Opinion ID: 1942881
Heading Depth: 2
Heading Rank: 1

Heading: In a medical-malpractice action,

Text: the plaintiff shall have the burden of proving by substantial evidence that the health care provider failed to exercise such reasonable care, skill, and diligence as other similarly situated health care providers in the same general line of practice ordinarily have and exercise in a like case. Ala.Code 1975, § 6-5-548(a). To meet this burden, the plaintiff ordinarily is required to present expert testimony as to the relevant standard of care. Martin v. Dyas, 896 So.2d 436, 441 (Ala.2004). This Court has recognized an exception to this rule `in a case where want of skill or lack of care is so apparent . . . as to be understood by a layman, and requires only common knowledge and experience to understand it.' [ Tuscaloosa Orthopedic Appliance Co. v. ] Wyatt, 460 So.2d [156,] 161 [(Ala.1984)] (quoting Dimoff v. Maitre, 432 So.2d 1225, 1226-27 (Ala. 1983)). This Court has recognized the following situations as falling within this exception: `1) where a foreign instrumentality is found in the plaintiff's body following surgery; . . . . '  Allred [ v. Shirley ], 598 So.2d [1347,] 1350 [(Ala.1992)] (quoting Holt v. Godsil, 447 So.2d 191, 192-93 (Ala.1984) (citations omitted in Allred)). Anderson v. Alabama Reference Labs., 778 So.2d 806, 811 (Ala.2000) (emphasis added). In Houserman v. Garrett, 902 So.2d 670, 673 (Ala.2004), a doctor left a surgical-gauze pad inside a patient. This Court held that it is the surgeon's responsibility `to remove before closing the incision all foreign objects due to be removed' and that `[t]he presence of [a] retained object is prima facie evidence of negligence by the surgeon in carrying out that responsibility.' 902 So.2d at 673 (quoting Breaux v. Thurston, 888 So.2d 1208, 1217 (Ala. 2003)). A plaintiff in a medical-malpractice action must also present expert testimony establishing a causal connection between the defendant's act or omission constituting the alleged breach and the injury suffered by the plaintiff. Pruitt v. Zeiger, 590 So.2d 236, 238 (Ala.1991). See also Bradley v. Miller, 878 So.2d 262, 266 (Ala.2003); University of Alabama Health Servs. Found., P.C. v. Bush, 638 So.2d 794, 802 (Ala.1994); and Bradford v. McGee, 534 So.2d 1076, 1079 (Ala.1988). To prove causation in a medical-malpractice case, the plaintiff must demonstrate `that the alleged negligence probably caused, rather than only possibly caused, the plaintiff's injury.' Bradley, 878 So.2d at 266 (quoting University of Alabama Health Servs., 638 So.2d at 802). See also DCH Healthcare Auth. v. Duckworth, 883 So.2d 1214, 1217 (Ala.2003) (`There must be more than the mere possibility that the negligence complained of caused the injury; rather, there must be evidence that the negligence complained of probably caused the injury.' (quoting Parker v. Collins, 605 So.2d 824, 826 (Ala.1992))); and Pendarvis v. Pennington, 521 So.2d 969, 970 (Ala.1988) (`The rule in medical malpractice cases is that to find liability, there must be more than a mere possibility or one possibility among others that the negligence complained of caused the injury; there must be evidence that the negligence probably caused the injury.' (quoting Williams v. Bhoopathi, 474 So.2d 690, 691 (Ala.1985), and citing Baker v. Chastain, 389 So.2d 932 (Ala.1980))). In Cain v. Howorth, 877 So.2d 566 (Ala.2003), this Court stated: `To present a jury question, the plaintiff [in a medical-malpractice action] must adduce some evidence indicating that the alleged negligence (the breach of the appropriate standard of care) probably caused the injury. A mere possibility is insufficient. The evidence produced by the plaintiff must have `selective application' to one theory of causation.' 877 So.2d at 576 (quoting Rivard v. University of Alabama Health Servs. Found., P.C., 835 So.2d 987, 988 (Ala.2002)). However, the plaintiff in a medical-malpractice case is not required to present expert testimony to establish the element of proximate causation in cases where the issue of proximate cause is not . . . `beyond the ken of the average layman.' Golden v. Stein, 670 So.2d 904, 908 (Ala.1995). Therefore, [u]nless the cause and effect relationship between the breach of the standard of care and the subsequent complication or injury is so readily understood that a layperson can reliably determine the issue of causation,' causation in a medical-malpractice case must be established through expert testimony. DCH Healthcare Auth., 883 So.2d at 1217-18 (quoting Cain, 877 So.2d at 576).
Sorrell alleged in her complaint that Dr. King breached the standard of care during the July 7, 2000, surgery when he left a foreign objectthe adapterin Sorrell's cervix. In support of his motion for a summary judgment, Dr. King argued that because Sorrell could not prove that he breached the applicable standard of care through expert testimony as required under Ala.Code 1975, § 6-5-548(a), he was entitled to a judgment as a matter of law. Sorrell argues, however, that because Dr. King concedes that he failed to remove the adapter immediately following the surgical procedure, expert testimony was not required to prove the relevant standard of care. However, we see no need to address the issue of expert testimony as it relates to the standard of care because Sorrell cannot present sufficient evidence establishing proximate causation, given that she has been barred from using an expert at trial. Sorrell argues that, although a plaintiff in a medical-malpractice case is generally required to present expert testimony to prove the element of proximate causation, under the facts of this case proximate causation need not be established by expert testimony. Specifically, Sorrell argues that the facts of this case are similar to the facts of Golden v. Stein, supra, and that expert testimony is not required under the facts here because, she contends, the proximate cause of her injuries are not beyond the comprehension of the average layman. In Golden, a woman sued her doctor alleging that he had performed an unnecessary procedure. Golden, 670 So.2d at 906. In response to the doctor's motion for a summary judgment, the plaintiff presented expert testimony indicating that the surgery was unnecessary and that in performing the surgery the doctor had breached the standard of care. Golden, 670 So.2d at 907. Because the expert did not testify as to causation, the trial court found that the plaintiff had failed to present sufficient evidence establishing that the alleged unnecessary surgery proximately caused her injuries. Therefore, the trial court granted the doctor's summary-judgment motion. Golden, 670 So.2d at 906. This Court held that the plaintiff presented sufficient evidence to establish that there was a genuine issue as to proximate cause. Golden, 670 So.2d at 907. The Court stated: In most medical malpractice cases, proximate cause must be established by expert testimony. See, e.g., Bradford v. McGee, 534 So.2d 1076, 1080 (Ala.1988). The reason for this rule is that issues of proximate cause in medical malpractice cases are ordinarily `beyond the ken of the average layman.' C. Gamble, McElroy's Alabama Evidence, § 127.01(5)(c), p. 333 (4th ed.1991). But in cases like this one, involving allegations that a defendant performed unnecessary medical procedures, the issue of proximate cause is not always `beyond the ken of the average layman.' Clearly, the average layman, without the assistance of an expert, can recognize a causal connection between the performance of an unnecessary operation and most items of harm or injury claimed by the plaintiffs in this case. The cost of the unnecessary procedure, any provable pain and suffering or lost consortium associated with the unnecessary procedure, and any wages that can be proven to have been lost during the normal recovery period for such an operation would constitute harm or damage the proximate cause of which would be `within the comprehension of average laymen.' See Williams v. Spring Hill Memorial Hospital, 646 So.2d 1373, 1375 (Ala.1994). However, any claims for damages based on complications from the unnecessary procedure would be subject to the general rule that expert testimony is normally required to establish proximate cause in the medical malpractice context. Golden, 670 So.2d at 907-08 (footnote omitted). Sorrell argues that, like the plaintiff in Golden, she is not required to present expert testimony establishing proximate cause. Sorrell contends that the cause-and-effect relationship between the alleged breach of the standard of careDr. King's leaving the adapter in Sorrell's cervixand the subsequent complications or injuriespain, bleeding, depression, etc. would be readily understood by a layman. We disagree. The facts of this case are distinguishable from the facts of Golden. The Court in Golden limited its holding to cases involving allegations that a defendant performed unnecessary medical procedures. Golden, 670 So.2d at 908. In addition, the Court held that the proximate cause of the cost of the procedure, pain and suffering, or lost consortium associated with the unnecessary procedure, and wages lost during recovery would be within the comprehension of the average layman, but that the proximate cause of any complications related to the unnecessary procedure would be subject to the general rule requiring expert testimony. Golden, 670 So.2d at 908. Sorrell's claims are based upon her assertions that her injuries were the result of medical complications related to Dr. King's leaving the adapter in Sorrell's cervix. Therefore, Golden actually supports the proposition that Sorrell was required to present expert testimony to prove proximate causation. Whether Sorrell's injuries were caused by Dr. King's leaving the adapter in her cervix would not be within the comprehension of the average layman. Thus, this case is not within the class of medical-malpractice cases in which proximate cause does not have to be established by expert medical testimony. Sorrell also argues that she should not be required to present expert medical testimony as to the proximate cause of her injuries because, she contends, Dr. King's own deposition testimony provides substantial evidence of proximate cause. In his deposition, Dr. King testified as follows: Q. [Sorrell's counsel:] What symptoms would you say would be symptomatic of a foreign body left in the vagina or in the cervix? A. Discharge, bleeding, pain, fever. Q. And when would you expect these problems to occur A. Well Q. time-wise, after a foreign object was left in there? A. It can be quite variable. If could be on the order of days to many months, if not years. . . . . Q. Well, let's specifically talk about [the adapter], then. What type of problems would you expect a person to have, having that piece of medical device in them for any period of time? A. They might develop Q. Let mego ahead, I'm sorry. A. They might develop those same symptoms I indicated, you know, in response to your question regarding any foreign object left in the vagina. Q. Discharge, bleeding, pain, fever? A. (Witness nods head up and down.) Although Dr. King's testimony establishes that Sorrell's pain and bleeding were possibly caused by the presence of the adapter in her cervix, Dr. King's testimony does not establish that the presence of the adapter probably caused her injuries. See Bradley, 878 So.2d at 266; DCH Healthcare Auth., 883 So.2d at 1217; and Pendarvis, 521 So.2d at 970. Dr. King testified that the adapter might cause discharge, bleeding, pain, and fever, but he did not testify that injuries Sorrell alleged she suffered were probably caused or even likely caused by the presence of the adapter in her cervix. Dr. King's testimony demonstrates only a mere possibility that the adapter caused Sorrell's alleged injuries. We reject Sorrell's contention that Dr. King's testimony amounts to substantial evidence indicating that the presence of the adapter was the proximate cause of her injuries. The record also contains evidence suggesting that Sorrell's complaints of pain, bleeding, and depression did not relate to the adapter. Dr. King testified that the bleeding could have been associated with her menstrual cycle because of her history of taking Depo-Provera and that the Depo-Provera could invoke irregular bleeding, break-through bleeding from time to time. . . . Dr. King also testified that bleeding is a frequent complaint of patients who undergo laparoscopic procedures. In addition, Dr. King testified that her continued complaints of pelvic pain could have been related to the endometriosis. Although Sorrell alleged that she suffered from depression after the procedure, there is no evidence in the record showing that the presence of the adapter could have caused her depression. Sorrell's medical records demonstrate that she had a history of depression and that she had taken multiple antidepressant medications before the surgical procedure. Dr. King's treatment notes from the scheduled November 10, 2000, postoperative visit state: [S]he has been tapering herself down off Serzone [an antidepressant]. She has been on multiple different anti-depressant medications in the past. She declines my offer to switch her to another medication. Dr. King offered to provide Sorrell with hormone-replacement therapy in an attempt to alleviate her depression, but Sorrell also refused that treatment. Because Sorrell has been precluded from presenting expert testimony in this case, she will be unable to present sufficient evidence to create a genuine issue of material fact on the issue whether the adapter was the proximate cause of her injuries. Therefore, the trial court did not err in entering a summary judgment for Dr. King as to Sorrell's claim that he breached the standard of care when the adapter was left in her cervix during the July 7, 2000, surgical procedure.
In her complaint, Sorrell also alleges that Dr. King breached the standard of care by failing to properly examine her during her three postoperative visits. Sorrell alleges that, given her symptoms and complaints, Dr. King should have performed a pelvic examination during those postoperative visits. Sorrell also contends that she is not required to present expert testimony establishing that Dr. King's failure to perform a pelvic examination was a breach of the standard of care. In Anderson, supra, this Court held that a plaintiff in a medical-malpractice action is not required to present expert testimony establishing the standard of care `1)where a foreign instrumentality is found in the plaintiff's body following surgery; 2) where the injury complained of is in no way connected to the condition for which the plaintiff sought treatment; 3) where the plaintiff employs a recognized standard or authoritative medical text or treatise to prove what is or is not proper practice; and 4) where the plaintiff is himself or herself a medical expert qualified to evaluate the doctor's allegedly negligent conduct.' 778 So.2d at 811. The allegation that Dr. King breached the standard of care in failing to perform a pelvic examination during one of Sorrell's postoperative visits does not fall within any of the exceptions set out by this Court in Anderson. Sorrell did not present any expert testimony indicating that the applicable standard of care required Dr. King to perform a pelvic examination during her scheduled postoperative visits. Dr. King testified that he did not think that the standard of care required him to perform a pelvic examination during those scheduled postoperative visits and that it was his clinical impression that such pelvic examinations were not necessary. Therefore, because Sorrell did not present any expert testimony establishing that Dr. King's failure to perform a pelvic examination was a breach of the standard of care, she failed to present sufficient evidence to overcome Dr. King's motion for a summary judgment as to this claim.