Opinion ID: 2175202
Heading Depth: 1
Heading Rank: 1

Heading: First entertained is plaintiffs' assignment regarding entry of a directed verdict for Dr. Wirtz.

Text: In this regard it is inceptionally urged, the patient's right leg was so negligently encased as to obstruct circulation of the blood, proximately resulting in the amputation. This necessitates a prefatory determination regarding the nature of evidence essential to establish a jury question. On that subject we have held substantial evidence of negligence must be adduced in order to create a fact issue. By the same token a mere scintilla of evidence will not suffice. Absent the necessary showing, it is error to submit an issue to a jury. See generally Wenndt v. Latare, 200 N.W.2d 862, 870 (Iowa 1972); Dobson v. Jewell, 189 N.W.2d 547, 553 (Iowa 1971); Ellingson v. Kramer, 255 Iowa 1257, 1262, 125 N.W.2d 777 (1964). Furthermore, evidence regarding requisite skill and care exercised by a physician must ordinarily be given by experts. There are, however, exceptions to this rule when (1) the physician's lack of care is so obvious as to be within the comprehension of a layman's common knowledge or experience, or (2) the physician harms a part of the body not under treatment. See Wiles v. Myerly, 210 N.W.2d 619, 629 (Iowa 1973). But those exceptions are inapplicable to the case at hand. See Sinkey v. Surgical Associates, 186 N.W.2d 658, 660-662 (Iowa 1971). Turning now to the record it reveals plaintiffs produced not one iota of evidence disclosing the cast affixed to patient's right leg was so tight it obstructed blood circulation. Moreover, no expert evidence was presented disclosing the techniques or procedures employed by Dr. Wirtz in affixing the cast were other than those customarily employed by physicians under like circumstances. See Grosjean v. Spencer, 258 Iowa 685, 691-692, 140 N.W.2d 139 (1966); cf. Johnson v. Van Werden, 255 Iowa 1285, 1290, 125 N.W.2d 782 (1964). We are satisfied no substantial evidence of negligence was presented by plaintiffs in support of the instant assignment. II. Next considered is plaintiffs' claim to the effect trial court further erred in directing a verdict for Dr. Wirtz because a jury issue had been generated as to his (1) failure to timely discover the circulatory blockage, and (2) failure, upon discovery thereof, to effect immediate corrective action or procure prompt vascular-surgical advice and assistance for that purpose. Since these issues are interrelated they will be accordingly reviewed. Without resolving the matter of negligence regarding the foregoing issues, trial court found a fatal absence of adequate evidence as to proximate cause. We last dealt with that subject in Winter v. Honeggers' & Co., Inc., 215 N.W.2d 316, 320 (Iowa 1974) and there said: `The actor's negligent conduct is a legal cause of harm to another if (a) his conduct is a substantial factor in bringing about the harm, and (b) there is no rule of law relieving the actor from liability because of the manner in which his negligence has resulted in the harm.' It must be prefatorily conceded proximate cause, like negligence, is usually a jury issue. See Iowa R.Civ.P. 344(f)(10). Here, however, causal connection is essentially a matter which must be foundationed upon expert evidence. See Cronin v. Hagan, 221 N.W.2d 748 (Iowa 1974); Barnes v. Bovenmyer, 255 Iowa 220, 228-229, 122 N.W.2d 312 (1963); Bradshaw v. Iowa Methodist Hospital, 251 Iowa 375, 382-383, 101 N.W.2d 167 (1960). More specifically, common knowledge and everyday experience would not suffice to permit a layman's expression of opinion as to whether Dr. Wirtz' failure to timely discover the circulatory blockage, or upon discovery thereof to promptly effect a circulatory correction or secure other expert advice and assistance for such purpose, was a substantial factor in bringing about the complained of result. Passing over the matter of negligence by Dr. Wirtz in any respect above set forth, the question posed is whether plaintiffs presented essential expert testimony disclosing Dr. Wirtz' conduct was a proximate cause of the right leg excision. Susan Scharnweber, a registered nurse and hospital employee, testified that a September 28, 1969, record entry by her stated, in part: Femoral pulse felt strong and full in left leg at 100 beats per minute. Could not be counted in right leg as was very weak and thready. Right foot very cold while left foot is warm. All toenails on right foot blue but second toe the darkest. Miss Scharnweber also related a record entry made September 29, 1969, by a student nurse reading in part: Turned two times before noon; toes and bottom of feet appeared purplish. Dr. Wirtz was another plaintiff called witness. His testimony reveals, as aforesaid, he first saw Mrs. Longstaff August 18, 1969, when he treated her external lacerations. The morning of September 28, 1969, defendant doctor noted in the patient's progress report:    patient has a cold right foot, left was warm, find no pulse in the right groin.    She does have a pulse in the left, that means the left groin. His next entry, made October 1, was: Cast removed from the right leg, there is motion at the site of fracture, patient has developed a gangrene on the right leg with demarcation    about three inches above the knee joint, patient should have amputation of the leg but the general condition is not good. Dr. Wirtz further testified the aorta runs from the heart to the abdomen ultimately branching off into the thighs, and he had examined the right groin area for pulse but found none. When asked the significance of this finding defendant doctor stated it would indicate a blockage of the aorta somewhere in the abdominal area resulting in a circulatory problem in the right leg. This blockage was attributed to Mrs. Longstaff's arteriosclerosis affliction. Dr. Wirtz also testimonially stated, with regard to his September 28 record entry, he continued to observe the foot for signs of demarcation which denote the point at which gangrene localizes. In this regard, gangrene may focus in the foot necessitating amputation of only that part of the body. Dr. Wirtz' observation of the foot continued through September 29 and 30. When the cast was removed October 1, Dr. Wirtz discovered the previously mentioned demarcation above the knee. As to any surgical procedure available by which to remedy the aforesaid circulatory blockage, defendant doctor stated that because of the patient's existing heart condition she would have never tolerated any type of artery surgery    she would have died on the table. The record discloses Mrs. Longstaff had suffered two heart ailments, one in early September, the other September 24. Additionally, her general condition had been failing since the latter part of August. Dr. Matthews was also a plaintiff called witness. On direct examination this expert testified he had been asked by Dr. Wirtz to examine Mrs. Longstaff. Such examination was effected October 2 and the leg was amputated October 3. The record also reveals this hypothetical question put to Dr. Matthews and his answer thereto: Q.    Assuming that the physician    Dr. Wirtz in this case, on September the 28th had noted as is contained in his progress record that he found no pulse in the right groin but does have a pulse in the left. And then assuming the situation as you found it at the time of your amputation, that is that there was no bleeding when you amputated this leg. Do you have an opinion doctor, based upon that which you saw at the time of your surgery, the pathologist's report, your examination and treatment of this lady, with respect to whether or not there was a blockage in her artery leading into the leg, and if so, where you believe that blockage to have existed? A. On the basis of what I saw both clinically before surgery and during surgery and also documented by the pathologist's report, this lady had severe generalized arteriosclerosis. This is a disease of the arteries that harden the arteries and then eventually occludes many of them   . The amount of disease in the arteries that I transected when performing the high amputation of this limb were such that the channel through which the blood comes to the extremity had been completely occluded not by fresh clot at the level of the amputation but by extensive hardening and occlusive disease of the arteries. The limb was dead and it was dead because it was not being profused by blood. Dr. Matthews further testified, in substance, there are ordinarily two alternative surgical procedures available by which to attempt the correction of such a circulatory blockage: (1) open the abdominal area and directly attack the occluded artery (major vascular surgery), or (2) pull an inflated balloon, attached to a catheter, through the affected artery (minor vascular surgery). When questioned as to whether, in light of the patient's existing heart condition, he would have undertaken any such vascular surgery September 27 or 28, the witness replied. With this information available to me I would not intervene surgically    because I would infer that I would jeopardize her life in order to save a limb, if I could save a limb. This expert further testified: I would not have operated this lady even if I had seen her earlier because of the fact that she had sustained a major myocardial infarction and I would have placed her life in jeopardy in an effort to do something to her limb. Another question put to Dr. Matthews was whether any treatment could have been effectively administered prior to the amputation. The answer was that either major or minor vascular surgery would have been too risky; the only available remedy was the amputation which he had recommended. Even when the evidence is viewed in a light most favorable to plaintiffs it is apparent they failed to establish the necessary causal relationship between any alleged acts of negligence by Dr. Writz and the amputation of which complaint is made. In this vein plaintiffs supplied no testimony, expert or otherwise, disclosing timely discovery of the blockage, instantaneous treatment, or prompt procurement of expert cardiovascular advice and assistance would, could or even might have obviated the ultimate surgery undertaken. See Winter v. Honeggers' & Co., Inc., 215 N.W.2d at 323. In fact, plaintiffs' only expert witnesses, Doctors Wirtz and Matthews, unequivocably stated no other course of treatment was available or advisable under the circumstances. In other words, had Dr. Wirtz discovered the blockage earlier and promptly secured expert cardiovascular assistance, no different result would have obtained. Since severance of Mrs. Longstaff's leg would have been necessary regardless of Dr. Wirtz' conduct it must follow this conduct could not have been a substantial factor in bringing about the harm of which complaint is made. See Restatement, Second, Torts, § 432(1) and comment (1)b. Trial court correctly found absence of proximate cause precluded plaintiffs' right to recover damages from Dr. Wirtz.