Opinion ID: 2321184
Heading Depth: 1
Heading Rank: 3

Heading: The Claim of Negligence

Text: In a medical malpractice case, the plaintiff has the burden of proving the applicable standard of care, a deviation from that standard by the defendant, and a causal relationship between that deviation and the plaintiff's injury. Derzavis v. Bepko, 766 A.2d 514, 519 (D.C.2000). [7] Due to the `great variety of infections and complications which, despite all precautions and skill, sometimes follow accepted and standard medical treatment,' an inference of negligence in a malpractice suit cannot be based solely on the fact that an adverse result follows treatment. Quin v. George Washington University, 407 A.2d 580, 583 (D.C.1979) (quoting Quick v. Thurston, 110 U.S.App. D.C. 169, 172-73, 290 F.2d 360, 363-64 (1961)). There must be a basis in the record or in common experience to warrant the inference. Quin, 407 A.2d at 583. The `purpose of expert testimony is to avoid jury findings based on mere conjecture or speculation.' Nwaneri v. Sandidge, 931 A.2d 466, 470 (D.C.2007) (quoting Washington v. Washington Hospital Center, 579 A.2d 177, 181 (D.C.1990)). Thus, [t]he sufficiency of the foundation for [expert] opinions should be measured with this purpose in mind. Washington, 579 A.2d at 181. An expert witness opinion must be based on fact or adequate data.... While absolute certainty is not required, opinion evidence that is conjectural or speculative is not permitted. Sponaugle v. Pre-Term, Inc., 411 A.2d 366, 367 (D.C.1980). Expert testimony may be excluded when the expert is unable to show a reliable basis for [his] theory. Haidak v. Corso, 841 A.2d 316, 327 (D.C. 2004).
Ms. Sherwood called Dr. Bruce Fellows, a vascular surgeon, as her expert witness. He had not examined Ms. Sherwood. Having reviewed medical records and deposition testimony, however, he opined that some standard had been breached to cause that neurological dysfunction.... [I]t would appear that untoward events happened. At one point the doctor stated that what [those events] were specifically is only a matter of conjecture. To be fair, however, he meant I was not there. Nobody else in this courtroom was there. Figuring out what happened therefore was a matter of drawing inferences. Dr. Fellows testified that he did not see how injury to the sciatic, obturator, or femoral nerves could occur [during the surgery] other than with some kind of negligence. [8] He conceded, however, that what was reflected in the operative report was within the standard of care. Although many details were not provided in the report, whatever is embodied in that report is appropriate. In other words, Dr. Fellows agreed that if you look at this operative report it would appear that the sympathectomy procedure which [Dr. Giordano] performed on April 29th met the appropriate standard of care.... Ms. Sherwood therefore assumed the burden of establishing, through direct or circumstantial evidence, that Dr. Giordano made mistakes not reflected in the medical records. Dr. Fellows identified three possible ways in which Dr. Giordano might have negligently injured the sciatic, obturator, or femoral nerves while performing the sympathectomy: (1) by local pulling or traction; (2) by devascularization (cutting off the blood supply to the nerves); or (3) by dissecting too far down into the area where the nerve trunks are located, either by coming into the back of the psoas muscle or by coming down along the rami communicantes structures [9] to the point where they attach to the nerve trunks. Dr. Giordano asserts that Ms. Sherwood faltered at the outsetthat she did not establish the standard of care. Although we agree that her expert approached this question in an atypical manner, we are not persuaded by this argument. Dr. Fellows did not set out to describe how a doctor would have performed the operation from start to finish while adhering to the standard of care. Rather, as summarized above, he stated three possible ways in which the nerves could have been injured during the surgery. According to his testimony, doing any or all of these three things would be a breach of the standard of care. Dr. Fellows elaborated that when accessing the sympathetic chain, you have to work your way through those [nerves and blood vessels] delicately and with deliberation to avoid damaging them. He explained that if a surgeon gets too far inside away from the ganglion, it could result in damage to the nerve trunks. Dr. Fellows indicated that there would be no reason [for Dr. Giordano] to get down there. Under the circumstances of this case, and viewing this evidence in the light most favorable to Ms. Sherwood, the testimony we have described was an adequate statement of the standard of care. Cf. Snyder v. George Washington University, 890 A.2d 237, 245 (D.C.2006) (expert's testimony about standard of care was not by any means a model of clarity, but, viewed in the light most favorable to the plaintiff, it was adequate); Levy v. Schnabel Foundation Co., 584 A.2d 1251, 1252, 1255 (D.C. 1991) (characterizing the proof of the standard of care as rather unorthodox, but concluding that it was sufficient, albeit barely so). [10]
The much more difficult question is whether the evidence allowed the jury reasonably to conclude that Dr. Giordano injured Ms. Sherwood by deviating from the standard of care. To meet these elements of proof, appellee primarily relies upon the testimony of Dr. Fellows, her expert witness, and upon some x-rays taken on the eve of trial.
Dr. Fellows inferred (his term) that the surgery had caused Ms. Sherwood's neurological dysfunction, and he explained that certain missteps could have led to that resultif they in fact occurred. However, he agreed that, when performing a sympathectomy, you don't even normally go in the area where the femoral or sciatic or obturator nerves are involved[.] He also acknowledged that there's no indication from the operative report that Dr. Giordano went into or came close to any of those areas.... Dr. Fellows also agreed that, if Dr. Giordano did the operation exactly the way it was described in his operative report and did not go into the area by way of retraction or anything else, didn't come close to it ..., the results of the EMG and the complaints by Ms. Sherwood would then have to be based logically on some other explanation. One would then have to look to other specialties, such as neurology, for an explanation. Dr. Fellows acknowledged that he would have to defer to the opinions of a neurologist; he did not hold himself out as an expert in the field of neurology. He agreed, moreover, that RSD is a disease process, it's an insidious process that is not and never has been well understood by the medical profession[.] Nevertheless, in his view, [t]he disease state, RSD, did not cause the dysfunction identified on the EMG nerve conduction study. Dr. Fellows' opinion was based upon his conclusion that, after surgery, Ms. Sherwood had the new onset of a problem involving the nerves to her upper part of her leg that had not been defined prior to surgery. And I inferred that some standard had been breached to cause that neurological dysfunction. But the expert may not base such an opinion merely on `a proximate temporal association' between a medical procedure and an injury. Derzavis, 766 A.2d at 522 (quoting Lasley v. Georgetown University, 688 A.2d 1381, 1387 (D.C.1997)). In a medically complicated case such as this, contemporaneity between a medical procedure and an injury is too weak a foundation upon which to infer causation. Lasley, 688 A.2d at 1387. Moreover, it is far from clear that a new problem affecting Ms. Sherwood's upper leg arose after, let alone as a result of, the surgery. As mentioned above, a post-surgery EMG provided objective evidence that something had injured nerves affecting her upper leg. Dr. Fellows acknowledged, however, that the pre-surgery EMG/nerve conduction study was directed primarily to the lower leg. It was not directed to the upper leg. See note 6, supra. Now, that's a problem[,] he admitted, because everybody now is comparing a little bit apples to oranges.... He resolved that problem in his own mind by making certain assumptions about our personalities: We, in the medical field, have different personalities for each different specialty that we enter. The neurologists are the most careful people, do detailed exams and order more exams than most other specialists. By inference if that neurologist who saw her did not order on that extremity examination in the upper leg, I have to feel 99 percent confident that either something that was there was so trivial that the specialist couldn't even identify it or it wasn't there at all. This sort of pop-psychology does not come close to supporting Dr. Fellows' inference (or assumptionsee note 8, supra ) that the nerves were free of injury before the surgery. Indeed, there was a great deal of conflicting evidence on that question.
Both at trial and on appeal, Ms. Sherwood's lawyer insisted that he was not relying on the doctrine of res ipsa loquitur. (The jury was not instructed on that legal theory.) Instead, he cites cases from Maryland for the proposition that expert witnesses may draw inferences from the facts. In Meda v. Brown, 318 Md. 418, 569 A.2d 202 (1990), as here, the plaintiff did not rely upon the doctrine of res ipsa loquitur, and neither of her expert witnesses could testify as to the precise act of negligence that caused injury to Mrs. Brown's ulnar nerve. Id. at 205. Nevertheless, the court held that the testimony was sufficient to support the inferential conclusion of negligence drawn by the plaintiff's experts. Id. at 203. The Maryland Court of Appeals did not ignore the distinction between inference and speculation, however. It explained that the expert witnesses had relied on a combination of direct and circumstantial evidence. The doctors recited in detail the physical facts they considered, and the medical facts they added to the equation to reach the conclusion they did. The facts had support in the record, and the reasoning employed was based upon logic rather than speculation or conjecture. Id. at 207; see also Tucker v. University Specialty Hospital, 166 Md.App. 50, 887 A.2d 74, 84 (2005) (The expert testimony, which was based upon reasonable inferences drawn from the available evidence, was sufficient to establish that the hospital was not entitled to judgment in its favor as a matter of law.). [11] [T]he law does not require proof of negligence to a certainty, Rich v. District of Columbia, 410 A.2d 528, 532 (D.C.1979) (reversing grant of judgment notwithstanding the verdict), and we do not quarrel with the proposition that experts, like juries, may draw appropriate inferences from the evidence. See District of Columbia v. Zukerberg, 880 A.2d 276, 282 (D.C. 2005) (plaintiff's evidence, including expert testimony, supports a reasonable inference that the position of the fulcrum was the cause of Jacob's fall); Rich, 410 A.2d at 533 (Appellant need only have adduced evidence from which a jury reasonably could infer that one of the holes in the brick sidewalk was the cause of her fall). But the expert's opinion must be based on fact or adequate data[,] Sponaugle, 411 A.2d at 367, and we see no reason to abandon our holdings that neither the jury nor an expert witness may rely upon speculation or conjecture. See, e.g., Majeska, 812 A.2d at 950 (jury); Washington, 579 A.2d at 181 (expert); see also Garby v. George Washington University Hospital, 886 A.2d 510, 516 (D.C.2005) (upholding grant of judgment as a matter of law; Dr. Cavanaugh's testimony ... failed to support an inference beyond conjecture....); Gregory v. Greater Southeast Community Hospital Corp., 697 A.2d 1221, 1221 (D.C. 1997) (agreeing with trial court's conclusion that the expert's opinion on causation lacked an adequate foundation as a matter of law [and] uphold[ing] the grant of a directed verdict in favor of the defendants); Talley v. Varma, 689 A.2d 547, 553 (D.C.1997) (Taken as a whole, [the expert's] testimony did not establish the requisite degree of likelihood that any negligence by Varma caused Talley's injury.); Twyman v. Johnson, 655 A.2d 850, 853-54 (D.C.1995) (expert had no foundation on which to conclude that this defect actually caused the accident; issue of causation properly taken from the jury when a finding that defects in the stairs had substantially contributed to the accident would have rested upon surmise). The soundness of the inference drawn by an expert witness must be measured against the legal standard for proving causation, and [t]he `more likely than not' standard is firmly embedded in our law. Grant v. American National Red Cross, 745 A.2d 316, 319 (D.C.2000); see Psychiatric Institute of Washington v. Allen, 509 A.2d 619, 624 (D.C.1986) (The expert need only state an opinion, based on a reasonable degree of medical certainty, that the defendant's negligence is more likely than anything else to have been the cause (or a cause) of the plaintiff's injuries.); cf. Quin, 407 A.2d at 585 (When plaintiff relies on circumstantial evidence to establish causation as an element of res ipsa loquitur, the evidence must make plaintiff's theory reasonably probable, not merely possible, and more probable than any other theory based on the evidence.).
Because we are not permitted to weigh the evidence or to judge the credibility of the witnesses, we will not dwell at length on the medical evidence in Dr. Giordano's favor. Nevertheless, in this procedural context, we must review all of the evidence in the record. Reeves v. Sanderson Plumbing Products, Inc., 530 U.S. 133, 150, 120 S.Ct. 2097, 147 L.Ed.2d 105 (2000). Moreover, [t]he opponent of the motion [for judgment as a matter of law] must be given the benefit of every reasonable inference from the evidence, but not inferences based on guess or speculation. Furline v. Morrison, 953 A.2d 344, 351 (D.C.2008) (internal quotation marks, editing, and citations omitted). It thus is important to acknowledge that Dr. Fellows' inference of negligence was challenged by many witnesses. For example, Dr. Frank Anderson, the only neurologist to testify at trial, had examined Ms. Sherwood in addition to reviewing her medical records. In his expert opinion, the ongoing problem of RSD was causing the changes long before the surgery. Furthermore, Ms. Sherwood suffer[ed] an exacerbation of her reflex sympathetic dystrophy as a normal consequence of having surgery that was necessary to save her leg. He also concluded that she was exaggerating her right leg problems. In his opinion, nothing in Dr. Giordano's surgical technique, in his approach to doing the sympathectomy would have caused any injury ... to her nerves, to her femoral, obturator, or sciatic nerve. Dr. Peter Moskovitz, Ms. Sherwood's treating orthopedic surgeon and the author of a book on RSD, opined that there is no reasonable possibility that Dr. Giordano had damaged the nerve roots. You've got to literally dig through [the psoas] muscle to get to the somatic nerve. It doesn't happen. In his opinion, Ms. Sherwood's post-operative symptoms were due to an exacerbation of her reflex sympathetic dystrophy. There certainly was no direct evidence that Dr. Giordano committed any of the mistakes that Dr. Fellows hypothesized. Contrary to Ms. Sherwood's suggestion, the pathology report in no way supports a conclusion that Dr. Giordano had been operating on the back side of the psoas muscle. See note 3, supra. The small amount of blood loss, and the short duration of the procedure, indicated that this had been a standard, uncomplicated operation. When asked whether he had clipped the femoral or sciatic or obturator nerves, Dr. Giordano replied, No. I didn't even see them in the operation. He testified that he had no contact with the femoral, obturator, or sciatic nerves. Moreover, retraction would have had no impact on those nervesthat's in the back. The retraction is in the front. See note 3, supra. In retrospect, Dr. Giordano thought that Ms. Sherwood probably had, as I told her she could have, ... a worsening of the RSD, and maybe the exacerbation that everybody has talked about after this kind of surgery.
This would be quite a different case if Dr. Fellows' opinion were supported by objective evidence that Dr. Giordano actually entered the area where the nerve roots are located. Attempting to demonstrate that this happened, Ms. Sherwood presented two x-rays taken on the eve of trial which, according to her counsel, showed a surgical clip in the area where Dr. Giordano testified he never entered or operated during the sympathectomy surgery, i.e., in the neuro-foramen or `area of the spinal nerve roots.' However, Ms. Sherwood did not present a radiologist to interpret those x-rays for the jury. (Dr. Fellows did not explain those x-rays in his testimony, nor did he rely upon them in forming his opinion.) Ironically, therefore, this aspect of Ms. Sherwood's case depends upon the testimony of Dr. Giordano. Ms. Sherwood asserts that Dr. Giordano conceded that an object visible in one of the x-rays was a surgical clip. We think a fair reading of his testimony demonstrates that he did not do so. But even if the jury might have thought that he made such a concession, Dr. Giordano did not testify that the object was in the forbidden area, and neither did anyone else. [12] Initially, when asked, Do you see a clip right here? Dr. Giordano replied, Yes. Later, however, he said, I'm not even sure if that's a clip.... I don't see a clip. I don't see that as a clip.... Ms. Sherwood's gloss on this exchange is that [t]he recantation of Dr. Giordano's testimony that the object ... was a clip, took place immediately after being shown an x-ray that likely would have guaranteed a finding of liability ... if his initial testimony remained unchanged. According to appellee, the jury could have made a credibility assessment that Dr. Giordano's initial testimony [that the object was a clip] [was] more credible than his later recantation. Even if the jury properly could have concluded from this testimony that the object was a surgical clip, appellee has glossed over a more fundamental point. No one testified that the object was located in the neuro-foramen or the nerve canal. Ms. Sherwood did not call a radiologist to interpret the x-rays, and the jurors were not competent to do soneither are we. Without the aid of a radiologist, Ms. Sherwood's counsel sought to extract an admission from Dr. Giordano. Counsel asked, Wouldn't that be ... in the nerve roots area? but Dr. Giordano replied, No, I don't think so. He pointed out that the x-ray offered a lateral view [a]nd when you're looking across, you can't say that's in the nerve canal.... [T]here's no nerve clipped in the canal. I wasn't anywhere near that. Counsel then showed him an x-ray taken from another point of view and asked, Wouldn't that be, given the two views, in the canal? Dr. Giordano replied, No, no, no. It's not in the canal. So I don't see a clip. I don't see that as a clip, but it certainly was not in the canal.... So there's no clip there as far as I can tell. There's no clip in the canal. I wasn't even close to the canal. Thus, the x-rays, and Dr. Giordano's testimony about them, fail to make up for the shortcomings in Dr. Fellows' testimony.
It often is difficult to discern, and it likely is impossible to define, the boundary that separates the realm of permissible inference from that of forbidden speculation. On this record, however, we conclude that Dr. Fellows relied on too much speculation and failed to heed our admonition that an inference of negligence in a malpractice suit cannot be based solely on the fact that an adverse result follows treatment. Quin, 407 A.2d at 583. Furthermore, an expert may not base [his] opinion [on the issue of causation] merely on a proximate temporal association between a medical procedure and an injury. Derzavis, 766 A.2d at 522 (internal quotation marks and citation omitted). In a medically complicated case such as this, contemporaneity between a medical procedure and an injury is too weak a foundation upon which to infer causation. Lasley, 688 A.2d at 1387. The x-rays and other medical evidence did not remove Ms. Sherwood's allegations from the realm of speculation and conjecture. Dr. Giordano therefore is entitled to judgment as a matter of law. See Garby, 886 A.2d at 512 (upholding grant of judgment as a matter of law; [W]e agree with the trial judge that the evidence was insufficient to support a reasonable inference by a jury that the alleged negligence of the defendants proximately caused Mr. Garby's death.); Derzavis, 766 A.2d at 516 (upholding trial court decision setting aside verdict in plaintiff's favor and granting doctor judgment as a matter of law); id. at 521-22 (rejecting plaintiff's argument that the jury could permissibly infer that her injury, because it was contemporaneous with the Pap smear, resulted from negligence on the part of Dr. Bepko).