Opinion ID: 2514133
Heading Depth: 1
Heading Rank: 3

Heading: DISCUSSION The Comparative Fault of Wesley Medical Center

Text: The physician defendants contend the district court erred by excluding the testimony of Audra's expert, John Bundren, M.D., on the breach of the standard of care by Wesley's nurses. See K.S.A. 60-258a (comparative negligence). The district court found Dr. Bundren was not qualified to testify on the nursing standard and granted Wesley's motion for judgment as a matter of law at the close of Audra's case because of the lack of expert testimony. We agree with defendants. The admission of expert testimony lies within the discretion of the district court, and its decision will not be reversed on appeal absent a showing of abuse of discretion. Olathe Mfg., Inc. v. Browning Mfg., 259 Kan. 735, 762, 915 P.2d 86 (1996). Wesley filed a motion in limine, requesting that the district court exclude the testimony of Dr. Bundren concerning nursing standards. Wesley points out that the limine motion, the supporting trial brief, and its motion to strike Dr. Bundren as an expert on nursing standards are not included in the record on appeal. According to Wesley, these submissions are vital to our review, and the appellants carry the burden to include them in the record on appeal. The appellants bear the burden to compile a record sufficient to support their arguments, not those of their opponents. Wesley had the opportunity to request additions to the record to support its arguments. See Supreme Court Rule 3.02(c) (2000 Kan. Ct. R. Annot. 21). It also had the ability to address arguments it advanced below in its appellate briefs. We conclude the question is properly before us on the record as it stands. The defendants argue that Dr. Bundren's more than 20 years of experience as an obstetrician/gynecologist in labor and delivery qualified him to testify on the standards applicable to nurses in labor and delivery units, particularly with respect to the review and maintenance of chart information on patients' infectious diseases. Dr. Bundren testified he had [w]orked with ... nurses on a daily or weekly basis in multiple sites across the country. He answered yes to the following question from Audra's counsel: Before I ask your opinions are you knowledgeable concerning the general standard for how nurses in a labor and delivery unit would handle prenatal records coming in from a doctor from the point of being received and getting into the chart? K.S.A. 60-419 says in part: As a prerequisite for the testimony of a witness on a relevant or material matter, there must be evidence that he or she has personal knowledge thereof, or experience, training or education if such be required. Such evidence may be by the testimony of the witness himself or herself. K.S.A. 60-456(b) says: If the witness is testifying as an expert, testimony of the witness in the form of opinions or inferences is limited to such opinions as the judge finds are (1) based on facts or data perceived by or personally known or made known to the witness at the hearing and (2) within the scope of the special knowledge, skill, experience or training possessed by the witness. A further review of Dr. Bundren's qualifications is appropriate. He is on the faculty of the University of Oklahoma College of Medicine, in the Department of Gynecology and Obstetrics. He is a board certified OB-GYN specialist and a tenured associate professor. He does a substantial amount of private practice. His focus currently is on the hospital's infertility patients. He is actively involved in teaching the 16 OB-GYN residents who work with him in the operating room and in his private practice office in the hospital. It is not uncommon for him to spend weekends in the hospital with residents delivering babies and managing obstetrical complications and problems. He sees private patients in his office and probably delivers the babies of 20 private patients a year. He is involved in about 200 deliveries a year as a resident supervisor or helper, and it has been that way for many years. He is familiar with high-risk obstetrical situations. He teaches residents about how to handle obstetrical situations and problem patients on a weekly basis in the clinic with patients. He has published and does research. He attends meetings of the American College of Obstetrics and Gynecology, which promotes national standards to make obstetrical care safe across the country. In his dealings with pregnant women over the years, he has considered the hepatitis B problem. Dr. Bundren also has been involved with teaching nurses. He has given numerous lectures to nurses and worked with them on various aspects of patient care in hospitals. He is on the staff of various medical centers in Tulsa and is familiar with labor and delivery unit standards for handling patient records as they come in and are put into patients' charts. The critical passage in the proffer of Dr. Bundren's testimony reads: Q.... [D]id you form an opinion as to whether the labor or any of the labor and delivery nurses at Wesley were negligent in any respect and fell below the standard acceptable nursing practice? A. I did form an opinion. Q. And what is that opinion? A. My opinion is that the nurses failed to follow their own policies and procedures. They failed to adequately assess the patient and document on their nurses assessment that the patient was hepatitis B surface antigen positive and failed to transmit that information on to the nursery nurses which is the usual means by which that information is moved around. Q. You're referring to that nursing admission assessment? A. I'm referring to the nursing admission assessment and the documents and testimony that I became aware of. Q. Can you tell us whether the nurses doing that function, that is adding the hepatitis B information from the prenatal record to the nursing assessment records, would be a standard thing for nurses to do? A. That would be a very standard thing for nurses to do. Q. You hold those opinions to a degree of medical probability? A. Yes, sir. Dr. Brown joined in the proffer, and this preserved the issues of Dr. Bundren's testimony and Wesley's dismissal for our review. The district judge excluded Dr. Bundren's testimony because he viewed Dr. Bundren as a physician who merely worked around nurses and not as one who possessed actual nursing expertise. We hold the district court erred as a matter of law in excluding Dr. Bundren's testimony on the general standard of care commonly applicable to nurses in labor and delivery units, particularly with respect to the review and maintenance of prenatal chart information. We visited the medical expert nursing standard of care question in Avey v. St. Francis Hospital & School of Nursing, 201 Kan. 687, 422 P.2d 1013 (1968). Avey supports defendants' contention that the district court abused its discretion in excluding Dr. Bundren's testimony. In Avey, we considered whether a physician was qualified to testify to nursing standards and hospital procedures. Avey's expert, Dr. Robert Stein, testified that he was a licensed physician practicing medicine in Kansas, Massachusetts, and California and that he was familiar with the nursing care standards and practices at issue in the case. Although he had not practiced in Wichita, Dr. Stein testified that he was familiar with the practices of St. Francis Hospital and with nursing care in general in the community. We reversed the district court's exclusion of Dr. Stein's testimony. 201 Kan. at 692-93. Wesley argues that Avey is distinguishable on the facts because the challenge to Dr. Stein's testimony was based on the locality rule. See 201 Kan. at 690-91. Dr. Bundren's testimony was challenged on the basis of his qualifications. We acknowledge the factual distinction; however, we extend the discussion in Avey surrounding a physician testifying as an expert on nursing standards to the situation here. See Chandler v. Neosho Memorial Hospital, 223 Kan. 1, 574 P.2d 136 (1977) (following Avey); Moore v. Francisco, 2 Kan. App.2d 526, 583 P.2d 391 (1978) (in a malpractice action against an orthopedic surgeon, it was error to exclude an anesthesiologist from testifying on the standard of care in taking a patient's personal history, a matter common to all areas of medicine). Wesley cites Hall v. Sacred Heart Med. Ctr., 100 Wash. App. 53, 995 P.2d 621, rev. denied 141 Wash.2d 1022 (2000), and Haney v. Alexander, 71 N.C. App. 731, 323 S.E.2d 430, cert. denied 313 N.C. 329 (1985), to support its contention that Dr. Bundren was not qualified to testify regarding nursing standards. These citations are puzzling, as the cases seem to support the defendants' contention that Dr. Bundren's testimony should have been admitted. In Hall, the defendant hospital sought to have a doctor, who was codirector of the hospital, testify regarding the standard of care for critical care nurses. Hall objected on competency grounds. The hospital elicited testimony showing that the doctor worked with ICU nurses on a daily basis, was involved in the education and training of nurses, and was involved with the supervision of critical care nurses. On appeal, Hall asked the appellate court to establish a bright line rule stating that only a nurse could testify as to the standard of care of another nurse. The Hall court refused and found the district court had properly admitted the doctor's testimony. See 100 Wash. App. at 59-60. The Haney court approved the testimony of two physicians who testified as experts on the nursing standards of care of the defendant hospital. Haney demonstrated one doctor had day-to-day dealings with registered nurses; taught nursing students in a clinical setting; and had worked with nurses who had comparable training, experience, and degree qualifications as the nurses who treated the plaintiff. 71 N.C. App. at 735-36. Haney's other expert also taught and worked with nurses of comparable training and experience. 71 N.C. App. at 736. Wesley cites Cox v. Lesko, 23 Kan. App.2d 794, 935 P.2d 1086 (1997), aff'd in part and rev'd in part on other grounds, 263 Kan. 805, 953 P.2d 1033 (1998), for the proposition that an expert cannot draw upon his or her personal experience alone to formulate his or her opinion. This reliance is misplaced. Cox found it improper for a doctor to testify regarding his or her own preferred method of treatment in determining whether another doctor deviated from the appropriate standard of care. 23 Kan. App.2d at 798-99. Cox said: The mere fact that one doctor prefers one method over another does not, by itself, mean that approach is better or preferable to the other. 23 Kan. App.2d at 798. Cox is not persuasive here. Dr. Moser cites K.S.A. 60-3412, which addresses the standard of care for a practitioner of the healing arts. K.S.A. 60-3412 is not applicable here. A nurse is commonly understood, as reflected in our statutory definition of nursing, to be a person who works in the same area as and under the supervision of a physician or other practitioner of the healing arts. (Emphasis added.) State Bd. of Nursing v. Ruebke, 259 Kan. 599, 627, 913 P.2d 142 (1996). A nurse is not a practitioner of the healing arts. K.S.A. 65-2872(m). We have no hesitation in holding that Dr. Bundren was qualified to testify regarding nursing standards and their breach. He has extensive experience working in hospital labor and delivery units and is familiar with the standards and practices applicable to nurses working in these units. He testified that he worked on a daily or weekly basis in multiple sites across the country. Dr. Bundren had also taught nurses and worked with them on various aspects of patient care in the hospitals. His testimony was well within the scope of his special knowledge, skill, experience or training, as required by K.S.A. 60-456(b). Thus, the district court erred in excluding his expert testimony regarding nursing standards. Assuming Dr. Bundren's testimony on retrial is as advertised, we also agree with Drs. Moser and Brown that the jury should be permitted to compare Wesley's alleged negligence. The district court's decision on Wesley's K.S.A. 2000 Supp. 60-250 motion for judgment as a matter of law, dependent as it was on the absence of Dr. Bundren's testimony, also was error. See Morris v. Francisco, 238 Kan. 71, 74, 708 P.2d 498 (1985). Reasonable minds might differ on the existence or extent of Wesley's liability, making judgment as a matter of law unavailable. The physician defendants are not precluded from making this argument because Dr. Brown joined in the proffer of Dr. Bundren's testimony; there was no agreement among all parties to allow Wesley's dismissal; and all defendants included Dr. Bundren in their witness lists by incorporating Audra's witness list. This situation is distinct from those in Cantrell v. R.D. Werner Co., 226 Kan. 681, 602 P.2d 1326 (1979), and Haberer v. Newman, 219 Kan. 562, 549 P.2d 975 (1976). Here, there was evidence to support a breach of the Wesley nurses' standard of care and no acquiescence by defendants in the result of Wesley's motion. Instruction Number 15 on Physicians' Duties and Negligence Audra filed a motion for partial summary judgment, in which she asked the district court to rule that, as a matter of law, the physician defendants providing medical care and treatment to Bonnie while she was pregnant with Audra also owed Audra a continuing duty of care. The district court, observing that the issue of a physician's duty to the fetus of a pregnant woman intending to carry to term was one of staggering proportions, entered an extensive ruling in Audra's favor on the record. That ruling, which the district court characterized as a new rule of law, was the precursor to jury Instruction No. 15, which read: The Court has ruled that there are standards that all physicians had to follow in providing care and treatment to Bonnie and Audra Nold. These standards have been set by the Court and no expert testimony is necessary to establish them. They are as follows: 1. When a physician undertakes health care or treatment for the condition of a woman's pregnancy, including without limitation prenatal, labor or delivery care, duties are assumed by the physician for reasonable health care of the fetus or unborn child. When a physician has knowledge or should have knowledge of the mother's communicable disease, which probably is communicable to the unborn child during delivery, and which communication to the child probably could have been avoided by inoculation upon birth, he has a duty to: a. advise other known health care providers furnishing the same or related care; b. advise public agencies charged by law to be so advised; and c. advise the pregnant mother of the communicable disease and its consequences thereby arming her with the knowledge of the need for inoculation. The physician who has knowledge or should have knowledge of the mother's communicable disease is not excused from these legal duties just because another physician assumes primary care in his place. 2. The duty to Audra, the unborn child, arose from the physicians' duties to the pregnant expectant mother, Bonnie Nold. Those duties are to review all medical records received, or that should have been received, and report all unfavorable test results. 3. The aforementioned duties of the physicians extend from the time of the initiation of the medical care relationship through the time for the effective inoculation of the baby following birth. A physician's deviation from these duties is negligence. (Emphasis added.) Defendants argue that Instruction No. 15 was in error because it outlined a duty that was overbroad in scope and time and because it failed to factor in expert testimony to establish a breach of duty or negligence. We agree on both counts and note other complications. In reality, Instruction No. 15 contained several new legal rules that require our attention. It made an exception to the requirement of expert testimony to establish negligence. It held that a doctor who undertakes the duty to care for a pregnant woman who intends to carry to term necessarily undertakes a duty to care for her fetus. When the pregnant woman may transmit a communicable disease during labor and delivery, it extended the duty to the fetus beyond birth and beyond termination of the doctor-patient relationship that gave rise to the duty in the first place and beyond a referral to a specialist or other provider. The district court held the duty did not terminate until preventive measures were taken. The court specified that the duty to the fetus included reviewing all of the pregnant woman's medical records that are or should have been received and notifying other health care providers, public agencies, and the pregnant woman of the communicable disease. Before this case can be retried, we must address each of these new rules.