Court Opinion

ID: 2964656
Source: CourtListenerOpinion
Date Created: 2015-09-21 21:29:02.348494+00
Date Added: 2024-06-11T11:42:59.294421
License: Public Domain

USCA1 Opinion

	

                            UNITED STATES COURT OF APPEALS
                            UNITED STATES COURT OF APPEALS
                                FOR THE FIRST CIRCUIT
                                FOR THE FIRST CIRCUIT

                              _________________________

          No. 96-1894

                               RAFAELA CORT S-IRIZARRY,

                                Plaintiff, Appellant,

                                          v.

                       CORPORACI N INSULAR DE SEGUROS, ET AL.,

                                Defendants, Appellees.

                              _________________________

                     APPEAL FROM THE UNITED STATES DISTRICT COURT

                           FOR THE DISTRICT OF PUERTO RICO

                   [Hon. Salvador E. Casellas, U.S. District Judge]
                                               ___________________

                              _________________________

                                        Before

                               Torruella, Chief Judge,
                                          ___________

                            Coffin, Senior Circuit Judge,
                                    ____________________

                              and Selya, Circuit Judge.
                                         _____________

                              _________________________

               David Efron, with  whom Kevin  G. Little was  on brief,  for
               ___________             ________________
          appellant.
               Elisa  M. Figueroa  B ez, with  whom  Law Offices  of Sigrid
               ________________________                              ______
          Lopez Gonzalez was on brief, for appellees.
          ______________

                              _________________________

                                    April 16, 1997
                              _________________________

                    SELYA,  Circuit  Judge.    Plaintiff-appellant  Rafaela
                    SELYA,  Circuit  Judge.
                            ______________

          Cort s-Irizarry  (Cort s), suing  on behalf  of her  minor child,

          Rafael  Jos  Mu iz  Cort s (Jos ),  challenges an  order granting

          summary judgment to  Corporaci n Insular de Seguros (CIS) and its

          insured, Juan Ram n Gonz lez Aristud (Dr. Gonz lez), in a medical

          malpractice action.  See Irizarry v. CIS, 928 F.  Supp. 141, 147-
                               ___ ________    ___

          48 (D.P.R. 1996).  We vacate the order and remand for trial.

          I.  BACKGROUND
          I.  BACKGROUND

                    Although the  accepted summary judgment  protocol calls

          for  us to cast the facts in  the light most complimentary to the

          plaintiff's position, consistent with record support,  see, e.g.,
                                                                 ___  ____

          Garside v. Osco  Drug, Inc., 895 F.2d 46, 48  (1st Cir. 1990), we
          _______    ________________

          temper that protocol here to the extent that we set off, as point

          and counterpoint,  conflicting evidence where the  clash helps to

          illuminate pertinent legal issues.  For simplicity's sake we omit

          any further reference to CIS and treat its insured as  if he were

          the sole defendant.

                    Dr.  Gonz lez,  a  specialist in  obstetrics,  provided

          prenatal care to Cort s after she  became pregnant with Jos .  On

          December 15, 1979, Cort s  related to Dr. Gonz lez that  her last

          menstrual  cycle prior  to  conception began  on  November 2  and

          lasted  only two days.   The length of  her immediately preceding

          menses was three days,  and her periods typically had  lasted two

          or three days  during the  year prior to  her current  pregnancy.

          Based  on this  data, Dr.  Gonz lez calculated  Cort s' estimated

          delivery date (EDD) to be  August 9, 1980.  He delivered  Jos  by

                                          2

          cesarean section on  July 30,  1980.  The  newborn weighed  eight

          pounds,  eight and  three-quarter  ounces (two  pounds more  than

          Cort s' first child) and exhibited no fetal distress.

                    According to the  defendant's computations, Cort s  was

          in her  thirty-ninth  week of  pregnancy when  the baby  arrived.

          This  calculation forms  the nub  of the  case.   The plaintiff's

          theory  is that Dr. Gonz lez misfigured the baby's fetal age and,

          consequently, allowed the pregnancy  to continue beyond forty-two

          weeks,  thus bringing  into play  a risk  factor known  as "post-

          datism" or "post-maturity."   A  post-dated fetus is  at risk  of

          oxygen deprivation during its extended stay in the mother's womb,

          and brain damage is a predictable result.  While Jos , at  birth,

          displayed   no  detectable   symptoms  suggesting   a  post-dated

          delivery,  the   circumstances  of  the  delivery  revealed  some

          indications  of potential  perinatal difficulties;  for instance,

          the cesarean  section took  twenty-one minutes (roughly  twice as

          long as  the norm), and,  on one  view of the  proof, a  tracheal

          catheter was used to intubate the newborn.1

                    Time resolved  these mixed signals.   Jos  showed signs

          of neurologic abnormality at three  months and was diagnosed with

                              
          ____________________

               1Other contemporaneous indicators were  inscrutable.  On the
          one hand, Jos  had a relatively high Apgar score.  An Apgar score
          is comprised of five components:  heart rate, respiratory effort,
          muscle  tone,  reflex irritability,  and  color.   It  usually is
          compiled by the anesthesiologist at one minute after the delivery
          and again  at the  five-minute mark.   A  low score  is generally
          thought to have predictive value in determining brain damage.  On
          the other  hand, testing at  birth revealed  a somewhat  elevated
          serum  bilirubin   level  (which  could   indicate  an  incipient
          metabolic problem).

                                          3

          impaired motor  development and hearing loss  at fourteen months.

          His condition worsened as the years passed.  As an adolescent, he

          was  diagnosed  as   severely  brain   damaged,  epileptic,   and

          profoundly deaf.   At that  juncture, Cort s, then  a citizen  of

          Florida,  sued Dr.  Gonz lez  in Puerto  Rico's federal  district

          court, see 28 U.S.C.   1332(a) (diversity jurisdiction), alleging
                 ___

          that the physician's negligence caused her son's infirmities.

                    Cort s'  case rests  primarily on  the opinions  of two

          experts.  An  obstetrician, Dr. Bernard Nathanson,  opined that a

          competent obstetrician, rather than  relying upon a reported two-

          day menstrual  period to  calculate a  gravid woman's  EDD, would

          have launched a more detailed gynecologic investigation.  Had Dr.

          Gonz lez done so,  the witness stated,  he would have  discovered

          that Cort s'  actual  EDD was  July 9,  1980, and  he would  have

          recognized that  a substantial risk of post-datism arose when her

          pregnancy extended past the EDD (a risk which he presumably could

          have negated  by performing  the cesarean section  earlier).   In

          reaching  these conclusions, Dr.  Nathanson stressed  the unusual

          brevity  of the  reported period  (especially as  contrasted with

          Cort s' previous menses) and Dr. Gonz lez' failure to confirm the

          EDD by  performing various tests  which the  witness stated  were

          available in  1979-1980 (e.g., a B-scan  ultrasound examination).

          In Dr. Nathanson's opinion, the pregnancy was post-dated, and the

          defendant's  failure to  realize  it and  take corrective  action

          violated the prevailing standard of care.

                    Dr. Nathanson  also  disputed Dr.  Gonz lez'  assertion

                                          4

          that  he in fact performed a manual pelvic examination at Cort s'

          initial   appointment  and   subsequently  measured   her  uterus

          throughout  her pregnancy to corroborate the  EDD.  Dr. Nathanson

          saw no evidence that  these steps had been taken.   Moreover, Dr.

          Gonz lez'  office  record did  not  mention  either the  periodic

          uterine measurements  or their results.  Although some of Cort s'

          prenatal charts apparently had  been lost,  Dr.  Nathanson stated

          that  these data  "are  so  vital that  they  should  be in  [Dr.

          Gonz lez'] record in any case had he done them."

                    The plaintiff's second expert, Dr.  Allan Hausknecht, a

          neurologist,  diagnosed Jos  as  suffering from  Lennox Gasteault

          Syndrome (LGS).  This neurological condition is caused roughly

          fifty percent of  the time by  perinatal brain damage  (resulting

          from  a lack of  sufficient oxygen to  the fetal  brain).  Doctor

          Hausknecht  stated  that,  in  his  experience,  this  percentage

          increases sharply when, as  in this instance, no evidence  of any

          other known cause exists.  Noting that the gradual development of

          Jos 's condition  was characteristic of a  post-mature fetus, Dr.

          Hausknecht rendered an opinion  that Jos 's brain damage resulted

          from the  post-datism which Dr.  Nathanson had identified.   This

          opinion was bolstered in some degree by Dr. Nathanson's statement

          that, while some  post-dated infants will show immediate signs of

          placental senescence, such as  meconium-stained amniotic fluid or

          peeling of the skin  (Jos  had neither), many others  will appear

          asymptomatic at birth yet manifest the  effects of post-datism at

          a later time.

                                          5

                    To  be   sure,  the  plaintiff's  evidence   was  hotly

          contested.  The defendant   claimed that he  had figured the  EDD

          accurately  and that many of the tests suggested by Dr. Nathanson

          were  unnecessary, or impracticable, or  both.  He also presented

          experts  who   offered  an  alternative   theory  of   causation:

          intrauterine  cytomegalovirus (CMV)  infection, a  rare condition

          which  occurs in  0.2 to  2.2 percent  of all  live births.   The

          results  of blood tests performed on Jos  at age fifteen revealed

          previous or  latent CMV infection,  but did not  indicate whether

          the   infection  had  been  contracted  in  utero.    This  is  a

          significant omission  because, while infants who  suffer from CMV

          may  be  asymptomatic  at  birth and  thereafter  develop  mental

          retardation  or deafness, CMV can  be transmitted in various ways

          and affects most individuals during their lifetimes.

          II.  THE SUMMARY JUDGMENT STANDARD
          II.  THE SUMMARY JUDGMENT STANDARD

                    A court  may grant summary judgment  "if the pleadings,

          depositions, answers to interrogatories, and  admissions on file,

          together  with  the affidavits,  if any,  show  that there  is no

          genuine issue as  to any material fact and that  the moving party

          is  entitled to a judgment as a matter  of law."  Fed. R. Civ. P.

          56(c).  We  have expounded this standard and its particulars in a

          symphony  of cases,  see, e.g.,  McCarthy v.  Northwest Airlines,
                               ___  ____   ________     ___________________

          Inc., 56 F.3d 313, 315 (1st Cir. 1995) (collecting cases), and we
          ____

          refrain from  rehearsing this  jurisprudential chorus here.   For

          our  purposes,  it  suffices   briefly  to  describe  the  rule's

          operation.

                                          6

                    The  objective of  summary judgment  "is to  pierce the

          boilerplate  of the  pleadings and  assay the  parties' proof  in

          order to determine whether trial is actually required."  Wynne v.
                                                                   _____

          Tufts Univ. Sch. of Med., 976 F.2d 791,  794 (1st Cir. 1992).  To
          ________________________

          defeat  a motion for  summary judgment, the  nonmoving party must

          demonstrate  the existence  of  a trialworthy  issue  as to  some

          material  fact.  See Coyne v. Taber  Partners I, 53 F.3d 454, 457
                           ___ _____    _________________

          (1st Cir.  1995).  A fact  is "material" if it  potentially could

          affect the  suit's outcome.   See  Garside, 895 F.2d  at 48.   An
                                        ___  _______

          issue  concerning  such  a  fact  is  "genuine"  if  a reasonable

          factfinder, examining  the  evidence and  drawing all  reasonable

          inferences helpful to the party resisting summary judgment, could

          resolve  the  dispute  in  that  party's  favor.    See  National
                                                              ___  ________

          Amusements, Inc. v. Town of Dedham, 43 F.3d  731, 735 (1st Cir.),
          ________________    ______________

          cert. denied, 115 S. Ct. 2247 (1995).
          _____ ______

                    Exercising de novo review,  see Coyne, 53 F.3d  at 457,
                                                ___ _____

          we  hold that the record in  this case presents triable issues as

          to whether  Dr. Gonz lez violated his  duty of care,  and, if so,

          whether his  actions caused  Jos 's injuries.   Consequently, the

          district  court   erred  in   granting  the  motion   for  brevis
                                                                     ______

          disposition.

          III.  ANALYSIS
          III.  ANALYSIS

                    We  first survey  the junction  where summary  judgment

          principles  and  the  standards  governing the  admissibility  of

          expert scientific evidence intersect.  We then evaluate the lower

          court's ruling.

                                          7

                                          A.
                                          A.
                                          __

                    The  defendant  asserts on  appeal  that  the entry  of

          judgment should  be affirmed because  the district court  had the

          power  to exclude  the  plaintiff's expert  evidence pursuant  to

          Daubert  v.  Merrell  Dow  Pharmaceuticals, Inc.,  509  U.S.  579
          _______      ___________________________________

          (1993),  and that,  without such  evidence, the plaintiff  has no

          case.  Cort s parries this thrust by contending that Daubert does
                                                               _______

          not  apply at  the  summary  judgment  stage.    The  truth  lies

          somewhere in between.

                    The  Daubert  Court  formulated  a regime  for  use  in
                         _______

          ascertaining  the  admissibility  of  expert  scientific evidence

          under  Fed. R. Evid. 702.2   This regime  contemplates that trial

          judges  will perform a gatekeeping function, determining "whether

          the  reasoning  or  methodology  underlying   [proffered  expert]

          testimony  is  scientifically  valid  and  .  .  .  whether  that

          reasoning  or methodology properly can be applied to the facts in

          issue."   Daubert,  509  U.S. at  592-93;  see United  States  v.
                    _______                          ___ ______________

          Sepulveda, 15  F.3d 1161, 1183  (1st Cir. 1993)  (discussing this
          _________

          function).

                              
          ____________________

               2The rule stipulates:

                         If   scientific,  technical,   or  other
                    specialized knowledge will  assist the  trier
                    of  fact to  understand  the  evidence or  to
                    determine   a  fact   in  issue,   a  witness
                    qualified as  an expert by  knowledge, skill,
                    experience,   training,   or  eduction,   may
                    testify thereto in the  form of an opinion or
                    otherwise.

          Fed. R. Evid. 702.

                                          8

                    The plaintiff  posits that Daubert is  strictly a time-
                                               _______

          of-trial phenomenon.  She  is wrong.  The Daubert regime can play
                                                    _______

          a role during the summary judgment phase of civil litigation.  If

          proffered expert testimony fails to cross Daubert's threshold for
                                                    _______

          admissibility, a  district court  may exclude that  evidence from

          consideration when  passing upon  a motion for  summary judgment.

          See Cavallo  v. Star Enter., 100 F.3d 1150, 1159 (4th Cir. 1996),
          ___ _______     ___________

          petition for cert. filed,  65 U.S.L.W. 2399 (U.S. Mar.  19, 1997)
          ________ ___ _____ _____

          (No. 96-1493); Peitzmeier v. Hennessy  Indus., Inc., 97 F.3d 293,
                         __________    ______________________

          297-99  (8th Cir.  1996), petition for  cert. filed,  65 U.S.L.W.
                                    ________ ___  _____ _____

          3539  (U.S. Jan.  29, 1997)  (No. 96-1212);  Claar v.  Burlington
                                                       _____     __________

          N.R.R.,  29 F.3d 499, 502-05 (9th Cir. 1994); Porter v. Whitehall
          ______                                        ______    _________

          Lab., Inc., 9 F.3d 607, 612, 616-17 (7th Cir. 1993).
          __________

                    The  fact that Daubert  can be used  in connection with
                                   _______

          summary judgment motions  does not  mean that it  should be  used

          profligately.  A  trial setting  normally will  provide the  best

          operating environment for the triage which Daubert demands.  Voir
                                                     _______           ____

          dire  is  an extremely  helpful  device  in evaluating  proffered
          ____

          expert testimony, see Sepulveda,  15 F.3d at 1184 n.15,  and this
                            ___ _________

          device is not readily available in the course of summary judgment

          proceedings.     Moreover,  given  the  complex  factual  inquiry

          required by Daubert, courts  will be hard-pressed in all  but the
                      _______

          most clearcut cases to gauge the reliability of expert proof on a

          truncated record.   Because the summary judgment process does not

          conform well to the discipline that  Daubert imposes, the Daubert
                                               _______              _______

          regime should be employed only with great care and circumspection

                                          9

          at the summary judgment stage.

                    We  conclude, therefore,  that  at  the junction  where

          Daubert  intersects  with summary  judgment practice,  Daubert is
          _______                                                _______

          accessible, but courts must be cautious   except when defects are

          obvious  on the  face of  a proffer    not  to exclude  debatable

          scientific  evidence  without  affording  the  proponent  of  the

          evidence adequate opportunity to  defend its admissibility.3  See
                                                                        ___

          Margaret A. Berger, Procedural Paradigms for Applying the Daubert
                              _____________________________________________

          Test, 78 Minn. L. Rev. 1345, 1379-80, 1381 (1994).
          ____

                    Having  rejected  the plaintiff's  broadcast contention

          that Daubert can never be used at  the summary judgment stage, we
               _______

          turn  to  the  defendant's  case-specific  argument  that Daubert
                                                                    _______

          necessitates  the  exclusion  of  the opinions  advanced  by  the

          plaintiff's experts.  This asseveration suffers from a very basic

          shortcoming:   the  defendant never  asked the district  court to

          exclude this evidence from  consideration, and the district court

          made no effort to do  so on its own initiative.   If trial courts

          should be slow to  employ Daubert at the summary  judgment stage,
                                    _______

          appellate courts should  be even  more hesitant to  head in  that
                              
          ____________________

               3Though such an opportunity is most easily afforded at trial
          or in  a trial-like  setting, courts have  displayed considerable
          ingenuity in devising  ways in  which an adequate  record can  be
          developed  so  as  to  permit  Daubert  rulings  to  be  made  in
                                         _______
          conjunction with motions for summary  judgment.  See, e.g., Brown
                                                           ___  ____  _____
          v. SEPTA  (In re Paoli R.R.  Yard PCB Litig.), 35  F.3d 717, 736,
             _____   _________________________________
          739  (3d Cir. 1994) (discussing use of in limine hearings), cert.
                                                 __ ______            _____
          denied, 115 S. Ct. 1253 (1995); Claar, 29 F.3d at 502 (discussing
          ______                          _____
          district court's  technique of ordering experts  to submit serial
          affidavits  explaining the  reasoning and  methodology underlying
          their  conclusions).   We  do  not  in  any  way  disparage  such
          practices; we merely  warn that  the game sometimes  will not  be
          worth the candle.

                                          10

          direction where there has been no development of the issue below.

          After all, the bifurcated  inquiry into reliability and relevance

          which Daubert  requires is best  performed by  trial judges  who,
                _______

          unlike appellate judges, have a broad array of tools which can be

          brought to bear on  the evaluation of expert testimony.4   Hence,

          we can  envision few, if  any, cases in which  an appellate court

          would venture to superimpose  a Daubert ruling on a  cold, poorly
                                          _______

          developed  record when  neither the  parties  nor the  nisi prius

          court has had a meaningful opportunity to mull the question.

                    This case falls squarely into the maw of these  general

          principles.   The  defendant, notwithstanding  the animadversions

          that he spouts on  appeal, never asked  in the district court  to

          strike or otherwise defenestrate the statements of Drs. Nathanson

          and/or Hausknecht.   The district court's  rescript neither cites

          Daubert nor  purposes to exclude the expert evidence submitted on
          _______

          the plaintiff's behalf.   And, moreover, the record as  it stands

          is wholly inadequate to  permit a reasoned Daubert determination.
                                                     _______

          For these reasons, we decline the defendant's odd invitation that

          we start from  scratch and  undertake a Daubert  analysis in  the
                                                  _______

                              
          ____________________

               4It  is for this reason,  coupled with the  special coign of
          vantage which trial  courts enjoy, that we have afforded district
          judges  broad   discretion  in  determining   whether  particular
          scientific testimony is or is not admissible at trial.  See Hoult
                                                                  ___ _____
          v. Hoult, 57  F.3d 1, 5  (1st Cir. 1995);  Sepulveda, 15 F.3d  at
             _____                                   _________
          1183.   In this vein,  we note that  the Supreme Court  soon will
          resolve a disagreement  among the circuits as  to the appropriate
          standard for reviewing  such decisions.   See  Joiner v.  General
                                                    ___  ______     _______
          Elec.  Co., 78  F.3d  524 (11th  Cir.  1996), cert.  granted,  65
          __________                                    _____  _______
          U.S.L.W.  3619 (U.S. Mar. 17, 1997) (No. 96-188).  That standard-
          of-review question need not concern us today.

                                          11

          context  of this appeal.5   This means,  of course, that  we must

          consider  the  entire  record,  including the  opinions  of  Drs.

          Nathanson and Hausknecht, as we ponder the merits of the district

          court's dispositive ruling.

                                          B.
                                          B.
                                          __

                    In this  diversity suit, the substantive  law of Puerto

          Rico controls.   See  Erie  R.R. v.  Tompkins,  304 U.S.  64,  78
                           ___  __________     ________

          (1938); Rolon-Alvarado v. Municipality of San Juan, 1 F.3d 74, 77
                  ______________    ________________________

          (1st Cir. 1993).   The Puerto  Rico Civil Code  states that  "[a]

          person who by an act or omission causes damage to another through

          fault  or negligence  shall be  obliged to  repair the  damage so

          done."    P.R.  Laws Ann.  tit.  31,    5141  (1991).  Under this

          proviso, three elements  comprise a prima  facie case of  medical

          malpractice; a plaintiff must establish (1) the  duty owed (i.e.,

          the minimum standard of professional knowledge and skill required

          in  the   relevant  circumstances),   (2)  an  act   or  omission

          transgressing  that  duty,  and  (3) a  sufficient  causal  nexus
                              
          ____________________

               5In all events, we  note that the two  grounds urged by  the
          defendant   in   support   of   his   exclusionary   request  are
          inappropriate.    First, Dr.  Gonz lez  asserts  that his  expert
          evidence is more persuasive than the plaintiff's.  His insistence
          that this circumstance warrants exclusion of the competing expert
          evidence contradicts  fundamental principles of  summary judgment
          practice.   See, e.g., Greenburg v. Puerto Rico Maritime Shipping
                      ___  ____  _________    _____________________________
          Auth.,  835  F.2d 932,  936 (1st  Cir. 1987).   Daubert  does not
          _____                                           _______
          reverse these principles.   See Daubert, 509 U.S. at  595-96; see
                                      ___ _______                       ___
          also  Ambrosini v. Labarraque,  101 F.3d  129, 140-41  (D.C. Cir.
          ____  _________    __________
          1996), petition for cert.  filed, ___ U.S.L.W. ___ (U.S.  Apr. 1,
                 ________ ___ _____  _____
          1997) (No. 96-1552).  Second, he claims that the testimony of the
          plaintiff's witnesses, if allowed, would  be confusing.  The fact
          that particular expert evidence might tend  to confuse or mislead
          a  jury can constitute grounds  for exclusion of  the evidence at
          trial, see  Fed. R. Evid. 403, but it is not directly relevant to
                 ___
          a Daubert analysis.  See Daubert, 509 U.S. at 595-96.
            _______            ___ _______

                                          12

          between the breach and the claimed harm.  See Lama  v. Borras, 16
                                                    ___ ____     ______

          F.3d 473,  478 (1st Cir. 1994); Rolon-Alvarado, 1 F.3d at 77.  On
                                          ______________

          whole-record  review,  we conclude  that  the  plaintiff produced

          sufficient evidence to establish a genuine factual controversy as

          to each element.

                    1.   Duty and Breach.   In this  case, the  elements of
                    1.   Duty and Breach.
                         _______________

          duty and breach are  inextricably intertwined.  Thus,  we address

          them in the ensemble.

                    Puerto  Rico  holds  health  care  professionals  to  a

          national standard of  care.  See Oliveros v. Abreu, 101 P.R. Dec.
                                       ___ ________    _____

          209, 226-27, translated in 1 P.R. Sup.  Ct. Off'l Trans. 293, 313
                       __________ __

          (1973).  Accordingly,  a health care provider has  "a duty to use

          the same degree of expertise as could reasonably be expected of a

          typically competent practitioner in the identical specialty under

          the  same  or  similar   circumstances,  regardless  of  regional

          variations  in  professional acumen  or level  of care."   Rolon-
                                                                     ______

          Alvarado, 1 F.3d at 77-78.  Nevertheless, because Puerto Rico law
          ________

          presumes  that physicians exercise  reasonable care,  a plaintiff

          bent  on  establishing a  breach of  a  physician's duty  of care

          ordinarily  must  adduce expert  testimony  to  limn the  minimum

          acceptable standard and confirm the defendant doctor's failure to

          meet it.  See id. at 78.
                    ___ ___

                    Cort s'  proffer  is  sufficient  to  this  end.    Dr.

          Nathanson,  a  specialist  in the  same  field  as  Dr. Gonz lez,

          clearly delineated the  standard of care  and identified what  he

          believed  to  be Dr.  Gonz lez' departures  from  it.   He stated

                                          13

          categorically that an "average gynecologist" would not rely on  a

          reported  two-day  menstrual period     unusually  short even  if

          relatively common  to that particular  individual   and  that the

          failure  to perform corroborating  tests then  available violated

          "the  prevailing  medical standard."    For  purposes of  summary

          judgment, affiants and witnesses need not be precise to the point

          of  pedantry.  Thus, we  treat Dr. Nathanson's  references to the

          "average gynecologist"  and to "the prevailing  medical standard"

          as meaning the  national standard of care.  Cf.  Lama, 16 F.3d at
                                                      ___  ____

          479 n.7.

                    The district court advanced three principal  grounds in

          support of its  conclusion that these issues    duty and breach  

          could  be resolved against the  plaintiff at the summary judgment

          stage, notwithstanding Dr. Nathanson's  opinion evidence.  All of

          these grounds lack persuasive force.

                    First,   the  court  observed  that  Cort s'  menstrual

          periods  had lasted  "an  average of  two  to three  days,"  and,

          accordingly,  "a two-day  period  was not  abnormal or  unusually

          short  for  her."   Irizarry,  928  F. Supp.  at  146.   But  Dr.
                              ________

          Nathanson's  testimony supported  the opposite  conclusion; thus,

          whether the menses was  abnormal and whether it triggered  a duty

          to inquire further became questions of fact not properly resolved

          on  summary  judgment.    See,  e.g.,  Greenburg v.  Puerto  Rico
                                    ___   ____   _________     ____________

          Maritime Shipping Auth., 835 F.2d 932, 936 (1st Cir. 1987).
          _______________________

                    Second, the court determined that, because Dr. Gonz lez

          measured  the  uterus  periodically  throughout   the  pregnancy,

                                          14

          yielding results consistent with  the EDD on which he  relied, he

          had no  reason to  suspect an  earlier date  of conception or  to

          order any additional tests.   See Irizarry, 928 F. Supp. at  146.
                                        ___ ________

          While Dr. Gonz lez so testified, the court erred in treating that

          testimony as conclusive.  When Dr. Gonz lez'  and Dr. Nathanson's

          assertions are juxtaposed, the  net result is a factual  issue as

          to  whether  the defendant  made  the measurements,  and,  if so,

          whether this procedure satisfied the applicable standard of care.

                    Third, the  court damned  Dr. Nathanson's  opinion with

          the faintest of  praise, characterizing it  as nothing more  than

          one doctor's  assertion that he  would have acted  differently in

          identical  circumstances  than  did another,  and,  consequently,

          denying  it effect in the summary judgment  calculus.  See id. at
                                                                 ___ ___

          147.  We accept the  court's premise that a mere disagreement  in

          medical  judgment, without more, does not prove duty or breach in

          a  medical malpractice case brought  under Puerto Rico  law.  See
                                                                        ___

          Rolon-Alvarado,  1 F.3d  at  78.    But  we  reject  the  court's
          ______________

          conclusion; Dr. Nathanson's declarations, read in context, amount

          to  a  satisfactory statement  of the  standard  of care  and the

          defendant's deviation from it which, if credited by a jury, could

          support  a finding  for the  plaintiff on  these elements  of her

          cause of action.   And in the absence of a  Daubert determination
                                                      _______

          excluding the Nathanson evidence as scientifically untenable, the

          trial court was not at liberty on summary judgment to ignore that

          evidence merely because it deemed other evidence more credible.

                    2.   Causation.  Notwithstanding proof of both duty and
                    2.   Causation.
                         _________

                                          15

          breach,  a  plaintiff  also  must  offer  competent  evidence  of

          causation in a  medical malpractice case.   See Rolon-Alvarado, 1
                                                      ___ ______________

          F.3d at 77.  The lower court found the plaintiff's submissions on

          this element wanting.   See Irizarry,  928 F. Supp.  at 147.   We
                                  ___ ________

          demur.

                    A medical  malpractice plaintiff can   and often does  

          establish causation through expert testimony.   See Lama, 16 F.3d
                                                          ___ ____

          at  478.   Cort s  took that  route.   Dr.  Nathanson offered  an

          opinion to a reasonable degree  of medical certainty that Cort s'

          EDD was actually  July 9, not August  9, and that  this one-month

          discrepancy had  dire consequences.  If  accepted, this testimony

          meant  that Dr.  Gonz lez  did not  perform the  cesarean section

          until the forty-third week of a post-dated pregnancy.

                    Relatedly,  Dr. Hausknecht diagnosed  Jos  as suffering

          from LGS,  which, in the  absence of any  genetic or other  known

          explanation, is generally thought to be caused by perinatal brain

          damage.  It is undisputed that the adverse effects of post-datism

          include oxygen  deprivation, and thus  can lead to  brain damage.

          Finding no evidence  of any hereditary  etiology and observing  a

          pathology consistent with post-datism, Dr. Hausknecht opined that

          Jos 's  cerebral damage  probably was  caused by  the post-datism

          which  Dr.  Nathanson identified.    Both  physicians also  noted

          likely indications of complications  at birth, and these findings

          buttress  the  plaintiff's   theory  of   causation.6     Drawing
                              
          ____________________

               6Dr.  Nathanson  dwelled  on  the unusual  duration  of  the
          cesarean section and the  apparent use of a tracheal  catheter to
          resuscitate the infant at birth.  Dr. Hausknecht noted that there

                                          16

          reasonable inferences  from this evidence, a  rational jury could

          find that Dr.  Gonz lez' negligent reliance upon  a reported two-

          day  menstrual period  and  his eschewal  of further  (available)

          tests  caused  a  post-dated  pregnancy,  the  effects  of  which

          included perinatal  brain damage  which manifested itself  in the

          form of LGS.

                    Of  course,  the   defendant's  experts  debunked   the

          plaintiff's  proof and offered an alternative causal theory   the

          presence  of a  CMV infection    which  the district  court found

          "more  compelling."   Irizarry, 928  F. Supp.  at 147.   But such
                                ________

          comparisons are invidious at the summary judgment stage.  Even at

          trial, a plaintiff in a medical malpractice suit need not prove a

          causal  connection with  mathematical accuracy nor  eliminate all

          other  possible  causes  of  damage.    See   Cruz  Rodriguez  v.
                                                  ___   _______________

          Corporaci n de  Servicios del Centro  M dico, 113 P.R.  Dec. 719,
          ____________________________________________

          744,  translated in  13 P.R.  Sup. Ct.  Off'l Trans.  931, 960-61
                __________ __

          (1983).  Legal rules  of this sort acquire added  significance on

          summary  judgment because Rule  56 "contemplates  an abecedarian,

          almost one  dimensional, exercise geared  to determining  whether

          the nonmovant's  most favorable evidence and  the most flattering

          inferences which can reasonably be drawn therefrom are sufficient

          to  create any authentic question  of material fact."  Greenburg,
                                                                 _________

          835 F.2d at 936.

                    In this  case, the defendant's evidence on the issue of
                              
          ____________________

          had been an  abnormal bilirubin  level at birth  and expressed  a
          belief  that this might  evince a metabolic  problem damaging the
          brain.

                                          17

          causation, as compelling as it might have seemed, did not warrant

          the  entry of  summary judgment.   The  plaintiff articulated  an

          alternative  theory of  causation  and backed  it up  with expert

          testimony  as to  the causal  nexuses between  LGS  and perinatal

          damage,  and between perinatal  damage and  post-datism.   At the

          same time, she cast doubt on the defendant's theory of causation,

          establishing the low incidence  of intrauterine CMV infection and

          suggesting  an alternate  origin of  any  CMV detected  in Jos 's

          system (related  to a  history of  sexual molestation  at school,

          thereby  opening up  the possibility that  any CMV  infection was

          sexually  transmitted).    This  evidence sufficed  to  create  a

          trialworthy issue vis- -vis the element of causation.  See Coyne,
                                                                 ___ _____

          53 F.3d at 460 (explaining that "when the facts support plausible

          but  conflicting inferences on a  pivotal issue in  the case, the

          judge may  not choose  between those  inferences  at the  summary

          judgment stage"); see also United States  v. Kayne, 90 F.3d 7, 12
                            ___ ____ _____________     _____

          (1st  Cir. 1996)  (stating that  disagreements among  experts are

          "properly the subject of searching cross-examination"  at trial),

          cert. denied, 117 S. Ct. 681 (1997).
          _____ ______

          III.  CONCLUSION
          III.  CONCLUSION

                    We need go no further.  Scrutinizing the  entire record

          in the  light most  congenial to  the plaintiff, rational  jurors

          could find all the  elements of medical malpractice.   Though the

          plaintiff's  evidence may  appear  thin to  some, it  establishes

          factual disagreements  as to  which reasonable minds  may differ.

          No  more is exigible.  See Greenburg, 835 F.2d at 936 (explaining
                                 ___ _________

                                          18

          that the  ground rules associated with  summary judgment practice

          "admit of no room for credibility determinations, no room for the

          measured  weighing  of conflicting  evidence  such  as the  trial

          process entails, no  room for  the judge to  superimpose his  own

          ideas  of probability  and likelihood  (no matter  how reasonable

          those  ideas  may be)  upon the  carapace  of the  cold record").

          Right or  wrong, the plaintiff is entitled to present her case to

          a jury.

                    The order granting summary  judgment is vacated and the
                    The order granting summary  judgment is vacated and the
                    _______________________________________________________

          case is remanded for trial.  Costs to appellant.
          case is remanded for trial.  Costs to appellant.
          __________________________   __________________

                                          19