Court Opinion

ID: 2964014
Source: CourtListenerOpinion
Date Created: 2015-09-21 21:19:02.518313+00
Date Added: 2024-06-11T11:37:23.060037
License: Public Domain

USCA1 Opinion

	

                            UNITED STATES COURT OF APPEALS
                                FOR THE FIRST CIRCUIT

                                                     
                                 ____________________

        No. 95-1288

                               ALBA FERNANDEZ, ET AL.,

                               Plaintiffs, Appellants,

                                          v.

                       CORPORACION INSULAR DE SEGUROS, ET AL.,

                                Defendants, Appellees.

                                                     
                                 ____________________

                     APPEAL FROM THE UNITED STATES DISTRICT COURT

                           FOR THE DISTRICT OF PUERTO RICO

                 [Hon. Raymond L. Acosta, Senior U.S. District Judge]
                                          __________________________

                                                     
                                 ____________________

                                 Cyr, Circuit Judge,
                                      _____________

                            Bownes, Senior Circuit Judge,
                                    ____________________

                              and Stahl, Circuit Judge.
                                         _____________

                                                     
                                 ____________________

             Kevin  G. Little,  with whom Law  Offices of  David Efron  was on
             ________________             ____________________________
        brief for appellants.
             Carlos A. Del Valle Cruz for appellees GIC, et al.
             ________________________
             Alfonso Miranda  Cardenas, with  whom Pedro J.  Cordova, Jose  A.
             _________________________             _________________  ________
        Miranda Daleccio, Jose E. O'Neil Font, Carmen M. Vivas Pietri and Jose
        ________________  ___________________  ______________________     ____
        M.  Torres Morales  were on  brief for  appellee Dr.  Ricardo Martinez
        __________________
        Cortinez.

                                                     
                                 ____________________

                                    March 21, 1996
                                                     
                                 ____________________

                    CYR, Circuit Judge.   Family members filed this medical
                    CYR, Circuit Judge.
                         _____________

          malpractice action in federal  district court following the death

          of  Hiram Fernandez, and a  jury ultimately found  for the health

          care defendants.   On appeal, plaintiffs  challenge several trial

          court rulings,  including  the denial  of  their motion  for  new

          trial.  We affirm the district court judgment.

                                          I
                                          I

                                      BACKGROUND
                                      BACKGROUND
                                      __________

                    On November 4, 1991, Hiram  Fernandez was taken to  the

          emergency room  of Federico  Trilla Hospital in  Carolina, Puerto

          Rico, after awakening  with chest pains,  severe leg cramps,  and

          vomiting.   The 64-year-old  Fernandez informed Dr.  Pedro Rivera

          Bermudez  ("Dr. Rivera") that the chest pain had stopped after he

          vomited,  but  the severe  leg pain  had  not abated.   Fernandez

          failed to tell  Dr. Rivera that he was taking medication for both

          asthma and  hypertension.  Since  Fernandez did  not complain  of

          recurring chest pain, and his vital statistics were within normal

          or borderline  range, Dr. Rivera tentatively  diagnosed a pinched

          nerve  but  nonetheless  ordered an  electrocardiogram  (EKG),  a

          urinalysis, and an x-ray  of the lumbosacral region and  the left

          leg.  All tests were negative.

                    A  few hours  later,  Dr. Rivera  was  relieved in  the

          emergency room by Dr.  Ricardo Martinez Cortinez ("Dr. Martinez")

          whose examination  confirmed that Fernandez was  in stable condi-

          tion, with no complaints of chest pain.  As a blood test showed a

          slightly  elevated  white blood  count,  Dr.  Martinez ordered  a

                                          2

          second urinalysis,  as well  as a chest  x-ray, to  rule out  any

          urinary or  pulmonary infection which  might have been  caused by

          the vomiting.  The chest x-ray coincidently revealed that Fernan-

          dez  had a dilated aorta, which Dr. Martinez attributed to normal

          borderline hypertension  in a  patient of Fernandez'  age, rather

          than  an  emergent  symptom  of aortal  dissection,  a  condition

          usually accompanied by excruciating  and unrelenting chest  pain,

          fainting  spells, profuse  sweating, and  tachycardia.   Like Dr.

          Rivera, Dr. Martinez diagnosed a pinched nerve.  Shortly thereaf-

          ter Dr. Martinez referred  Fernandez to a neuropathic specialist,

          and discharged him. 

                    The next  day, when  Fernandez was unable  to recognize

          family  members,  he was  taken  to his  personal  physician, Dr.

          Abelardo Vargas, who performed a physical examination and another

          EKG (also negative), and ordered an upper gastrointestinal series

          to  determine whether there was a hiatal  hernia.   The next day,

          on  his way to undergo these tests, Fernandez collapsed and died.

          An autopsy  revealed the cause of  death as a  dissected aorta, a

          condition treatable with surgery in more than 90% of cases.

                    The  decedent's  spouse,  children,  and  grandchildren

          filed  a  medical  malpractice  suit in  federal  district  court

          pursuant  to 28  U.S.C.    1332 (diversity  jurisdiction) against

          Drs. Rivera,  Martinez, and Vargas, and  against various insurers

          of  the  Federico  Trilla  Hospital, including  Global  Insurance

          Company.    Subsequently, Dr.  Vargas  was dismissed  as  a party

          defendant.  

                                          3

                    At trial,  Dr. William T. Brown,  a Miami-based cardiac

          specialist, provided expert testimony  in behalf of plaintiffs on

          the  applicable duty of care.  Drs. Rivera and Martinez testified

          in  their  own  defense,  but presented  no  independent  medical

          testimony.  After the jury returned a verdict for all defendants,

          plaintiffs unsuccessfully  filed a motion for  new trial pursuant

          to Federal Rule of Civil Procedure 59, then brought this appeal.

                                          II
                                          II

                                      DISCUSSION
                                      DISCUSSION
                                      __________

                    Appellants challenge  four trial court rulings.  First,

          they focus  on the denial  of their request  for rebuttal  to the

          closing argument  made  by the  defense.   Although  trial  court

          rulings on the conduct, timing, and ordering of closing arguments

          are  reviewed only for abuse of discretion, see Bonilla v. Yamaha
                                                      ___ _______    ______

          Motors Corp., 955  F.2d 150, 155 (1st Cir. 1992); see also United
          ____________                                      ___ ____ ______

          States v. Wood, 982 F.2d 1, 4  (1st Cir. 1992), appellants insist
          ______    ____

          that civil-action plaintiffs  have an absolute right to rebut the
                                                ________

          closing argument  of  the defense.   See  Martin v.  Chesebrough-
                                               ___  ______     ____________

          Pond's, Inc., 614 F.2d  498 (5th Cir. 1980) (noting  that "[n]or-
          ____________

          mally the  party with the burden  of proof has the  right to open

          and  close," but  holding that  a  particular codefendant  had no
                                                        ___________

          right to  rebuttal as against  another codefendant where  the two

          had asserted mutual cross-claims).  
                       ______

                    Appellants  are mistaken.    The Martin  court did  not
                                                     ______

          describe  a  civil-action  plaintiff's  "right"  to  rebuttal  as

          absolute,  but merely  reconfirmed  that the  decision to  permit

                                          4

          rebuttal is  a procedural  matter  which rests  within the  sound

          discretion  of the trial judge, id. at  501, and rarely (if ever)
                                          ___

          provides fertile  ground for appeal.   See Lancaster  v. Collins,
                                                 ___ _________     _______

          115 U.S. 222,  225 (1885);  Montwood Corp. v.  Hot Springs  Theme
                                      ______________     __________________

          Park, 766 F.2d 359, 364 (8th Cir. 1985); Moreau v. Oppenheim, 663
          ____                                     ______    _________

          F.2d  1300, 1311  (5th Cir.  1981), cert.  denied, 458  U.S. 1107
                                              _____  ______

          (1982); Commercial Iron & Metal Co. v. Bache Halsey Stuart, Inc.,
                  ___________________________    _________________________

          581 F.2d  246, 249 (10th Cir.  1978), cert. denied, 440  U.S. 914
                                                _____ ______

          (1979).  

                    Appellants  further  argue that  rebuttal was  vital to

          counteract the  "inflammatory"  statements made  in  argument  by

          defense  counsel,  who  portrayed, as  inexplicable,  plaintiffs'

          voluntary dismissal of  their claims against Dr. Vargas.  Defense

          counsel  argued to the jury that Dr. Vargas, the decedent's long-

          time personal physician,  was the  one most likely  to have  been

          negligent  since he  was the  last to  treat Fernandez,  and more

          familiar  with  his medical  history.    Defense counsel  further

          argued that  Dr. Vargas,  like the defendant-physicians,  had not

          suspected  that the  Fernandez  symptoms indicated  an  incipient

          aortal dissection but rather a  hiatal hernia.  Appellants there-

          fore  contend that  they  were entitled  to  remind the  jury  in

          rebuttal that:  (1)  the defendants had the right to  implead Dr.

          Vargas if they  believed he was the only  negligent party and the

          sole  proximate cause of Fernandez' death, and (2) Dr. Vargas had

          not  treated Fernandez  in a  hospital; thus,  unlike defendants,

          could not as readily have obtained a chest x-ray.  

                                          5

                      As plaintiffs failed to challenge the statements made

          by  defense counsel in closing argument, we review only for plain

          error.   See Johnson  v. National Sea Prods.,  Ltd., 35 F.3d 626,
                   ___ _______     __________________________

          631 (1st  Cir. 1994).   The  statements  made by  the defense  in

          closing were  in  no sense  inflammatory, but  rather a  measured

          response to earlier observations by plaintiffs' counsel that "Dr.

          Vargas [is not] responsible  for anything here simply  because he

          did not have the x-rays that  these defendants had the benefit of

          having because he was not in a position of having a full clinical

          picture."    Indeed,  plaintiffs  not only  invited  the  defense

          response they now claim gave rise to  a vital need for rebuttal,1

          but their  invitation was itself  a sufficient "reminder"  to the

          jury that plaintiffs had adduced evidence that Dr. Vargas did not

          treat Fernandez in a hospital  setting where x-rays were  readily

          obtainable.   Thus, the district court ruling was well within its

          sound discretion.  

                    In  addition,  though Fed.  R.  Civ.  P. 14(a)  permits
                                                                    _______

          defendants to implead a joint tortfeasor, see also Reyes-Lopez v.
                                                    ___ ____ ___________

          Misener Marine  Constr. Co., 854  F.2d 529,  535 n. 23  (1st Cir.
          ___________________________

          1988) (citing  to Puerto Rico case  law allowing joint-tortfeasor

          contribution), Rule 14 is not mandatory.  Appellants do not cite,

          nor have we found, any authority for  the proposition that a jury

          must be permitted to draw an adverse inference from a defendant's

          decision  to forego a Rule  14 impleader.   We therefore conclude
                              
          ____________________

               1In fact,  defense counsel expressly noted  in closing argu-
          ment:  "This is the same Dr.  Abelardo Vargas and I refer to this
          because brother counsel did refer to it [in his closing]."

                                          6

          that there was no plain error.

                    Second,  appellants  claim  that  it was  an  abuse  of

          discretion to  refuse their timely  request to instruct  the jury

          that defendants could have impleaded Dr. Vargas.  For the reasons

          discussed above,  we find no abuse  of discretion.  See  Makuc v.
                                                              ___  _____

          American  Honda Motor Co., 835 F.2d  389, 393 n.1 (1st Cir. 1987)
          _________________________

          (noting that proponent  must cite to  some legal authority  which

          would support its proposed jury instruction).

                    Third, appellants  contend that over-repetition  of the

          district court's unexceptionable jury instruction     that plain-

          tiffs must establish  all elements of their  negligence claims   

          constituted reversible error because it exaggerated the burden of

          proof in the minds  of the jury.  See United  States v. Assi, 748
                                            ___ ______________    ____

          F.2d  62, 66  (2d Cir.  1984).   Similar reversible  error arose,

          plaintiffs say, from the  district court's over-repetition of its

          "error in judgment"  instruction, viz., that  a physician is  not
                                            ____

          liable under Puerto Rico law for a faulty diagnosis or failure to

          treat if  there existed "a reasonable or educated doubt as to the

          [appropriate]  medical  course  to  [have]  follow[ed]."2    Once

          again, we must disagree.

                     As appellants  failed to object to the burden-of-proof

          instructions  before the jury retired  to deliberate, see Fed. R.
                                                                ___

          Civ. P.  51,  we review  for  plain error.    See Kerr-Selgas  v.
                                                        ___ ___________

                              
          ____________________

               2Appellants  also argue that no "error-in-judgment" instruc-
          tion was  appropriate because defendants failed  to adduce expert
          medical testimony to support a jury finding that "a reasonable or
          educated doubt" existed.  But see infra pp. 8-10. 
                                    ___ ___ _____

                                          7

          American Airlines,  Inc., 69  F.3d  1205, 1213  (1st Cir.  1995).
          ________________________

          Even though there may be a threshold beyond which further repeti-

          tion of an otherwise proper jury instruction creates an unaccept-

          able risk that the  jury will be misled, see  Davet v. Maccarone,
                                                   ___  _____    _________

          973 F.2d 22, 26 (1st Cir.  1992), appellants do not approach such

          a showing by citing three brief references to the burden of proof

          in the eleven-page jury charge.  

                    Similarly, though plaintiffs asserted a contemporaneous

          objection to the "multiple" error-in-judgment instructions, there

          was no  error.  A correct understanding  of the error-in-judgment

          principle, the  seminal legal concept  defining the duty  of care

          incumbent upon  physicians under Puerto  Rico medical malpractice

          law, was vital  to a  proper jury verdict.   Moreover, the  trial

          court's  error-in-judgment  instructions,  individually   and  in

          combination, were neither suggestive nor prejudicial.

                    Finally, appellants claim that the district court erred

          in denying  their motion for new  trial. See Fed. R.  Civ. P. 59.
                                                   ___

          Plaintiffs'  independent expert, Dr.  Brown, testified  that Drs.

          Rivera and  Martinez were negligent in failing  to record Fernan-

          dez'  past medical history on the hospital charts; and in failing

          to diagnose the  aortal dissection  on November 4,  based on  the

          complaints of earlier  chest pain, and the chest x-ray disclosing

          aortal dilation.    Appellants argue  that the  jury verdict  was

          against the weight of the evidence  because the duty of care in a

          malpractice  action can  only  be proven  through expert  medical

          testimony;  their expert,  Dr.  Brown, was  the only  independent
                                                          ____

                                          8

          medical expert to testify at trial; and the self-serving,  biased

          testimony by the defendant-physicians themselves concerning their

          own duties of care was inherently untrustworthy. 

                                          9

                      A Rule  59 ruling,  denying  a motion  for new  trial

          based on  an alleged insufficiency  of evidence, is  reviewed for

          abuse of discretion.   See Lama v. Borras, 16  F.3d 473, 477 (1st
                                 ___ ____    ______

          Cir.  1994).  A new trial should  be granted only if the verdict,

          though rationally based on the evidence, "was  so clearly against

          the weight of the evidence as to amount to a manifest miscarriage

          of  justice."   Id.  But  where there is  substantial evidence to
                          ___

          support the verdict,  it is "'only in a very  unusual case'" that

          denial of a Rule 59 motion  will be ruled an abuse of discretion.

          Wagenmann v. Adams, 829  F.2d 196, 200 (1st Cir.  1987) (citation
          _________    _____

          omitted).  This is not such a case. 

                    At  trial, plaintiffs had to establish:   (1) the basic

          norms of knowledge and medical care applicable to general practi-

          tioners or  specialists;   (2) that the  defendant-physicians did

          not  meet these basic norms in their treatment of Fernandez;  and

          (3) a causal relation between the  defendants' acts or omissions,

          and  Fernandez' death.  See Rolon-Alvarado v. Municipality of San
                                  ___ ______________    ___________________

          Juan, 1 F.3d 74, 77 n.2  (1st Cir. 1993).  Although jurors rarely
          ____

          are  able to  determine the applicable  standard of  medical care

          without the  benefit of expert  testimony, under Puerto  Rico law

          "there exists  always a presumption that  the treating physicians
                                  ___________

          have observed a reasonable degree of care . . . in the process of

          giving medical attention and  treatment.  [And] [p]laintiff bears

          the  burden of refuting this  presumption."  Id.  at 78 (emphasis
                                                       __

          added).  Thus, appellants' premise    that malpractice defendants

          must  invariably introduce  independent  expert testimony  on the

                                          10

          applicable duty of care    is flawed.  Although  defendant-physi-

          cians often do adduce independent  expert testimony on the appli-

          cable standard of medical care, the jury's implicit  rejection of

          Dr.  Brown's  testimony in  this  case was  itself  sufficient to

          support  a  verdict  for  defendants because  of  the  rebuttable

          presumption of due care indulged under Puerto Rico law, see id.  
                                                                  ___ ___

                    The  jury  was  not  compelled to  credit  Dr.  Brown's

          testimony.  "While not allowed to speculate, the factfinder is of

          course  free to  find some  experts more  credible than  others."

          Lama, 16 F.3d at  478.  On cross-examination, Dr.  Brown admitted
          ____

          that he was not able  to read or speak Spanish fluently,  that he

          had not  been provided initially with  certified English transla-

          tions of the  hospital and medical records relating to Fernandez,

          and that until  shortly before  trial he had  relied on  informal

          translations    whose accuracy was seriously disputed at trial   

          prepared by his  secretary and plaintiffs'  counsel.3  Given  the

          infirmities in the only expert testimony presented by plaintiffs,

          there was no abuse of discretion in denying a new trial.4 
                              
          ____________________

               3For example, the hospital records stated that Fernandez had
          vomited before  arriving at the  hospital, and that  this "ended"
          his  chest pain, while the informal translations relied on by Dr.
          Brown  merely indicated that the  chest pain had  "improved."  In
          addition,  presented with a  medical treatise  describing typical
          symptoms  of an  impending  aortal dissection,  Dr. Brown's  only
          response was  the unexplicated assertion  that he simply  did not
          care what the medical treatise provided.  

               4As concerns the contention by Dr. Brown that the defendant-
          physicians were negligent in failing to record Fernandez' medical
          history  on the medical charts,  the jury was  entitled to credit
          the defendant-physicians'  testimony that they left  the "medical
          history" section  of the hospital record  blank because Fernandez
          informed them  (inaccurately) that he had  no significant medical

                                          11

                    The  district court  judgment is  affirmed.   Costs are
                    The  district court  judgment is  affirmed.   Costs are
                    __________________________________________    _________

          awarded to appellees.
          awarded to appellees.
          ____________________

                              
          ____________________

          history.  See supra p. 2.
                    ___ _____

                                          12