Opinion ID: 4507859
Heading Depth: 2
Heading Rank: 2

Heading: expert testimony about breaches in the

Text: STANDARD OF CARE AND CAUSATION ¶12 Having reviewed the proximate-cause element of a medical malpractice claim, we analyze whether the district court properly dismissed Ruiz’s claim for the lack of this element. To do so, we must first identify the alleged breaches of the standard of care. Butterfield v. Okubo, 831 P.2d 97, 104 (Utah 1992) (“Because we cannot determine whether [the expert] sufficiently averred a causal link between defendants’ purported negligence and [the baby’s] death without knowing what negligence [the expert] identified, we will examine [the expert’s] affidavit for specific allegations of negligence before we turn to the question of causation.”). After that, we examine the testimony as to causation. A. Expert Testimony About Alleged Breaches in the Standard of Care ¶13 To stave off summary judgment, Ruiz must produce expert testimony that the defendants’ negligence proximately caused G.R.’s injury. Thus we focus on the expert testimony about __________________________________________________________ 4 Not every medical malpractice case requires expert testimony. We have recognized a “limited ‘common knowledge’ exception to the general requirement, which may excuse a lack of expert testimony in some circumstances.” Bowman v. Kalm, 2008 UT 9, ¶ 9, 179 P.3d 754. The common-knowledge exception “applies when the causal link between the negligence and the injury would be clear to a lay juror who has no medical training— i.e., when the causal connection is readily apparent using only ‘common knowledge.’” Id. This exception has not been raised by the parties here. 5 RUIZ v. KILLEBREW Opinion of the Court how the nurses and Killebrew breached the standard of care. Ruiz designated two standard-of-care experts—Tracy Keith to opine on the labor-and-delivery nurses’ breaches of the standard of care and Janis Cox to testify as to the midwife’s breaches of the standard of care. 1. The Nurses’ Alleged Breaches in the Standard of Care ¶14 Keith, the sole standard-of-care expert as to the laborand-delivery nurses, testified that the nurses breached the standard of care in seven ways: (1) “Failed to assess, recognize, and/or document fetal heart rate and decelerations[5] in a timely manner;” (2) “Should have waited before increasing oxytocin[6] ([also known as] Pitocin or ‘Pit’);” (3) “Should have recognized tachysystole[7] and lowered the oxytocin;” (4) “Should have repositioned the patient and/or performed other interventions;” (5) “Failed to timely place a fetal scalp electrode;” 8 (6) “Allowed Ms. Ruiz to push without a documented fetal heart rate assessment;” and (7) “Failed to document that Killebrew was present and aware of difficulty in obtaining a continuous heart rate tracing.” 9 __________________________________________________________ 5 Dr. Luciani testified that late decelerations are “indicative of fetal hypoxia” and that variable decelerations “come from cord compression.” 6From the expert testimony, it appears that oxytocin is a drug used to induce labor. 7According to Keith, “[t]achysystole is more than five contractions in a ten-minute period.” 8 The expert testimony explains that a fetal scalp electrode is a device that allows a medical professional to “monitor the fetal heart rate.” The Hospital identified these seven breaches in its motion for 9 summary judgment, citing to lines of Keith’s deposition. Ruiz (continued . . .) 6 Cite as: 2020 UT 6 Opinion of the Court For more context, we now emphasize the timing of the seven breaches, along with any pertinent details. ¶15 As for the first breach, the nurses breached the standard of care by not assessing or documenting the fetal heart rate several times between 12:00 p.m. and 10:26 p.m. They also breached the standard of care by not recognizing or documenting decelerations many times between 12:15 p.m. and 9:35 p.m. ¶16 The nurses’ second breach came at 12:32 p.m. when they increased the oxytocin. The third breach happened at 6:15 p.m.; the nurses failed to recognize or document tachysystole and did not lower the oxytocin. The fourth breach is related to the first breach. The nurses lacked due care by not intervening—e.g., by changing the patient’s position—in response to the decelerations that occurred at 7:18 p.m., 7:21 p.m., 9:12 p.m., 9:14 p.m., 9:16 p.m., and 9:18 p.m. As for the fifth breach, the nurses lacked due care by not placing a fetal scalp electrode at 10:04 p.m. The sixth breach happened when the nurses allowed Ruiz “to push without a fetal heart rate assessment” from 10:01 p.m. to 10:31 p.m. And the seventh breach occurred from 10:04 p.m. to 10:11 p.m., when the nurses did not document that they notified Killebrew of their “inability to locate the fetal heart rate.”10 responded by admitting that Keith had testified to these breaches and by adding, “Expert witness Nurse Keith also provided substantial additional criticisms beyond these of the labor and delivery nurses at defendant Hospital.” But Ruiz did not specify what those criticisms were, nor did she cite to the record for that argument. We review only what was properly presented to the district court. Stichting Mayflower Mountain Fonds v. United Park City Mines Co., 2017 UT 42, ¶ 43, 424 P.3d 72 (“The district court had no duty to look beyond [the plaintiff’s] bald statements to identify supporting evidence buried somewhere in the record.”). Thus we limit our review to these seven breaches and the specific deposition testimony cited to for support. 10The Hospital points out that Ruiz said in her brief that “the Hospital’s nurses breached the standard of care by ‘fail[ing] to contact on-call Ob-Gyn Dr. Lawrence.’” This argument, the Hospital contends, is not preserved because it was “never made to the district court or at any time and her brief cites no record evidence.” Ruiz did not respond to this argument in her reply (continued . . .) 7 RUIZ v. KILLEBREW Opinion of the Court 2. Killebrew’s Alleged Breaches in the Standard of Care ¶17 We now pivot to the expert testimony about the ways in which Killebrew breached the standard of care. Cox, the only standard-of-care expert as to midwifes, testified that Killebrew breached the standard of care in four ways: (1) “Failure to apply a fetal scalp electrode;” (2) “Failure to utilize an intrauterine pressure catheter with Pitocin in a vaginal birth after Cesarean;” 11 (3) “Failure to notify [obstetrician-gynecologist] Dr. Lawrence and get her involved earlier;” and (4) “Failure to stop Pitocin.” Again, we draw attention to the timing and relevant details of these four alleged breaches. ¶18 The first breach arose at 7:12 p.m. At that point, Killebrew should have placed and left on a fetal scalp electrode “so that the baby could have been monitored internally.” According to Cox, with a fetal scalp electrode, a midwife “should be able to get a continuous fetal heart tone.” ¶19 The record is muddy as to what time the second breach occurred. But Cox did explain that placing an intrauterine pressure catheter allows a midwife to know about any decelerations in the baby’s heartrate. ¶20 The third breach happened at 7:12 p.m. According to Cox, at that time, “Dr. Lawrence should have been notified and just kept . . . updated on the . . . progress of this patient . . . .” ¶21 Killebrew’s fourth breach, according to Cox, happened at 10:00 p.m. Cox explained that a midwife should not “run Pitocin without an adequate fetal heart strip” if the midwife is “going to have [the mother] start pushing.” brief. We agree with the Hospital, and so do not consider this alleged breach. 11 According to Cox, an intrauterine pressure catheter allows a medical professional to “see the actual pressure that’s being exerted on the uterus.” It is used when a woman is going to have a vaginal birth, aided by Pitocin, but had a cesarean section for a prior delivery. 8 Cite as: 2020 UT 6 Opinion of the Court B. Expert Testimony About Proximate Cause ¶22 Having reviewed the testimony as to the nurses’ and midwife’s lack of due care, we turn to the causation experts’ testimony. Ruiz argues that two causation experts—Dr. Michael Katz and Dr. Richard Luciani—have established that “it was the failure on the part of those attending this labor (the nurses and nurse midwife) to recognize evidence of fetal distress in G.R. and to expedite in any fashion delivery of G.R. prior to 10:30 p.m. and that proximately caused G.R.’s brain damage.” 12 ¶23 Dr. Katz agreed that “it was the delay in delivering [G.R.] . . . that led proximately to his injury.” Dr. Katz did not testify that the midwife’s or the nurses’ lack of due care caused the hypoxia; he testified only that the child would “not have been neurologically impaired” had he been delivered an hour earlier. More specifically, he agreed that “if the child had been delivered during some time prior to that last hour, the probability is that the child would have been neurologically intact.” ¶24 Dr. Luciani 13 explained the fetal monitor strips from 10:03 p.m. to 11:07 p.m. He said that “the baby was absolutely fine prior to 10 p.m. in terms of its fetal monitoring.” But starting at 10:03 p.m., the fetal monitor strips showed “late decelerations.” And those late decelerations were “absolutely indicative of fetal hypoxia.” 14 Then, beginning at 10:11 p.m., the fetal monitor strip __________________________________________________________ 12 Neither Dr. Katz nor Dr. Luciani testified as to breaches in the standard of care. That is because during discovery, the parties stipulated that each party would have only one standard-of-care expert per specialty—i.e., Keith would be the one standard-of-care expert for the labor-and-delivery nurses and Cox would be the sole standard-of-care expert as to Killebrew. Besides that, in Katz’s and Luciani’s depositions, they were careful to clarify that they were not speaking as to breaches in the standard of care. 13 Before his deposition, Dr. Luciani did not read the depositions of the standard-of-care experts. After his deposition, Dr. Luciani submitted a correction sheet for his deposition. In it, he said that he had “subsequently reviewed the depositions of Janis Cox CNM and Tracy Keith RN which did not change my opinions in this case.” The correction sheet, however, has no effect on our analysis, since it did not add testimony creating a link between the defendants’ alleged breaches and G.R.’s injuries. 14 Hypoxia is the “decreased oxygenation of the fetus.” 9 RUIZ v. KILLEBREW Opinion of the Court showed “variable decelerations.” 15 A few minutes later, at 10:19 p.m., the fetal monitor strip was still “nonreassuring,” showing signs of hypoxia. ¶25 Dr. Luciani ultimately concluded that “major damage occurred after [10:30 p.m.] because of the persistent hypoxia and acidosis that was developing.” That conclusion is reiterated in a note that Dr. Luciani attached to his deposition, which read: “Earlier delivery before 10:30 p.m. equals normal or markedly less injured infant. Nonreassuring strips after 10 p.m. . . . The failure to recognize the problem and expedite delivery, led to infant born damaged.” In his deposition, he was asked whether he was saying in this note that the “baby should have been delivered before 10:30 p.m.” “That’s not what I said,” he responded, “The way I wrote it down is that, in my opinion, if the baby was born before 10:30 p.m., based on what I’ve seen in the fetal monitor strips, that baby would have been either normal or markedly less injured. . . . I believe that major damage occurred after [10:30 p.m.] because of the persistent hypoxia and acidosis that was developing.”