufficient to render Dr. Teitelbaum's conclusion unreliable given the obvious corollary that cases must exist where no signs of pulmonary edema are exhibited by a HACE sufferer. 33 A similar issue arises from the Railroad's citation to the Statement on High Altitude Illnesses, Canada Communicable Disease Report (Nov. 15, 1998), II R. at 424, which states that HACE rarely occurs without high altitude pulmonary edema. Id. at 430. Although this is a stronger statement than that made in the High Altitude Medicine and Physiology chapter just discussed, it still fails to contradict materially Dr. Teitelbaum's opinion. Once again, this statement is limited by its own terms, i.e., rarely. Id. In addition, the Statement continues by stating that HACE is characterized by symptoms including an altered level of consciousness in the form of confusion [and] impaired thinking. Id. at 431. Its discussion of AMS again relies on the parameters listed in the Lake Louise Consensus. Id. at 427. Therefore, when read as a whole, the Report does not cast serious doubt on Dr. Teitelbaum's opinion and is certainly insufficient as a basis for finding that the district court abused its discretion by concluding otherwise. 34 The Railroad's attempted reliance on isolated passages and concepts in the following sources is similarly unavailing: Peter H. Hackett, The Cerebral Etiology of High-Altitude Cerebral Edema and Acute Mountain Sickness, 10 Wilderness and Envtl. Med. 97 (1999), II R. at 446; M. Jay Porcelli & Gary M. Gugelchuk, A Trek to the Top: A Review of Acute Mountain Sickness, 95 J. Am. Osteopath Ass'n. 718 (1996), II R. at 309; and Phillip R. Yarnell et al., High-Altitude Cerebral Edema (HACE): The Denver/Front Range Experience, 20 Seminars in Neurology 209 (2000), II R. at 535. When read as a whole, none of these articles calls Dr. Teitelbaum's opinion into question. In fact, our review of them substantially buttressed Dr. Teitelbaum's analysis given their consistency with the Lake Louise Consensus parameters. Our review of Railroad expert Dr. Neil Rosenberg's affidavit, III R. at 599-609, likewise provides no additional evidence that Dr. Teitelbaum's opinion is not supported by the cited studies; Dr. Rosenberg's affidavit falls well short of a showing that would allow us to conclude that the district court abused its discretion. 35
36 The Railroad also apparently argues that the studies cited by Dr. Teitelbaum do not support a conclusion that it is even possible for a person to develop HACE at altitudes at or near 9,200 feet. Aplt. Br. at 35-36; id. at 35 (reiterating Dr. Rosenberg's opinion that the altitudes attained by Mr. Goebel are not capable of causing HACE). In the Railroad's view, the studies demonstrate that HACE is very rare and occurs at altitudes well above the 9,200 feet of Moffat Tunnel. Id. at 36. While subtle inconsistencies might well exist across the various studies noted by the Railroad, we are unable to conclude that the district court abused its discretion by finding that the studies as a whole supported Dr. Teitelbaum's opinion. 37 It is worthwhile to note first that none of the studies pointed to by the Railroad state that a person cannot develop HACE at altitudes of 9,200 feet. On the contrary, the studies in the record largely agree that it is possible to suffer from altitude illnesses such as AMS and HACE at such elevations. The consensus appears to be that high-altitude illnesses are an issue to be considered for humans at altitudes of only 5,280 feet, the beginning of what is commonly referred to as high altitude elevation. M. Jay Porcelli & Gary M. Gugelchuk, A Trek to the Top: A Review of Acute Mountain Sickness, 95 J. Am. Osteopath Ass'n. 718, 718 (1996), II R. at 309; All About Altitude Illness, High Altitude Medicine Guide, II R. at 415 (noting that high altitude begins at or near 5,000 feet). 38 The studies also agree that although high altitude illnesses can affect people at altitudes around only 5,000 feet, such illnesses are rare below 8,000 feet. All About Altitude Illness, II R. at 415, 417; Statement on High Altitude Illnesses, Canada Communicable Disease Report, II R. at 424 (noting that some susceptible individuals may experience symptoms of altitude-related illness beginning as low as 2,500 m[eters].); Altitude Illness Clinical Guide for Physicians, High Altitude Medicine Guide, II R. at 405. However, the studies make it clear that above the 8,000 foot line, high altitude illnesses are a real concern and become much more likely to cause people problems. E.g. American Academy of Family Physicians, High-Altitude Illness: How to Avoid It and How to Treat It (1998), II R. at 499. Therefore, the medical literature in the record lends ample support to the conclusion that Mr. Goebel could suffer from high altitude illnesses at elevations of 9,200 feet. 39 What is even more critical, however, is that Dr. Teitelbaum's opinion is not that Mr. Goebel developed HACE solely from the altitude exposure; rather, he opined that other factors contributed to the onset, including the oxygen context of the air, the heavy diesel-fume pollution, the counterproductive use of the respirator, Mr. Goebel's increased activity during the incident, and Mr. Goebel's individual physiologic response. II R. at 245. No individual study in the record attempts to account for and control additional factors such as those relied upon by Dr. Teitelbaum. The Railroad's argument based on studies relying solely on altitude as the cause of a given high altitude illness therefore misses the point. See Aplt. Br. at 35 (citing N.A. Lassen, Increase of Cerebral Blood Flow at High Altitude: Its Possible Relation to AMS, 13 Int'l J. Sports Med. S47 (1992) (dealing with altitudes of 12,000 to 15,000 feet), II R. at 298). The district court did not abuse its discretion by concluding that the studies supported Dr. Teitelbaum's opinion that Mr. Goebel could have developed AMS and HACE at an elevation near 9,200 feet. 40
41 The Railroad's final argument relating to the studies is that [n]othing in the medical or scientific literature suggests that HACE can be developed in an exposure of less than one hour. Aplt. Br. at 37. In the Railroad's view, although HACE would ordinarily require one to three days to develop, onset might possibly occur after 12 hours but is simply not going to manifest in the span of one hour. Id. We perceive more than one error in the Railroad's argument. 42 First, we disagree with the Railroad's characterization of the facts. According to its own statement of facts, on the night of the incident Mr. Goebel started work at 7:30 p.m. at an altitude of approximately 5,198 feet (i.e., in Denver). Aplt. Br. at 3-4; I R. at 99. He was directed to operate his helper locomotives through the Moffat Tunnel at elevations near 9,200 feet and to wait on the other side at Tabernash, elevation 8,318 feet. Id. The Railroad states that five hours (i.e., around 12:30 am) after he started work in Denver, Mr. Goebel had traversed the tunnel and sat waiting on a siding at Winter Park, elevation approximately 9,100 feet. Aplt. Br. at 4; I R. at 99. After meeting the train he was assigned to assist and experiencing the tunnel incident, Mr. Goebel descended to Rollinsville, elevation 8,367 feet, to await an ambulance. Aplt. Br. at 8; I R. at 99. At 2:50 a.m., more than seven hours after he began the ascent in Denver, Mr. Goebel was placed on pure oxygen en route to the hospital. Aplt. Br. at 8. 43 Consistent with our earlier observation from the studies, Mr. Goebel was technically at high altitude elevations from the moment he began his ascent from Denver. Although it is not clear precisely how long Mr. Goebel spent at elevations over 8,000 feet, it is absolutely clear that he was exposed for far longer than one hour to elevations where altitude illnesses are a real concern. The Railroad confuses two important timelines. The first is Mr. Goebel's exposure only to high altitudes in excess of 8,000 feet, which was clearly well over one hour. The second is his exposure to various added factors inside the tunnel, including the diesel-fume polluted atmosphere and his counterproductive use of an ineffective respirator. This second window of time was indeed approximately one hour. 44 This important distinction focuses us on the second and most critical error in the Railroad's argument. Once again, the Railroad fails to address directly the substance of Dr. Teitelbaum's opinion. Dr. Teitelbaum has never claimed that Mr. Goebel developed HACE solely from the altitude exposure; instead, Dr. Teitelbaum has repeatedly averred that the high altitude and the other factors combined to produce the onset of HACE. II R. at 245. The Railroad's failure to recognize and address this fact renders unpersuasive its citation to studies for the proposition that altitude exposure alone does not usually lead to HACE in under 12 hours. Aplt. Br. at 36-37. It is clear that Mr. Goebel was exposed to altitudes exceeding 8,000 feet for much longer than one hour. More importantly, he was inside the tunnel at altitudes exceeding 9,000 feet for approximately one hour and was subjected to a variety of other factors that, in Dr. Teitelbaum's view, significantly worsened his condition. The studies cited by the Railroad do not render Dr. Teitelbaum's opinion unreliable and do not give us reason to conclude that the district court abused its discretion. 45