Court Opinion

ID: 9607472
Source: CourtListenerOpinion
Date Created: 2023-08-22 02:59:06.292922+00
Date Added: 2024-06-11T13:27:36.022059
License: Public Domain

KNUDSON, Justice.
On May 29, 1961, plaintiff-appellant, while engaged in the loading of a horse into a truck, was thrown from the truck on to the ground, as a result of which he suffered, among other things, a compound comminuted fracture of the tibia and fibula of his right leg approximately 6 inches above the ankle joint.
Plaintiff was promptly taken to a hospital in Nyssa, Oregon, where he was treated by Dr. Kenneth E. Kerby, under whose care he remained until June 3, 1961, at which time he returned to his home at Paul, Idaho.
Upon returning to his home in Paul, Idaho, during the afternoon of June 3rd plaintiff’s wife contacted defendant, Dr. James R. Kircher, by telephone, under whose care plaintiff remained until June 19th, on which date plaintiff was transferred to the Bannock Memorial Hospital in Pocatello, Idaho, and into the care of Dr. David Nelson, an orthopedic surgeon. Dr. Nelson saw plaintiff for the first time on June 20th. Following examination, treatment and evaluation of plaintiff’s condition by Dr. Nelson during the five succeeding days, plaintiff’s leg was, on June 26th, amputated at about 6 inches below the knee.
By this action plaintiff seeks to recover damages from Dr. Kircher allegedly resulting from defendant’s negligence in his care and treatment of plaintiff. Trial was had before the court sitting without a jury, and judgment was entered in favor of defendant. This appeal is from the judgment entered.
*292Although the trial court found that defendant was negligent in his care and treatment of plaintiff, the court also found that it was not established that such negligence was the proximate cause of the loss of plaintiff’s leg. Plaintiff contends that the court erred in so finding.
During our consideration of the questions presented by this appeal and as an aid to clarification of the facts, we shall follow the format adopted by the trial court by dividing the history of plaintiff’s injury and treatment into five periods:
Period No. 1 (May 29th through June 3rd) includes the time when the trauma occurred. The bones of the fracture were forced through the clothing and boot which plaintiff was wearing and into the barnyard earth which contained manure and other debris.
This space of time also includes the period during which plaintiff was hospitalized at Nyssa, Oregon under the care of Dr. Kenneth Kerby. As a part of Dr. Kerby’s treatment he debrided non-viable tissue and otherwise cleaned the wound; the fracture was manipulated and reduced; the skin edges were sutured together, leaving a small area for drainage, and a cast applied. The cast extended from just above the middle one-third of the right thigh to the toes. On the second day, due to swelling and numbness of the toes, the cast was split on the anterior side, up to the ankle. On the succeeding day by reason of tightness, due to swelling of the leg and foot, the cast was split to the knee. A combiotic, a combination of streptomycin and penicillin, was administered twice each day, and on the day plaintiff left the hospital at Nyssa he was changed to declomycin.
Period No. 2 (June 3rd through June 9th) The record discloses that upon arriving at their home in Paul, Idaho, during the afternoon of June 3rd, plaintiff’s wife called defendant by telephone and advised him of the date and nature of plaintiff’s injury; of plaintiff’s stay in the Nyssa hospital, and that plaintiff’s leg was in a cast. She also read to the defendant a note sent by Dr. Kerby which was a brief résumé of treatment which had been given plaintiff. The evidence is conflicting as to whether defendant was told, during said telephone conversation, that plaintiff possessed antibiotic tablets; however the court found that during this period plaintiff had medication which had been sent by Dr. Kerby. It is uncontradicted that defendant was at that time requested to provide medication for pain, which was prescribed. Plaintiff’s wife testified that during this period she called defendant by telephone on an average of at least every other day because plaintiff “was having so much pain.” Plaintiff testified that on Thursday, June 8th, he observed a watery colored spot about the size of a quarter on the cast, which developed, within a couple of days, into “a rather large brown spot.”
Period No. 3 (June 9th through June ISth) Pursuant to previously scheduled appointment, on June 9th plaintiff went to defendant’s office which was the first occasion defendant had seen the plaintiff. The details of this visit are also in dispute. It is undisputed that defendant took plaintiff’s temperature, X-rayed the fractured leg and stated to plaintiff that the position and allignment of the fracture were satisfactory. Defendant acknowledges that he at that time observed a spot on the cast approximately 2 inches in diameter which he stated to be dry and appeared to be normal drainage from the wound; that there was no evidence of active drainage from infection. Plaintiff testified that he expressed his anxiety concerning his condition and specifically requested defendant to open the cast and examine the wound; that he stated to defendant, “I am afraid the damn thing is going to rot off.”
Defendant’s office record relating to his examination and treatment of plaintiff on that day is as follows:
“6-9-61 .. .No temp, needs considerable pain pills (excp & cod. gr ss)
EXAM: Has cast to mid-thigh which split to just below knee.
*293Has had bloody drainage in cast but no appearance fresh drainage.
X-ray-position OK cast OK
Rx. Percordon Carbitol
To Lower leg-
up for meals and bathroom ret in 1 wk.
prob tighten upper end cast.”
As concerns defendant’s treatment during this period the trial court found that
“On June 9, 1961, the Plaintiff’s supply of antibiotics was exhausted. The Defendant knew, or should have, in the exercise of the standard of medical practice of this community, known of this fact. Good practice demanded that anti-biotic therapy continue from this date for at least another ten days but the Defendant prescribed no antibiotics and supplied none to the Plaintiff. This was a departure from the standard of medical practice in the community.”
At this time an appointment was arranged for plaintiff to return to defendant’s office on June 17th.
Period No. 4 (June ISth through June 19th) Plaintiff’s wife testified that she called defendant by telephone on June 15th and told him that the cast on plaintiff’s leg was getting moist at the site of the fracture and that the odor was getting to be so bad that she could hardly stay in the house with him, and wondered if there was something that could be done; that defendant only advised them to keep the appointment [June 17] as arranged. Defendant admits that he received a telephone call from plaintiff’s wife on June 15th or 16th, at which time he told plaintiff’s wife “that inasmuch as he was coming to my office the next day, that this additional time would not make any difference.” In this connection defendant’s office record contains the following notation:
“6-15-61 Darvon 65 mg. q. 3^1 hours”
As concerns defendant’s duty following receipt of the telephone call above referred to, the court found:
“On June 15, 1961, the wife of the Plaintiff telephoned the Defendant that the cast around the site of the fracture was getting moist and there was an odor connected with it, and that on the previous day the Plaintiff had run a temperature of 99 degrees. Good medical practice required the Defendant at this time to see the Plaintiff, to window the cast or otherwise subject the wound to observation, to take appropriate tests to determine the proper anti-biotics to administer to control the infection and to administer a broad spectrum antibiotic different from declomycin until the tests indicated the proper antibiotic to use. His failure to do this was a departure from the local medical standard of care.”
On June 17th defendant saw plaintiff for the second time. The leg was still enclosed in the original cast. In describing the condition of the leg at that time defendant testified:
“There was an area on the anterior surface of the cast just above the ankle of approximately four inches in diameter which was quite moist. The cast was quite soggy and wet and there was some drainage exuding in the previous split in the cast in the same area. There was a definite odor to this drainage, which indicated that there was infection or some necrotic process going on underneath it in the leg.”
Defendant’s treatment on that occasion consisted principally of applying additional plaster on the posterior surface of the cast to provide additional rigidity. He also lengthened and tightened the cast at the upper end. No medication was prescribed. Defendant’s office records contain the fol*294lowing notations relative to plaintiff’s interview and treatment on that day:
“6-17-61 .. .Feels about same temp 99+ one day. Pías increased drainage.
EXAM: Cast loose knee and above. Has soupy foul drainage site injury
Rx. Cast tightened and extended higher on thigh.
To return to remove window and then poss. hospital care.”
Plaintiff’s wife testified that on the following day, Sunday, June 18th, she called the defendant and told him that plaintiff was in “terrific pain”; that they were quite worried and inquired if something couldn’t be done about it; that defendant replied, “We won’t do anything today. We will keep the appointment tomorrow.” Defendant refutes receiving such telephone call.
On June 19th plaintiff called at defendant’s office and defendant described his treatment as follows:
“Q What did you do then on the 19th, Doctor ?
“A On the 19th I cut a large window in the anterior surface of this cast, as I had informed them that I would. And we removed this wet portion of the plaster cast; below this was a considerable amount of the padding that one puts under a cast. Below that a layer of surgical four by four sponges approximately three quarters of an inch thick. This was all soaked with this foul smelling drainage. And after that I was able to expose the leg itself and view the portion of the leg that was visible through the window. It was evident that the leg had become infected. Some of the sutures that had been previously placed had been pulled through the tissues; there was a separation of the wound edges; there was a small portion of the tibia exposed in this area, which appeared to be dead and non-viable. I removed the sutures remaining that I could get at through the window. I cleaned the area with zephiran chloride, placed some surgical sponges over the area which I taped to the cast, and advised them of the seriousness of this complication. I advised them I thought it would be best if they obtained the services of a specialist, * *
As to the happenings on that day the defendant’s office records contain the following quoted notations:
“6-19-61... Cast window. Foul drainage. Silk sutures removed. Necrotic tissue bottom end of 3-4 inch Laceration exposing bone.
referred to Dr. Nelson of Pocatello.”
Period No. 5 (June 19th through June 26th) Immediately upon leaving defendant’s office on June 19th plaintiff went to the hospital at Pocatello, where he was seen by Dr. Nelson on the following day. A brief statement of Dr. Nelson’s participation in plaintiff’s treatment is contained in the Doctor’s letter addressed to defendant under date of September 5, 1961 (Plf. Exh. B), from which the following excerpt is taken:
“Examination: The right leg was examined through a large window cut on the cast and found that the skin was very reddened; a great deal of drainage was coming from the wound and the tibia was exposed, ‘after trimming away a lot of dead skin. X-rays brought along with the patient show that the bone is in fairly satisfactory position without any internal fixation.
“The patient was admitted to the hospital for evaluation and antibiotics did not show any sign of cutting down the amount of infection and most of the infection was of a resistant strain. The bone was dead for quite an area and because of its location and because *295of-.the infection and loss of skin, I-felt, that an amputation was the only reasonable treatment, as it might- well go on for months or a year and still have to be amputated. I had a Dr. Bacon, another orthopedic surgeon, see the patient and he agreed that an amputation was the best procedure. Therefore on 6-26-61, after further examining the leg under anesthesia, an amputation was done six inches below the knee.”
The trial court found that one of the areas in which defendant was guilty of departure from the standard medical practice was that during the period of defendant’s treatment subsequent to June 9th defendant failed to direct that antibiotic therapy be continued. The record well supports this finding. Medical expert witnesses expressed the view that with this type of fracture and under such conditions the wound is particularly dangerous and fraught with potential of uncontrollable infection; that the treating physician is required to give the utmost attention and cautious care to such wound; that the administration of a proper antibiotic is a standard effective treatment of an infection. However there is no showing that the defendant, during his entire treatment of plaintiff (16 days), ever prescribed or supplied a single antibiotic.
The record clearly sustains the court’s finding that defendant failed to pursue the standard medical practice in the community when he refused to see and examine plaintiff promptly after being advised by plaintiff’s wife on June 15th that the cast was getting moist and there was odor from it and that on the previous day plaintiff’s temperature was 99°. Although defendant was thereby informed of unmistakable signs of infection and was specifically requested to see the plaintiff, he took no further action and advised plaintiff in substance that since he was coming to defendant’s office on the 17th it would be taken care of then “and that the additional time would not make any difference.” Such medical. advice and treatment was in violation of accepted medical practice.
The uncontradicted evidence is that in this kind of injury infection is a definite' possibility and that it can develop rapidly. In fact defendant testified that upon . his first consultation with plaintiff he advised plaintiff that infection was a likely possibility, in language as follows:
“Q Doctor, I think you stated previously on the visit of the 9th of June that you informed the Formonts that complications were always a possibility with this kind of injury. What type of complications did you mean when you said that?
“A With this type of injury, infection is the most notable complication, although there can be others.
“Q But infection is the most serious possibility ?
“A The most likely possibility.”
In the opinion of experts who testified, the necessity of prompt and continued treatment of infection is strongly emphasized; that it is the standard practice to perform, as soon as possible, what is known as an “antibiotic sensitivity test,” which is to culture the organism in an infection and treat it with various antibiotics which might be effective against it. Defendant acknowledged that such tests are an aid and a guide to the physician; that they are a standard part of the practice nowadays ; that the drug which is discovered by such tests would in all probability be effective in a particular situation.
Such a test was never made by defendant, nor did he at any time make any test with a view to determining what antibiotic would likely be effective treatment for plaintiff. In contrast with defendant’s treatment it is proper to note that one of the first things Dr. Nelson did upon seeing plaintiff on June 20th was to order that plaintiff be immediately given 250 mg. of Chloromycetin, an antibiotic given to counteract infection. An antibiotic sensitivity test was made the same day which disclosed *296that the organism present in plaintiff’s infection was hemolytic strephylococcus and that it was sensitive to eight different antibiotic drugs. It is worthy of note that defendant acknowledged that the staph which was determined, through said sensitivity test, to he present in plaintiff’s infection, in all probability should have been controllable.
Notwithstanding the repeated complaints by plaintiff of severe pain at the fracture site and his repeated requests that something be done during the 16 days of defendant’s treatment, no medication was prescribed or provided other than for the relief for pain and as an aid to rest. The wound was never viewed or visually examined by defendant until the last day of his treatment, at which time defendant discovered that the leg had become infected; that necrotic flesh and purulent matter existed in and around the wound and serious complications existed. Among the serious complications which had set in was disclosed by the examination conducted by Dr. Nelson that “the bone was dead for quite an area.”
The record discloses that Dr. Nelson advised plaintiff of the seriousness of the existing conditions, the damage to the soft tissue and the interference with the circulatory system and that it would take many months to procure a union if it could be done at all and that in the end he still might have to amputate the leg. Plaintiff thereupon consented to the amputation on June 26, 1961.
The principal question presented by this appeal is whether the trial court erred in finding that “the care or lack of care by the defendant for plaintiff was not established to be the proximate cause of the loss of plaintiff’s leg.” We think this conclusion was error.
The applicable and governing rule in this case is stated in Reinhold v. Spencer, 53 Idaho 688, 26 P.2d 796, as follows:
“The rule would seem to be that respondent was not required to prove his case beyond a reasonable doubt, nor by direct and positive evidence. It was only necessary that he show a chain of circumstances from which the ultimate fact required to be established is reasonably and naturally inferable. Helland v. Bridenstine, 55 Wash. 470, 104 P. 626. As is said in Dimock v. Miller, 202 Cal. 668, 262 P. 311:
“ ‘If the rule of law is as contended for by defendant and appellant, and it is necessary to demonstrate conclusively and beyond the possibility of a doubt that the negligence resulted in the injury, it would never be possible to recover in a case of negligence in the practice of a profession which is not an exact science.’ Walter v. England, supra [133 Cal.App. 676, 24 P.2d 930]; Barham v. Widing, supra [210 Cal. 206, 291 P. 173]; Roberts v. Parker, 121 Cal.App. 264, 8 P.2d 908.”
Our review of the record discloses that as concerns the period of June 9th through June 15th the court stated in his opinion that “there is a serious factual question whether there was evidence of increasing infection demanding care which the defendant did not give” during this period. The court specifically found that defendant’s care and treatment of plaintiff subsequent to June 15th constituted a breach of the local standard of care. The evidence clearly establishes that defendant’s treatment of plaintiff’s wound was negligent; that such negligence resided more in what was not done than what was done and that the failure of defendant in properly treating plaintiff greatly increased the danger of infection and its uncontrollable status and was in violation of accepted medical practice.
The evidence is convincing that at the time plaintiff was transferred to the care of Dr. Nelson the infection had developed to the uncontrollable stage thereby necessitating the amputation. Dr. Nelson tes*297tified that staph infections are usually controllable and replied as follows:
“Q Are they controllable to the extent that the leg could be saved?
“A Yes usually.”
In this connection the trial court stated:
“The fact, I find, is that while infections of this sort are sometimes uncontrollable, they can ordinarily be controlled if treated properly. It is not to be expected that a person with this type of injury and infection will lose his leg.”
In considering this question it is significant to note that the trial court stated “there is evidence that proper care over the entire period of treatment could have been expected to produce different results” and that “it would not be difficult to hold the defendant responsible if he had had the plaintiff’s case during the entire course of the treatment.” There is no evidence whatever from which it can be reasonably inferred that plaintiff was not given proper care and treatment by either Dr. Kerby or Dr. Nelson, they being the only persons besides defendant who provided any special care or treatment for plaintiff. We find no evidence in the case which would justify even an inference that said doctors’ services to the plaintiff were not strictly in keeping with the standard medical practice in their communities.
The evidence is clearly sufficient to establish that defendant’s lack of attention and care constituted negligence which resulted in the loss of plaintiff’s leg. No intervening cause was shown. It is convincing that ordinary prompt standard treatment should have been given by defendant to retard and inhibit the growth of infection in plaintiff’s leg, and by applying the rule stated in Reinhold v. Spencer, supra, it was reasonable and natural to infer that such negligence was the proximate cause of the loss of plaintiff’s leg. The evidence on the issue of proximate cause is so conclusive as to establish proximate cause as a matter of law. We find that defendant’s negligence was the proximate cause of the loss of plaintiff’s leg and that the trial court erred in failing to so find.
The judgment is reversed and the cause remanded with instruction to enter judgment for plaintiff in such amount as the court shall determine to have been established as plaintiff’s damages. The court may at its election reopen the case and permit the introduction of such additional evidence as the court deems proper tending to establish the amount of damages recoverable by plaintiff.
Costs to appellant.
McQUADE, C. J., and McFADDEN, TAYLOR and SMITH, JJ., concur.