Opinion ID: 2407473
Heading Depth: 1
Heading Rank: 4

Heading: The Hospital Report and Medical Testimony

Text: Mrs. Wood pleaded that as a direct result of the accident she suffered a heart attack. Her counsel sought to establish this causal connection by offering into evidence a hospital consultation report written about Mrs. Wood by an attending physician one year and nine months after the escalator accident occurred. Counsel for Otis objected to the admission of the report on the basis that it did not record opinions and evaluations resting in reasonable medical certainty. The trial judge overruled the objection, and the report was admitted into evidence. The report related to surgery to remove a breast because of a tumor. It was not shown that the escalator accident caused the tumor, and that brought about a point on jury argument to be discussed later. The report read: Following the surgery, she seemed to be very weak and had a fairly marked tachycardia and because of this and because of the fact that on X-ray the heart showed slight enlargement, I ordered an electrocardiogram. To my considerable surprise, it came back showing very definite marked myocardial damage compatible with the residuals of an infarct. A repeated electrocardiogram a few days later was similar. Whether this was an old infarct with scarring and not related to her present symptoms or whether this actually represents a recent infarct of a silent type or of a relatively silent type with no pain and with no cardiac failure, but only some weakness is not yet certain. At any rate we may say the following things: She has done well from the standpoint of recovery from surgery. She is a mild diabetic, well controlled. She has hypertensive heart disease with the hypertension well controlled at the present time. Finally, she has definite evidence of residuals of a myocardial infarct on the electrocardiogram, but the age of this infarct is undetermined. She will still be treated conservatively and another EKG will be taken. The problem of the admissibility under Article 3737e, Vernon's Tex.Rev.Civ.Stat. Ann. (Supp. 1967), of medical opinion entries was considered by this Court in Loper v. Andrews, 404 S.W.2d 300 (1966). Article 3737e, a statutory exception to the hearsay rule, was construed in Loper to permit the admission into evidence of a medical diagnosis appearing in a hospital record if the diagnosis records a condition resting in reasonable medical certainty. 404 S.W. 2d 300 at 305. This requirement stems from the need to cross-examine the doctor making the entry when his opinion is an expert conjecture, one not resting on demonstrable medical facts and about which there could be genuine dispute among doctors. The adversely affected party should in that instance be given an opportunity to challenge the basis of the expert's conclusions. In Loper the subject of dispute between the parties was whether the condition diagnosed in the hospital report, a skull fracture, ever existed at all. In the case before us, however, the argument is not that there had been no heart attack at any time. Otis argues instead that the report is inadmissible because the doctor said that he was uncertain whether the heart damage was the result of a recent attack or whether it was due to an older attack and therefore unrelated to the condition for which Mrs. Wood was hospitalized at the time the report was written. We disagree. Otis' argument is that the report itself reflects a lack of reasonable medical certainty because the doctor reveals that he does not know when the heart attack had occurred. Otis concludes that the admission of the report into evidence denied it cross-examination of the physician whose opinion was being placed before the jury for its consideration. However, the only damaging aspect of the report as far as Otis was concerned was the doctor's diagnosis that Mrs. Wood had suffered a heart attack. Apparently this diagnosis was not disputed, because Otis concedes in its brief in this Court the existence of a heart condition. Since it is not disputed that the diagnosis recorded a condition that rested in reasonable medical certainty, the policy behind Article 3737e of admitting reliable business entries without a mandatory right of cross-examination is satisfied. The added fact that the doctor stated that it was uncertain as to when the attack occurred did nothing, standing alone, to help Mrs. Wood establish the element of causation. An entry in a hospital report should not be excluded, and Article 3737e held inapplicable, on the grounds that the opportunity to cross-examine has been denied, unless there is a need to disprove what the entry tends to establish. In the case before us, the doctor's uncertainty as to when the attack occurred does not tend to establish any fact that would be damaging to Otis' position. We hold that the report was admissible. Whether the accident at the escalator did, in reasonable medical probability, cause the heart attack is another problem which we now reach. In connection with the above report, Dr. Fadal, who treated and examined Mrs. Wood, was asked to assume the facts of the accident, to assume that a year and nine months later the facts were as found in the hospital report, and to assume the facts set out in the cardiogram. He was then asked: In your opinion could the experience that this sixty-one year old lady with diabetes and hypertension and the pain and the bruising of her body and the exertion of running to that escalator at her age and her physical condition and being hurled through it in the manner I've described, in your opinion, could that have caused the scarring of her heart with the myocardial infarct.    [?] [Emphasis added.] Counsel for Otis objected to the question on the ground that it did not purport to bring the conclusion within the realm of reasonable medical probability, as opposed to a mere possibility. There followed a colloque at the bench, the substance of which was that the court reminded counsel for the plaintiff that the ultimate question would be based on reasonable medical probability. The Court told plaintiffs' counsel that he was not ruling that counsel could not ask the could have question, but the court suggested that counsel ask the question both ways; i.e., both could have and did cause the heart attack in reasonable medical probability. The court then overruled the objection of defense counsel to the could have question, and Dr. Fadal's answer was: From this report, there was electrocardiographic evidence to surprise the doctor, because she had no symptoms at this time, that was compatible with the residuals of her previous myocardial infarction; which meant that the change in the electrocardiogram must have occurred sometime in the past. They were old changes, they were not acute or new changes. There are mycardial infarctions or heart attacks that are called silent that occur with damage to the heart that are not as full-blown as the classical type that people are used to seeing, and the situation you described, certainly it could have been a possible cause of that. [Emphasis added.] Plaintiffs' counsel thereafter asked some other questions and never got around to asking the reasonable medical probability question of Dr. Fadal. Otis' points of error relating to this question and response complain that it was error for the trial court to admit Dr. Fadal's testimony. Our decision in Insurance Company of North America v. Myers, 411 S.W. 2d 710 (1966), is cited in support of this contention. Myers, however, involved the question whether there was some evidence, including a doctor's testimony, to support the jury's finding of causal connection between injury and death. We held that the doctor's testimony was no evidence of causal connection because the substance of his testimony was that it was not a reasonable medical probability that the injury caused the death; it was only a possibility. The basis of the holding was that [c]ausal connection    must rest in reasonable probabilities; otherwise, the inference that such actually did occur can be no more than speculation and conjecture. 411 S.W.2d 710 at 713. We added, however, that reasonable probability is determined by a consideration of the substance of the testimony of the expert witness and does not turn on semantics or on the use by the witness of any particular term or phrase. Myers, supra. While under Myers the ultimate test or question is the substance of reasonable medical probability, it was not error for the trial court to admit the preliminary question of  could the accident have caused the heart attack. The fact the counsel did not follow with the reasonable medical probability question will be dealt with below. Refusing to allow Mrs. Wood's counsel to ask a could have question and excluding the testimony of Dr. Fadal on the same basis would also undercut the principle that it is the substance, not the form, of the testimony that is determinative. Myers makes it clear that evidence sufficient to support an inference of fact may consist of statements that an injury was possibly caused by a particular event, or could have or might have been the result of the event. Consequently, requiring that a question and response be phrased only in terms of reasonable medical probability prevents a plaintiff from demonstrating that the substance of an expert's view, however expressed, is that a causal connection is a reasonable medical probability. In short, the context of a witness' testimony may demonstrate that when he said could have he was using the phrase in the sense of probably did. There is serious doubt that the substance of the doctor's testimony met the test of reasonable medical probability. As stated, however, the point before us is the admissibility of the could have question. The question of causation of the heart attack is not otherwise before us. No special issue was given or requested as to whether the injury caused the attack. There was no objection to the charge or any special issue on that ground. No request was made at the time the charge was given to the jury or otherwise that they be instructed that they should not take into consideration the heart attack because there was no evidence that in reasonable medical probability the injury caused the attack. If after hearing the testimony Otis did not regard causal connection as resting in reasonable medical probability, a proper manner in which to object was by requesting a special instruction to the jury to exclude the heart attack from their consideration on damages. See American Surety Co. v. Semmons, 413 S.W.2d 732 (Tex.Civ.App.1967, writ refused, n.r.e.). Otis did not request such an instruction. It did make a general objection that there was no evidence to support the damages issue, but there was evidence that Mrs. Wood suffered other injuries than the alleged heart attack; and therefore it was not error to submit the damages issue. Otis did request, and there were given, instructions that in considering the damages, if any, suffered by Mrs. Wood, the jury was not to consider preexisting conditions except to the extent that they were aggravated, and that the jury was not to consider subsequent ailments independent of the accident. This latter instruction, of course, was probably intended to include the consideration of the subsequent breast surgery. It is our opinion, as stated that these actions did not render the admission of the could have question erroneous or raise reversible error for the failure to have obtained an affirmative answer to the substance of a reasonable medical probability question.